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Distinguished Member (Clinical Research) Medical Staff, Roswell Park Cancer Institute.
Professor Emeritus, School of Medicine, State University of New York at Buffalo.
Medical Director Emeritus, John M. Lore, Jr., Head and Neck Center, Sisters of Charity Hospital.
Former Head, Department of Otolaryngology-Head and Neck Surgery, Sisters of Charity Hospital.
University Chief, Department of Otolaryngology, Buffalo Children's Hospital and Erie County Medical Center.
Consultant, Veterans Administration Medical Center
Consultant, Roswell Park Cancer Institute
Director of Surgery, Good Samaritan Hospital, Suffern, New York.
Illustrated by
Robert Wabnitz
Director Emeritus of Medical Illustration, University of Rochester Medical Center, Rochester, New York.
and
Margaret Pence
M.F.A. in Medical Illustration, Rochester Institute of Technology
Adjunct Professor, School of Fine Art, College of Imaging Arts and Sciences,
Rochester, New York.
ELSEVIER
SAUNDERS
ELSEVIER
SAUNDERS
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NOTICE
Surgery is an ever-changing field. Standard safety precautions must be followed, but as new
research and clinical experience broaden our knowledge, changes in treatment and drug therapy
may become necessary or appropriate. Readers are advised to check the most current product infor-
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Printed in China
v
CONTRIBUTORS
t Deceased.
CONTRIBUTORS
Dr. John M. Lore, Jr., passed away on January 12,2004. He continued active medical
practice and cared for his patients until shortly before his death. Dr. Lore was world
renowned as a head and neck surgeon. After receiving his medical degree from New
YorkUniversity, he completed residencies in both otolaryngology and general surgery.
He was the Chairman of the Department of Otolaryngology-Head and Neck Surgery
at the State University of New York at Buffalo School of Medicine, 1966 to 1991. He
later joined the Department of Head and Neck Surgery at Roswell Park Cancer Institute.
Dr Lore was one of the founders of the American Society of Head and Neck Surgery.
He was a past president of that society as well as of the Society of Head and Neck
Surgeons. He contributed to the early efforts to combine the two Head and Neck
Societies. He was also a founding member, and former chairman of the Joint Council
for Advanced Training in Head and Neck Oncologic Surgery, which was instrumental
in establishing the fellowship programs in advanced Head and Neck Surgical Oncology,
accredited by the American Head and Neck Society. During his long and distinguished
career, Dr. Lore received many honors and awards recognizing his many contribu-
tions to the specialty of Head and Neck Oncology. He was passionate and tenacious
in the practice of his profession; he was an early pioneer and champion of the use
of adjuvant chemotherapy in the treatment of head and neck cancer.
Jack was equally passionate and tenacious in his many nonprofessional interests
and pursuits. He was an avid and accomplished skier, sailor, and photographer.
Professionally, his most enduring and cherished attribute was his compassion and
his dedication to his patients. When I first met Dr. Lore, he was one of the leading
members of our specialty. I then became one of his collaborators and colleagues.
Eventually, 1 came to know Jack as my friend. He will be greatly missed. An Atlas
of Head and Neck Surgery, 4th edition, serves as a legacy and tribute to his memory.
IX
Recognition by
The Board of Managers of St. Vincent's Hospital, New York,
New York, at the time of his death.
To My FATHER
Dr Lore, Sr. was born in Caleane, Sicily, and came to the United States of
America at age 5. He was a naturalized citizen of the United States and served in
World War I as an officer in the United States Navy.
XI
PREFACE
Over 40 years have passed since the publication of the follow-up period if indicated. With the use of chemo-
first edition of An Atlas of Head and Neck Surgery, therapy, the surgeon must not compromise the scope of
including three English editions and one Spanish surgical resection when there is a favorable response to
edition. This Fourth Edition has further broadened its the chemotherapy. Please confer preoperative chemo-
background-an increased scope of each chapter with therapy in Chapter 3.
an additional number of contributors. As more tissue and bone are removed, the reconstruc-
Jesus E. Medina, M.D., is welcomed as an associate tive measures must be further improved and expanded
editor to this Fourth Edition. He has been instrumental from a cosmetic and a functional point. A caveat that
in a number of facets, namely in obtaining Robert W. must be emphasized is that wherever possible or prac-
Dolan, M.D., Department of Otolaryngology, Head and tical the reconstructive measures should not mask early
Neck Surgery, Lahey Clinic, to author the new chapter or late recurrence of disease. At times this is not possible.
on Microvascular Surgery, and Keith F. Clark, M.D., As an expansion of the reference to microvascular
Ph.D., for the addition of Endoscopic Sinus Surgery to surgery in the preface of the Third Edition, a new
Chapter 5. Dr. Medina also has contributed to a number Chapter 24 has been added. The indication for micro-
of other areas. vascular surgery has broadened and has served well in
The additions, it is believed, cover items that hit the a number of reconstructive problems, especially free skin
highlights of a number of aspects of head and neck flaps for major skin defects of the cheek, as well as muscle
surgery, which are available to the surgeon as up-to- and bone transfers. This new chapter by Dr. Dolan serves
the-minute help. It is not a cookbook of surgery, how- two purposes: (1) to demonstrate to the head and neck
ever. This could be an inherent danger in an atlas. The oncologic surgeon what can be achieved by microvas-
surgeon must be experienced with the various proce- cular surgery and (2) to present the techniques involved.
dures and modifications thereof. No dabblers.! The These techniques are not for the dabblers-only for
choice of the surgical procedure must not be based on experienced microvascular surgeons.
the easiest and quickest minimum resection but rather Take time to evaluate and record the extent of disease
must be aggressive'> There is a danger of preserving utilizing tattoo, when possible, prior to any manage-
soft tissue and bone with disease-free minimum margins ment plan. Do not depend on the site evaluation at the
and even no margins. time of the initial surgical procedure. This admonition
Reference is made to Dr. Murray F. Brennan's presi- is an absolute with the use of preoperative chemotherapy
dential address to the Society of Surgical Oncologists or, for that matter, radiotherapy, especially if salvage
in 1996.3 There should be no such attitude as "leave surgery becomes necessary following any recurrence
disease right up to the line of resection." It appears that after the radiotherapy.
widespread use of radiotherapy as a routine postoper- Regular careful and thorough follow-up of patients
ative modality is fraught with the misconception for must be carried out to the best possible degree. Follow-
the surgeon that if a little tumor is left behind it is up must be done by the surgeon and by those expert in
really no worry since routine radiotherapy is the catch- the field of head and neck examination and knowledge
all. Margins in this methodology mean little since ion- of the natural history of the disease. The primary respon-
izing radiation will handle all that the surgeon neglects. sibility is the surgeon's and not the primary care physi-
Radiotherapy, as well as chemotherapy, plays an impor- cian's. Keep records, which will be valuable as an eval-
tant part in the management of head and neck squa- uation of outcome-not only the physical examination,
mous cell carcinoma, Stage III and Stage IV, but is not but also the quality of life. When evaluating the quality
meant to give a false sense of security to the surgeon. of life, take into account the family support or lack
Hence, it is believed that radiotherapy should not be of support.
routinely used postoperatively but rather selectively. This It may be worthwhile at different times to have
spares the patient of the side effects of radiotherapy, as different physicians in other allied disciplines involved
well as making radiotherapy available during the entire in the search for early recurrence. For example, the
XIII
PREFACE
reconstructive surgeon, the prosthodontist, the radia- Description of Head and Neck Services
tion oncologist and the medical oncologist, and the at Sisters Hospital4
specially trained nurse clinicians all should be involved
in evaluation. This approach is time consuming both Over the years, management of neoplastic disease as well
for the medical professionals as well as the patient, as other diseases has crossed time-honored established
and sometimes it's shattering for the HMOs. These disciplines. In head and neck neoplasia, including thy-
follow-up examinations should be based on a regular roid malignancy; surgical, medical, and radiation oncol-
schedule-usually one time per month for the first year ogy; and endocrinology, other supportive disciplines
and then every two months for the second year and so and services are involved. The input from these disci-
on up to five years. They continue every 5 to 6 months, plines is usually achieved by multidisciplinary confer-
as enumerated later. There is some indication or recur- ences. To further develop this ecumenical approach, to
rence following preoperative chemotherapy. New pri- avoid "turf battles," and to further enhance cooperative
maries may appear between the seventh and the tenth and close exchange of ideas regarding diagnosis and
year. Follow-up should not be more than every 5 to management of head and neck neoplasia, a Head and
6 months; sooner if there appears to be a predisposing Neck Oncology Service within the John M. Lore, Jr.,
factor to squamous cell carcinoma. M.D., Head and Neck Center at Sisters Hospital, Buffalo,
Follow-up is for life. A patient who continues to smoke NY, was established 8 years ago. This service encom-
or who has an indication of field carcinogenesis is an passes the aforementioned disciplines plus all other
example. Frequencies may be increased or decreased, germane disciplines and services, including General
depending on the anticipated natural history of the Otolaryngology, Reconstructive Surgery, Vascular Sur-
disease. This is time consuming yet most important. gery, Microvascular Surgery, Neuro-otology, Skull Base
Review all images-not just reports. CT, MRl, MRA, Surgery, Oncologic Ophthalmology, Diagnostic Imag-
angiograms, and PET scans, when appropriate, must ing, Head and Neck Pathology, Nuclear Medicine,
be reviewed by the surgeon. It is not unusual to spend Psychiatry, Maxillofacial Prosthetics, Dental Pathology,
upwards of one hour in this type of preoperative evalu- Swallowing and Speech Pathology, Nutrition and
ation. Postoperative examination, especially long-term, Biostatistics.
likewise involves considerable time and effort. This is The main purpose is to render the best possible
another problem for those from the HMOs to compre- patient care, to attract the best qualified physicians and
hend even though they may be physician consultants. other professionals (thus sifting out the dabblers), and
One HMO recognized this "unique specialty practice" to promote an academic atmosphere. This oncology
involving training in both otolaryngology and general service functions as an autonomous service with the
surgery. All this is a significant and tremendous respon- cooperation and support of the Chairman of the Depart-
sibility for the surgeon and all those concerned. ment of Surgery and the Chairman of the Department
In the Preface of the Third Edition, the concept of of Internal Medicine. The Service is responsible for
centers of excellence was introduced in the manage- its own quality review data, which is supplied to the
ment of neoplasms of the head and neck. In 1993, this Quality Review hospital committee. Outpatient; in-
concept was initiated at Sisters of Charity Hospital in patient; speech and swallowing professionals with labo-
Buffalo, NY. The following is a description of such a ratory staff, physicians, fellows, and nurse clinicians;
center. It has flourished well and its weekly tumor as well as oncologic dentistry, conference rooms, library
conferences with surgery, medical oncology, radiation and nutritional offices are all contiguous and on the
oncology, and endocrinology, as well as with its special- same floor of the hospital.
ized nurses and support personnel, has attracted local On the same floor is the Pathology Department and
physicians from other hospitals in the Buffalo area. Since up one flight are the OR and ICU. Down one flight is
its inception, it has trained fellows with backgrounds Diagnostic Imaging and Nuclear Medicine. On another
in otolaryngology, general surgery, and plastic surgery. floor is the Microsurgical Laboratory.
The center supports the concept of excellence in patient It appears that this approach to head and neck neo-
care plus the important addition of academia and ecu- plasia, including thyroid and parathyroid tumors, truly
menism. The academia in itself is desirable, and when improves patient care without the stigma of "treatment
joined in a single service including all of the disciplines by committee." We may agree or disagree yet each indi-
involved becomes a sine qua non in the management vidual is free to treat the patient as he or she sees fit.
of head and neck neoplasms, including thyroid diseases. This type of service avoids the wasted time involved in
A dedicated interest in academia produces interest turf conflicts. The Head and Neck Oncology Service is
in newer concepts-for example, molecular biology a complete system where the sum of all the components
with gene therapy-which may well become the basis is much better for patient care than any independent
of future treatment of head and neck squamous cell part. At the very beginning of this project was and still
is Robert E. Rich, the founder of Rich Products, who
carcinoma.
PREFACE
gave me the impetus to go ahead with this idea. He year to maintain an adequate workforce of some 400
produced the wherewithal to start basically a "one- to 1,000 head and neck oncologic surgeons to manage
step" facility, which minimizes "wasted time" in the this number of patients. Thus, we must minimize the
diagnosis and management of head and neck neo- number of 'dabblers.'] There is simply no reason to
plastic disease. accept physicians who are not well-trained in this field.
There are four team players who helped in the inau- Quality and not quantity is the objective.
guration of this multiple discipline service: Kenneth There is no doubt that, except in the rare case, the
Eckhert, M.D., Chief of Surgery; Nelson Torre, M.D., residents interested in this field must be dedicated to it
Chief of Medicine; Sister Angela Bontempo, Adminis- and spend extra time in a fellowship, preferably approved
trator at Sisters of Charity Hospital; and Charles Massaro, by the American Head and Neck Society. This would
M.D., Vice President of Medical Affairs at Sisters of help them reach near perfection in their chosen field as
Charity Hospital. Without the cooperation of these indi- best as possible. This concept in medicine has been
viduals this service could never have been developed. useful in the training of hand surgeons, since it involves
It had previously been proposed when I was Chairman the disciplines of general surgery, orthopedic surgery,
of the Department of Otolaryngology at the State and plastic surgery. In hand surgery, this has been recog-
University of New York at Buffalo to the dean, and nized by the three boards as an important facet in the
twice he turned this concept down saying, "We are not training of a hand surgeon. Unfortunately, in head and
ready for anything like that just yet." Hence, the medical neck surgery, the three boards involved, namely, otolaryn-
school was bypassed in this endeavor. gology, general surgery, and plastic surgery, have not
The amalgamation of the Society of Head and Neck seen fit to endorse this concept. Unless the individual
Surgeons, founded by Hayes Martin and Grant Ward is a genius, there is simply no way to adequately train a
in 1954, and the American Society for Head and Neck resident in the various facets of head and neck oncology
Surgeons, established in 1958 by the hard work of George and endocrinology in a residency training program,
Sisson, M.D., along with other dedicated head and neck since the training in that particular specialty involves a
surgeons, was a great step forward. Among the other number of other aspects over and above head and neck
dedicated surgeons as founders of the American Society oncology. As Harvey Baker, M.A.,s discussed in his
for Head and Neck Surgery was Edwin W Cocke, M.D., presidential address to the Society of Head and Neck
John S. Lewis, M.D., W. Franklin Keim, M.D., William Surgeons entitled Head and Neck Surgery: The Pursuit
M. Trible, M.D., and John M. Lore, Jr., M.D. This amal- of Excellence in 1971 and pointed out that to be active,
gamation in 1999 united the two societies into one for example in general otolaryngology, simply does
society, now known as The American Head and Neck not afford the time and effort needed to become a well-
Society. This joined the disciplines of otolaryngology, trained and practicing and active head and neck onco-
general surgery, and plastic surgery into one endeavor. logic surgeon.
There are many benefits to this amalgamation, not the Logical conclusion to these standards is the active
least of which, of course, is improvement of patient participation in one of the approved fellowships. Having
care by the sharing of various ideas among the various been the originator of this additional fellowship train-
disciplines all present at the same meeting. ing plus having the position of president of both head
The main downside as I see it is the fact that the and neck societies, I have had, and I say this with
larger the society is, the less discussion there is from humility, experience in the endeavor. Changes in the
the floor and membership. I would strongly suggest fellowship curriculum were made from time to time
that adequate time be allowed in meetings for this type and rightly so. The latest one of admitting graduates of
of discussion, because this enhances the exchange of well-trained foreign programs is strongly commended.
different ideas and different methodologies of treatment. Remember, American surgeons at the time of the late
There is an interesting and laudable result of this 1800s and early 1900s were afforded the benefits of
amalgamation in that it should and will eliminate the learning from their European counterparts. We have
striving of one society to have more members than the the same obligation and advantage today to share all
other. This inherent danger, which previously existed, our ideas and techniques with our European colleagues.
should be eliminated once and for all. This attempt at We learn from one another.
getting more members led to the admission of surgeons Some flexibility is worthy of implementation, namely,
regardless of background who were not fully qualified possibly one or two types of fellowships. The one-year
in the field of head and neck oncology. There is no need fellowship would primarily focus on the clinical aspects
for an unlimited supply of head and neck surgeons of head and neck oncology but would also include a
since, to quote from the Third Edition, "There are only reasonable amount of clinical research. The two-year
about 50,000 new patients each year with head and neck fellowship would involve basic research along with
cancer, and only approximately 35 to 75 new, well-trained clinical exposure in a suitable institution where the
head and neck oncologic surgeons are necessary each candidate's desires can be realized. Selected arrange-
PREFACE
ments for rotation of fellows from one parent institu- Battlefields,and Wounds that Will Not Heal.6 I quote
tion to one or two other institutions-for one month- him as follows: "If we act like a trade or business rather
would afford the fellow an excellent exposure to other than a profession, we shouldn't complain about words
methodologies in the overall management of head and used to describe us such as healthcare providers and
neck neoplasia. our patients as clients." Dr. Beyers goes on to quote
Again, it is my strong admonition that two years Simon H. Rifkind, a lawyer, who expressed his views
of basic surgical training in an approved general surgi- about how a profession loses its professionalism. It is
cal training program is highly recommended for those recommended that Dr. Beyers's presidential address be
who wish to pursue a head and neck oncologic fellow- read in its entirety.
ship. The exposure to basic surgical principles cannot
be achieved, I believe, in a single discipline-oriented And Now a Few Caveats
program. I can attest to this again by personal experi-
ence, having completed the approved residency in the Insecurity is the main stumbling block for a joint venture.
American Board of Otolaryngology and the American For management with the best overall survival for
Board of Surgery. I am not inferring that double boards advanced squamous cell carcinoma of the head and
are necessary. But otolaryngology residents would cer- neck, aggressive surgery is the mainstay.2 Radiation
tainly benefit from two years of general surgery. The Oncology and Medical Oncology are ancillary and
reverse, namely, dedicated training in otolaryngology, required fine-tuning. Molecular Biology may alter this
is also true for the general surgery and plastic surgery sequence in years ahead.
residents. Ideally, another year of plastic surgery would For organ preservation in advanced squamous cell
be fortuitous. carcinoma of the head and neck, chemotherapy and
The next step in the joint venture of all three disci- radiotherapy are the primary modalities with salvage
plines, namely, general surgery, otolaryngology, and surgery for failures and backup. Patients must be aware
plastic surgery, would be the recognition by the three of the complications and effect on survival and quality
boards concerned relative to an approval of this fellow- of life, specifically the significant complications of sal-
ship. To attempt to achieve this objective, plans were vage surgery. These complications were experienced
modeled after the three boards of general surgery, plastic some 40 to 50 years ago when radiation was the first
surgery, and orthopedic surgery, agreeing on a post- treatment modality followed by surgery. Because of
residency hand training program. Dr. George Omer, these complications, the sequence of treatment was
from Albuquerque, New Mexico, was the driving force changed to surgery followed by radiotherapy.
in this venture. It appears that they have succeeded Physicians must be the real leaders in medicine.
with the cooperation of the three boards recognizing an Unfortunately, from time to time, physicians have abro-
acceptable fellowship in hand surgery. gated this responsibility and opportunity. Do not admit
Following this concept that was developed in hand physicians into the American Head and Neck Society
surgery, an attempt was made to achieve the same type who are not adequately and completely trained. Quality
of recognition by the three boards involved in training and not quantity is the objective. Our prime objective
of head and neck oncologic surgeons. The initial data- is the best of care, the highest quality for patients, regard-
gathering trip was made by Dr. William Nelson and me less of the pressures of paperwork and other limitations
going to Albuquerque to review with Dr. George Omer by insurance companies and government. Closely related
how he achieved the cooperation of the three boards. to the prime objective is evaluation of each and every
Following his ideas, Dr. Elliott Strong and I developed service's end results, performance data, and quality of
a similar concept for the recognition of head and neck life- "evaluate your track record." Just because a pro-
oncologic surgery by the American Boards of Otolaryn- cedure can be done, that is not the reason to do it.
gology, Surgery, and Plastic Surgery as "added qualifi- Develop the atmosphere of academia, which stimulates
cations." Unfortunately, we failed despite our efforts at intellectual curiosity and improves quality of patient
the board level and at the American College of Surgeons care.
level and it was then that we simply gave up the Randomization-Is this always necessary? Does it
endeavor. I decided then to take the next step and that make any and every presentation valid? Review the pros
was to develop a center of excellence in our particular and cons of randomized study techniques when you
field and, hence, the development of the Head and Neck report your end results.8 (Suggest review of this refer-
Oncologic Service at Sisters of Charity Hospital. ence by Drs. Fung and Lore.)
Another aspect that is most important in the develop- There are shadows that surround us. Namely, the
ment of our field is the realization that we are a profes- insurance companies, the paperwork, and the loss of
sion and not a business. This is aptly referred to in valuable time in the encountering and fighting of these
Dr. Robert M. Beyers's presidential address to the Society obstacles. In any event, we must not be complacent
of Head and Neck Surgeons in 1996 entitled, Barberpoles, and discouraged. We must not lose the main objective
PREFACE
of our calling in life. We must not be dabblers. I We Donald P. Shedd, Historical Landmarks in Head and
must assume our responsibilities.? We must return to Neck Cancer Surgery, 2000, American Head and
the philosophy of the founding fathers of our country Neck. Society.
and Constitution when they saw fit to engrave on our
coins In God We Trust.
REFERENCES
Recommendations 1. Lore, JM, Jr: Dabbling in head and neck oncology (a plea for
added qualifications). Arch Otolaryngology Head Neck Surg 1987;
113:1165-1168
It is recommended that the head and neck surgeon, 2. Forastiere, A, Koch, W, Trotti, A, Sidransky, D: Head and neck
especially the younger ones who are not aware of the cancer. N Engl J Med 2001; 345:1890-1900.
background of this entire field, review a number of 3. Brennan. MF: The enigma of local recurrence. Ann Surg Oncol
1997; 4:1-12.
excellent resumes and books. They are as follows:
4. Lore, JM, Jr., Massaro, M: Description of Head and Neck Services
at Sisters Hospital Abstract submitted.
The Head and Neck Story, by George A. Sisson, M.D., 5. Baker, HW: Head and neck surgery: The pursuit of excellence. Am
1983, published by the American Society for Head J Surg 1971; 122:433-436.
and Neck Surgery, produced by Kascot Media, 6. Beyers. RM: Barber poles. battlefields and wounds that will not
Chicago, IL. heal. Am J Surg 1996; 172:613-617.
7. Lore. JM, Jr: Bill of responsibility. The Hayes Martin Lecture. Am
The Making of a Specialty, Hayes Martin Lecture, by J Surg 1992; 164:556-562.
Jatin P. Shah, M.D., American Journal of Surgery, 8. Fung E, Lore, JM, Jr: Randomized control studies for evaluating
Vol. 176, Nov. 1998, pp 398-403. surgical questions. Accepted for publication Arch Otolaryngol In
History of Head and Neck Surgery,by Jerome C. Goldstein, press.
First, I wish to once again thank my wife, Chalis, for all Other acknowledgements go to the staff of our Head
the ancillary work she did as well as her quiet support and Neck Service at Sisters of Charity Hospital in Buffalo,
despite the mess of "paper" that I managed to disperse NY: Karen Stawiasz, MS, RN, NP, OCN (Oncology
throughout our home during these more than five years Certified Nurse), an incredible person who is Jill-of-all-
of work on this Fourth Edition. trades and master of all and, specifically, our Oncology
Shortly after deciding to go ahead with the Fourth Clinical Nurse Specialist and Nurse Practitioner. To all
Edition, Robert Wabnitz, our master illustrator, suffered our specially trained head nurses, who tolerated my
a stroke, which to everyone, especially his wife, Sue, idiosyncrasies during this protracted period, to complete
was a terrible shock. He could no longer continue on this edition: Joyce Clemons, our patient coordinator,
with this venture. Fortunately, he had taught medical Jennifer Feltz, Maureen Heatley and Nancy Wojtulski,
illustration at the University of Rochester Medical Center. Kathleen Killion, RN, OCN, Tracy Trifilo, RN, Jean
Margaret Pence, one of his students, took over for Robert. Errington, RN, Elizabeth Gryzybowski, RN, and James
She uses the same style that her teacher taught her, and Sped ding, a key helper and patient. Thanks to Barbara
she has done an excellent and professional job. Not only Lowe, MS, RD, our nutritionist. Thanks goes to a num-
for her expertise as an illustrator are we all grateful, but ber of other transcribers: Becky Lonczak, Sandra Ochs,
also her pleasant cooperation in anything and every- and Linda Eick. To the office secretaries and adminis-
thing we asked of her in her chosen field. She is a trative assistants over the years, I'm indebted to Dottie,
superb Medical Illustrator. and Linda Runfola. My deepest appreciation goes to
I wish to also thank Jesus E. Medina, our associate Sharon Eagles who bridged the gap from one Hospital
editor, and all of our contributors-in the previous to another, Sisters of Charity Hospital to Roswell Park
editions and in this edition-for their time, interest, Cancer Institute.
and expertise. They are all detailed in the list of contri- Many thanks to Elsevier Saunders, especially to
butors. Many, many thanks. The extent of their contribu- Rebecca Schmidt Gaertner, Stephanie Smith-Donley,
tions is noted in the various chapters. These included Christian Elton, and Arlene Chappelle, who were of
contributions for an entire chapter, for example, Chapter exceptional help in manuscript review, as well as all
24, to major portions, inserts, and commentaries. the previous medical editors and associates, for with-
To a very grateful patient, supporter, and sponsor of out them this publication could not have existed.
the John M. Lore, Jr., M.D., Head and Neck Center at Among these are John Dusseau, Robert Rowan, and
Sisters Hospital-Robert E. Rich. He recognized the Sam Mink.
importance of an ecumenical approach in the develop- My condolences to the families of William Bukowski
ment of a medical and surgical service to achieve quality and Paul Milley-both contributors who have passed
of patient care. The center is a byproduct of this atlas, away since the Third Edition. Their contributions were
and I am deeply appreciative of Bob's involvement and valued. Bill was my personal primary care physician.
support. Paul was an excellent head and neck pathologist. (I
The next expression of gratitude goes to the two remember when he examined 137 sections of a thyroid
transcriptionists: Lauri L. Hess, of Dr. Medina's office, gland for the primary tumor in a patient who had an
who, in dedicated fashion, transcribed my illegible incidental finding of metastatic papillary carcinoma of
inserts onto the disks, and Leslie Berry, a freelance the thyroid in a radical neck dissection, which was
transcriber par excellence, who, under considerable done for squamous cell carcinoma.)
pressure, completed the final draft. Dottie Kane, who Many thanks to all and to all Ave atque Vale.
did most of the transcribing for the Third Edition, helped
us with initial note-taking relative to this Edition of An JOHN M. LORE,JR.
Atlas of Head and Neck Surgery.
XIX
PREFACE
TO THE THIRD EDITION
Twenty-six years have elapsed since the first edition of tissue expanders that lead to interesting possibilities for
this atlas, and 15 years since the second edition. This reconstruction. The number of contributors has also
third edition has in some respects departed from the increased.
original concept of being simply an atlas. It contains The anatomic sectional x-ray plates in Chapter 1 have
much more information, with background material in a been related to the newer techniques of imaging. These
number of subjects, such as endocrine surgery of the reproductions can be of great aid in the correlation
head and neck and chemotherapy. This background with both CT scans and MRI.
material is most important if the surgeon is not to be The comments in the preface of the previous editions
relegated to the position of being solely a technician, are still valid for the most part. Progress has been made
which, sad to say, is occurring in a number of surgical in the training of head and neck oncologic surgeons by
disciplines. This is not to say that diagnosis and manage- the formation by the American Society for Head and
ment of problems such as endocrine diseases involving Neck Surgery and the Society of Head and Neck
the head and neck are to be performed solely and inde- Surgeons of a Joint Council for Approval of Advanced
pendently by the head and neck surgeon. The endocri- Training in Head and Neck Oncologic Surgery. This was
nologist, specialists in nuclear medicine, and imaging accomplished during 1976 to 1977 with the result being
and surgical pathologists are all necessary, integral mem- the formation of a carefully structured fellowship follow-
bers of the management team. It does mean, however, ing the completion of a residency in otolaryngology,
that the surgeon operating on, for example, the thyroid general surgery, or plastic surgery. This fellowship is the
gland and parathyroid glands must have more than just only one of its kind in head and neck surgery having a
a superficial knowledge of these endocrine organs. carefully structured evaluation system, site visits, and
The third edition has been expanded in a number of review by the executive councils of both head and neck
facets. The number of chapters has been increased surgical societies. A diploma is awarded by these two
from 21 to 23 with the addition and further clarification societies to those candidates who follow the rigid criteria
of Emergency Procedures (Chapter 2) and Base of the and successfully complete the fellowship. The fellow-
Skull Surgery (Chapter 23). Although both these new ship encompasses three phases: Phase [-basic surgical
chapters include some procedures that were covered in training involving 1 or 2 years; Phase II-residency in
the previous editions, this material has now been signifi- one of the aforementioned disciplines; and Phase [[[-
cantly revised and relegated to these two new chapters. the fellowship portion of 1 or 2 yeats. Details of this
Virtually every chapter has been enlarged with new fellowship have been previously reported (Lore, J.M.,
and other time-proven procedures, encompassing addi- Jr.: Head and neck oncologic training: Where we have
tional text and plates. The reader has simply to refer been and where we are going. Am. J. Surg. 142:504-505,
to the table of contents to see the increased amount 1981). Sixteen programs are now approved for this type
of material. To emphasize these additions, examples of training-IS in the United States and one in Canada.
include the following: expanded listing of complications The term head and neck oncology might be the better
following most procedures along with air embolism and term applied to this fellowship, since it involves not
blindness and pitfalls; adjuvant chemotherapy; carbon only surgical training but also a knowledge of radio-
dioxide laser surgery; myocutaneous and myomucosal therapy, chemotherapy, and, where applicable, the future
flaps; updated management of cleft lip and palate; of immunotherapy. This facet of head and neck oncol-
compression plates in the management of facial frac- ogy is only one of five categories involved in head and
tures; various types of neck dissections and their appli- neck surgery, with the others being congenitallesions,
cations; expansion of thyroid and parathyroid surgery; cosmetic surgery, and infectious disease. Likewise
rehabilitation following laryngectomy; expansion of involved in head and neck surgery is reconstructive
various reconstructive procedures related to the pharynx surgery, which relates to both head and neck oncologic
and esophagus; and updated vascular procedures and surgery and cosmetic surgery.
xxi
PREFACETO THE THIRD EDITION
Head and Neck Oncologic Surgery by a surgeon and team who perform only a few such
procedures a year. We as surgeons must seek the solu-
The concept of regional surgery appears to be well tion, rather than have nonmedical forces outline the
established. Stumbling blocks still remain, one of them solution for us. Yet with all this protectionism, general
being the cliche "fragmentation" of the parent disci- surgery has in fact been fragmented. Otolaryngologists
plines. Interestingly enough, it all depends on one's are going down the same course with the fear of frag-
biases as to whether the changes of a specific aspect of mentation. Hence, it appears that this concern only
a major discipline are termed "fragmentation" or "spe- enhances fragmentation rather than alleviating it. The
cialization." Regardless, it is the marketplace that sets basic problem is that the profession of medicine and
the pace-specifically, the number of patients available. its physicians and specialty societies react to obvious
To borrow the words of James Humphreys, M.D., "sur- changes that are in the making, rather than acting.
gery was fragmented when the surgeon left the barber Physicians must be the leaders in this change, rather
shop." The bottom line, however, is the search for than the followers. They must shape these changes,
excellence in patient care and physician training. These since they are the ones who know the problem and can
two aspects must not be compromised. best suggest and initiate the changes best suited to
The thrust of head and neck oncologic surgery is a excellency in patient care and physician training.
cooperative and joint venture encompassing all disci- Unless this is achieved, a number of legitimate con-
plines that can and should contribute to this endeavor. cerns that exist will become aggravated. Following is
The initial step has been made with the two head and a list of such concerns (from Lore, J.M., Jr.: Issues in
neck surgical societies setting up the guidelines, site community hospital or cancer center care of head and
evaluations, approval, and awarding of a diploma. The neck cancer patients. In Myers, E. N., Barofsky, I., and
next step is the formal implementation and recognition Yates, J. W. [eds.]: Rehabilitation and Treatment of Head
of these postresidency fellowships by the residency review and Neck Cancer. Washington, D.C., U.S. Department
committees and the specialty boards involved, an exam- of Health and Human Services, Public Health Service,
ination, and board recognition. Currently, it appears that National Institutes of Health [NIH Publication No.
this recognition could be achieved by "added qualifica- 86-2762], 1986, pp. 155-165).
tions" in head and neck oncology by the boards. These
"added qualifications" could then be affixed to the exist- 1. The occasional patient manager or "dabbler."
ing certificate of each board. It is hoped that this would 2. Loss of expertise and proficiency for even the well-
be accomplished by the three boards jointly agreeing trained physician.
on the same guidelines and examination. An excellent 3. Marginal and then inadequate treatment for head
example of this type of joint venture is the solution of and neck cancer patients.
education in hand surgery, which has been worked out 4. Loss of concentration of training clinical material.
by the two hand societies and the three boards of ortho- 5. Loss of any significant number of patients for evalu-
pedics, general surgery, and plastic surgery. George ation as to treatment methods, old and new.
Omer, after many years of dedicated work developing 6. Increased morbidity, mortality, and cost of medical
articles of agreement, is to be congratulated on its fruition. care.
I hope that a similar modus operandi will be achieved
in head and neck oncology. To achieve the solution to these problems, it appears
To date, this concept of added qualifications has that the three boards and the three residency review
been stalled by the concern of the three boards and the committees should pursue the concept of added qualifi-
three residency review committees as well as a number cations and recognize the additional training beyond
of practicing surgeons in the three disciplines. Their the residency years so necessary to achieve the desired
fears surround the worry of fragmentation of their excellency. In other words, support the fellowship con-
disciplines as well as the misgivings that such added cept and officially recognize the fellowship concept.
qualifications will lead to "a special club" of head and To aid in the solution to these problems in a recog-
neck oncologic surgeons and thus restrict their prac- nized manner, several additional steps are suggested.
tice. It must be remembered that there are only about
50,000 new patients each year with head and neck Training
cancer and that only approximately 35 to 75 new well-
trained head and neck oncologic surgeons are neces- 1. The American Board of Surgery should develop recog-
sary each year to maintain an adequate work force of nized training in basic surgery that might encom-
some 400 to 1000 head and neck oncologic surgeons to pass 2 years, with examination and certification for
manage this number of patients. Thus, we must mini- the trainee.
mize the number of "dabblers." No one who requires 2. The trainee then completes the standard residency
coronary artery bypass surgery would seek treatment in general surgery, otolaryngology, or plastic surgery.
PREFACETO THE THIRD EDITION
3. The trainee enrolls in a fellowship approved by the practical problem, which can best be summarized as
three boards. An alternate route could be a similarly follows: Just because a procedure can be technically
approved preceptorship. performed, that is not the indication to perform the
procedure. Advances in medicine and surgery require
Centers of Excellence the development and trial elfnew procedures. Neverthe-
less, these trials must be tempered to a certain degree
Centers of excellence in head and neck oncology can by past as well as present experience. Again, there
either be achieved in a university or community hospital is the "gray zone." Specifically, a number of techniques
center with adequate patient load, professional person- and procedures come to mind, for example, microvas-
nel, and support staff. The interested reader is referred cular surgery. These procedures have a selected place
to the aforementioned NIH publication as well as the in head and neck surgery relative to the following
author's Presidential Address at the annual meeting surgical problems:
of the American Society for Head and Neck Surgery
(Dabbling in head and neck oncology-A plea for 1. Augmentation of soft tissue with microvascular anas-
added qualifications. Arch. Otolaryngol. 113:1165-1168, tomosis, e.g., involving massive defects of the top of
1987). the scalp that cannot easily be reached by a myocu-
taneous flap (tissue expanders may have a signifi-
Controversial Items cant application in closing such defects).
2. Certain congenital lesions in which a transposed flap
There are a number of controversial items quite apart or myocutaneous flap is not indicated.
from the preceding that this author wishes to enumerate.
On the other hand, microvascular techniques do not
Correct and Exact Terminology appear routinely warranted in, for example, the
following:
In the evaluation of statistics relative to survival with
or without disease, a distinction should be made at the 1. Reconstruction of the mandible (associated with
onset of treatment as to whether a patient is "operable" ablative surgery) with an iliac bone graft and over-
and whether the lesion is "resectable" for cure or lying skin. The added time necessary to accomplish
palliation. Operability refers to whether the patient can these procedures must be taken into account when
safely undergo a major surgical procedure, whereas ablative surgery has already consumed a significant
resectability refers to whether a neoplasm can in fact number of hours of operating time. These microvas-
be totally removed by the surgeon. Nonresectability cular techniques on the other hand are applicable to
distinctly implies advanced disease and actually further massive defects resulting from trauma.
implies a stage beyond stage IV, namely a stage V 2. Reconstruction of the laryngopharynx with a free
disease. This concept has been previously suggested in jejunal graft or gastric pull-up. The latter procedure
a publication entitled Head and Neck Cancer; Proceed- or colon interposition is definitely indicated when a
ings of the First International Conference, The Society total esophagectomy is necessary.
of Head and Neck Surgeons (Chretien et aI., St. Louis,
C.V. Mosby, 1985, p. 434). Often, a much simpler reconstructive procedure does
Another point of contention are the words partial, in fact achieve the same end results related to the
subtotal, near total, and total in regard to the various reconstructive surgery. For example:
surgical procedures, especially thyroidectomy. Granted,
there are fine lines that separate these terms and defy 1. Mandibular resection that is reconstructed with the
total exactness, but regardless a more accurate designa- simple use of a bent Kirschner wire with tie wires.
tion of the surgical procedure is warranted as well as a 2. Total laryngectomy with total hypopharyngeal, oro-
close adherence to the exact implication of these terms. pharyngeal, and partial nasopharyngeal resection
The same goes for the terms referring to the various reconstructed with a myomucosal tongue flap with
types of neck dissections, e.g., radical neck dissection, dermal graft or pectoralis major flap with dermal
classical neck dissection, modified radical neck dissec- graft. These simpler forms of reconstructive sur-
tion, functional neck dissection, and conservation neck gery make total hypopharyngectomy a very feasible
dissection. and relatively easy procedure. These techniques are
believed to afford a much better chance of resecting
Indications for Surgical Procedure the entire structure, thus leading to improved survival
rates. Preserving a narrow strip of posterior hypo-
As for indications for surgery, my bone of contention is pharyngeal mucosa for reconstruction of the gullet
a fundamental philosophical and, for that matter, hardly seems justified.
PREFACETO THE THIRD EDITION
During the years taken to expand this atlas many his time, which he afforded me in the numerous prob-
friends have contributed-some as formal contributors, lems associated with surgical pathology. John Sheffer,
others in ways and at times unknown to them either M.D., and Ashok Koul, M.D., likewise were helpful in
in the sharing or exchanging of knowledge, others in this phase of surgical pathology, which is reflected in
technical help, and still others in the various phases of hidden ways in many of the surgical procedures. These
patient care, which in effect has had significant bearing three surgical pathologists are placed among the best
on this revision and expansion. in the field of head and neck surgical pathology, espe-
My wife, Chalis, has tolerated this third episode with cially related to frozen section, cytology, and recuts and
exceptional calm and has also helped in selective typing. searching through many surgical specimens. This is
For the third time, Bob Wabnitz has joined me as the specifically applicable not only to carcinoma hidden in
one and only medical artist and illustrator of all the those specimens that had a complete clinical response
editions of this atlas, demonstrating his skill par excel- to chemotherapy but also in thyroid specimens where
lence. Working with Bob is actually a pleasure. His skill there has been a search for primary tumors as well as
in his chosen profession as well as his knowledge of C-cell hyperplasia.
anatomy and surgical procedures is only surpassed by I am indebted to Martha Schmidt, M.D., the expert
his humor and cooperative attitude. I repeat, "without in nuclear medicine, especially that related to thyroid
him, the atlas would not be." scanning, as well as to Joseph Prezio, M.D., who is
For the bulk of the stenographic labor, I am deeply chairman of the Department of Nuclear Medicine at the
indebted to Dottie Kane, who like Bob Wabnitz simply School of Medicine, State University of New York at
smiled when I asked that more had to be done, and of Buffalo and Kwang Joo, M.D., who covers Sisters
course, done yesterday. Hospital. Gratitude is also extended to their technicians,
In the patient care arena, which is so important to who are most important in this particular phase of
a surgeon and the success of patient management, I diagnostic imaging.
extend gratitude in a special way to those primarily In a similar vein, Monica Spaulding, M.D., and
associated with the Sisters of Charity Hospital of Buffalo. Kandala Chary, M.D., our medical oncologists are a
This includes in administration Sister Mary Charles and great help in the management of patients with advanced
Sister Eileen, and more recently, Sister Angela and her neoplastic disease.
staff; in the operating room, Sister Thomasine, and after Included on our team is William Bukowski, M.D.,
her, Pat Archambault, R.N., and on the special head our internist, and David Casey, D.D.S., our maxillofacial
and neck nursing unit, the head nurse, Diane Smeeding, prosthodontist, who have contributed significantly to
R.N., and her staff of devoted and skilled nurses, prac- the team approach in the management of our patients.
tical nurses, aides and our floor secretary, Beth Powalski. Without the expert contribution of the Department
Along with patient care and many of the facets related of Diagnostic Radiology and Imaging under the direc-
to this endeavor, I am grateful to my office staff, espe- tion of David Rowland, M.D., and the person who I
cially Nan Sundquist, R.N. and Debbie Foschio, and pester the most, David Hayes, M.D., many of the surgi-
also to Joan Bilger, R.N., who is our nurse clinician at cal procedures would not have been brought to a suc-
the Erie County Medical Center. cessful conclusion.
I have picked the brains of many physicians, espe- When speaking of "brain picking," the participants
cially my former associate, Duck Kim, M.D., and my in our endocrine conferences contributed much to my
current associate in practice, Keun Lee, M.D. They understanding of thyroid and parathyroid disease. The
filled in for me while I struggled along with this revi- "regulars," Robert LaMantia, M.D., Donald Rachow,
sion. Also in this aspect I am grateful to the Pathology M.D., Jack Cukierman, M.D., and James Kanski, M.D.,
Department of Sisters Hospital. To Paul Milley, M.D., I are the stalwarts. However, I must say if there are
am deeply grateful for his contributions both in his differences of opinion in the endocrine chapter, these
section and in the chapter on endocrine surgery and for are my responsibility, not theirs. Contributing in this
xxv
ACKNOWLEDGEMENTS IN THE THIRD EDITION
same fashion is Richard Blanchard, M.D., who would involved in the operating room but also in the work-up
come to my office and spend hours reviewing cases of of patients who are suspected of having vascular prob-
patients with thyroid and parathyroid disease, thus ems associated particularly with neoplasia.
affording me a learning experience seldom available to In all of this, a chairman of a department at a medical
a surgeon. school needs the support of his chief, viz. Dean John
I am deeply indebted to Paul J. Davis, M.D., Professor Naughton, M.D., who is also Vice President of Clinical
of Medicine and Chief of Endocrinology at the State Affairs. This support is afforded in many ways-some
University of New York at Buffalo, for his review, sugges- not immediately recognized, but always appreciated.
tions and additions to the endocrinological aspects of In the publishing of a medical book with all its
the chapter on Endocrine Surgery. His help was most applications, decision making, changes, and additions,
important. the staff of the W.B. Saunders Company has been
Part of the learning experience is exemplified by understanding, helpful, and cooperative.
many of my residents and fellows who were involved When I try to remember all who have been an inspi-
in the exchange of knowledge and ideas-so well stated ration and at the same time contributed much to head
by John Henry Cardinal Newman in his treatise "The and neck surgery, George Sisson, M.D., Chairman,
Idea of a University." Department of Otolaryngology, Northwestern Medical
Several general surgeons have been significant contri- School, comes often to my mind. Many thanks George.
butors to this endeavor in many facets. Frank Marchetta, Although my mother has passed away during the
M.D., a head and neck surgeon par excellence, is respon- period between the second and third edition, she was
sible for many original contributions to head and neck and still is an inspiration, and once again I dedicated
surgery, as is Alfred Luhr, M.D., who operated with me this atlas to my Dad, who was the inspiration behind
on some two-team procedures. Joseph Anain, M.D., a this entire endeavor.
certified general vascular surgeon and co-author of
Chapter 22, was and is a significant collaborator in our JOHN M. LORE,JR.
head and neck vascular procedures. He is not only
PREFACE
TO THE SECOND EDITION
Eleven years have passed since the publication of the rather with certain autocratic and political forces who
first edition of this atlas. The convictions expressed attempt to control a major portion of surgery-the so-
in the preface of the first edition are reiterated here called "umbrella of general surgery," an antiquated and
and, in addition to them, the grave importance of the obsolete concept. However, it is the conviction that
cooperation of the various disciplines involved in sur- general surgery serves as the foundation and the special-
gery of the head and neck-both in the management of ties as the superstructure. Therefore it appears that the
patients and in the training of residents-is empha- concept of regional surgery of the head and neck will
sized. The combined efforts, contributions, cooperation be the end-result.
and sharing of patient problems and management must It was not so long ago that mutual scorn and distrust
be part of every aim in medicine and surgery, especially between several disciplines were so intense that any
in head and neck surgery in which there is so much exchange of ideas was tantamount to proclaimed heresy.
overlap among the various disciplines. Now, it is changing toward a mood of basic ecumeni-
Fortunately, during the past five years, a definite calism. The two head and neck societies, the Society of
cooperative trend among the prime disciplines of general Head and Neck Surgeons and the American Society for
surgery, otolaryngology, plastic and reconstructive sur- Head and Neck Surgery, have had a joint meeting in
gery and oral surgery has been developing. A number 1973-an event which might well have been unthink-
of various types of combined head and neck services at able a few years ago. Both societies have opened their
universities known to the author are participants in this memberships to capable surgeons in the various disci-
trend-the State University of New York at Buffalo, plines with similar standards and requirements. It is
Northwestern University, the University of Virginia and believed that this cooperation is leading to a more com-
Yale University-and others are surely in existence. plete exchange of ideas and that this can be achieved
However, even more important than these services is without the destruction of some of the good points of a
the emergence of a spirit of cooperation which has been competitive climate.
spread as seeds throughout the surgical community. As we proceed along the common pathway, a num-
Unfortunately, among the fruitful seeds are still the ber of questions are encountered. For example:
weeds which attempt to choke out the wheat because
of inherent parochialism, insecurity, jealousy and greed I. What does the field of head and neck surgery encom-
of power or whatever. Regardless of the type of arrange- pass?
ment of a combined venture, its success or failure depends 2. What is the need in quality and quantity of surgeons
not so much on signed documents as on a spirit of equal well trained in this field?
cooperation, understanding and trustworthiness. To insist 3. Should all residents in general surgery, otolaryngology
that a combined head and neck service lies solely within and plastic and reconstructive surgery be trained as
one discipline or is a subspecialty of general surgery is head and neck surgeons?
to lead the entire endeavor to certain doom. 4. What should this training entail?
Flexibility should be tolerated. For example, if need 5. Should there be a cooperative effort among the various
be, a multidiscipline head and neck service could be disciplines or boards, and if so, how best is this objec-
established within one department and thus achieve an tive achieved?
objective similar to that of a head and neck service 6. Should there be a certificate of competency issued
which involves more than one department. It is interest- by the various boards involved?
ing to note that during the past decade otolaryngology 7. Is some type of basic framework for residency training
has made significant strides and at present is believed desirable, or rather, should there be an individual solu-
by many to be the prime discipline in the complete train- tion to the training problem at the various large centers?
ing of the head and neck surgeon.
The problem does not appear to lie among the various These queries cannot be answered or solved over-
head and neck surgeons of different backgrounds but night, and yet a few responses are possible at present.
xxvii
PREFACETO THE SECOND EDITION
The field and training in head and neck surgery ing, which recently has been passed by both the
should have a broad base and be flexible. Individual American Board of Otolaryngology and the Conference
surgeons and groups of surgeons may have their own Committee on Graduate Education in Surgery, repre-
specific interests; there is no criticism of this action. senting the American Board of Surgery, the American
Nevertheless, it is important that the trainee develop College of Surgeons and the Council of Medical
a versatility in the changing world of medicine and Education of the American Medical Association. This
surgery, and hence it is believed that to have a lasting experimental program, applicable to certain selected
and firm foundation head and neck surgery should candidates with approval on an individual basis, exists
encompass four categories. at the State University of New York at Buffalo with
instruction in otolaryngology, general surgery and
1. Malignant and benign tumors. plastic surgery.
2. Reconstructive surgery. This concept was originally planned with the coop-
3. Congenital lesions. eration of John R. Paine, then Chairman of Department
4. Infectious surgical diseases. of Surgery. Glenn Leak played an integral part in the
original outline. With the untimely passing of both of
Thus it is quite obvious that such training crosses these friends, G. Worthington Schenk, Jr., now Chairman
and encompasses a number of specialties as we know of the Department of Surgery, gave his support and
them today. The old boundaries are no longer valid nor effort to achieve the final approval of this plan. The
. practical, and the new boundaries are far more flexible. program entails a five-year residency which, in step-
It must be emphasized that the various surgical spe- wise fashion, integrates in graded responsibility the basic
cialties, as well as general surgery, are not in existence aspects of otolaryngology and general surgery and the
for their own benefit but rather for the promotion of principles of plastic surgery. The years in training would
ultimate excellence in patient care. alternate between general surgery and otolaryngology,
Another point appears quite clear. There is not a need with plastic surgery training incorporated within general
for a large number of head and neck surgeons, but rather surgery, and additional reconstructive surgery within
a need for a moderate number (how many??) of well otolaryngology. Senior resident levels in both general
trained head and neck surgeons. For example, many of surgery and otolaryngology would be reached in the
the procedures outlined in this atlas are not intended final two years. Not all residents in either of these two
for the occasional operator with limited background, fields would be included in the program-only one or
but are intended as a reminder or review for those two at the most in anyone year. Nor is this program
well educated in the overall field of head and neck intended to be the only avenue of training in head and
surgery. For the latter audience, this atlas may be a neck surgery.
source of material in the ever-continuing field of medical In summary, the second edition of this atlas is
education. directed to the ecumenical approach in both patient
During the past six years as a program director, the care and resident training in the field of head and neck
author has realized a number of problems. First of all, surgery.
not all residents in either otolaryngology, general sur-
gery or plastic surgery need be, nor should be, trained REFERENCES
as head and neck surgeons per se. Secondly, a solid Baker. H. w.: Head and neck surgery: The pursuit of excellence.
block of time in general surgery (two to four years) Amer. J. Surg., 122:433-436, 1971.
followed by a solid block of time in otolaryngology Beahrs, O.H.: The next plateau. Amer. J. Surg. 114:483-485, 1967.
Bordley, J.E.: Problems facing otolaryngology today. Ann. Otol.,
(three years) has certain drawbacks. There is a psycho-
80:783,1971.
logical problem of a candidate being a senior resident Chase, R.A.: I'm against a rigid core curriculum prior to specialty
in general surgery and then starting at the bottom in training in plastic surgery. Plast. Reconslr. Surg., 46:384-388,
otolaryngology. This is no small matter. Another prob- 1970.
lem is that of graded training in both fields. It would Chase, R.A.: The "core knowledge" principle and erosion of specialty
barriers in surgical training. Ann. Surg., 171:987-990, 1970.
seem much easier to train a resident in physical diag- Eckert, C. (panel member): Panel discussion: Head and neck surgical
nosis in both specialties at an early stage in his career. training. Medical Society of the State of New York Convention,
The same comparison goes for the senior levels in February 1972.
which major surgery will be performed. It is at this Fitz-Hugh, G.S. (panel member): Panel discussion: Head and neck
stage of one's training that senior responsibility in both surgical training. Medical Society of the State of New York Con-
vention, February 1972.
specialties should be achieved, almost side by side, and James A.G.: Board to Death. Amer. J. Surg., 116:477-481, 1968.
certainly not separated by several years, as is the case Klopp, C.T.: Presidential address. Tenth annual meeting of Society of
in the solid block concepts. Head and Neck Surgeons. Amer. J. Surg., 108:451-455, 1964.
At any rate, it appears worthwhile to outline an inte- Lore J.M., Jr.: Editorial. Head and neck surgery. Surg. Gynec. Obstet.
grated step-wise plan for head and neck surgical train- 118:117-118, 1964.
PREFACE TO THE SECOND EDITION
Lore, J.M., Jr.: Future of head and neck surgery. A combined head and Sisson, G.A.: Otolaryngology, maxillofacial surgery embark on chal-
neck service: An ecumenical approach. Arch. Otolaryng. 87:659-664, lenging course. From the Department of Otolaryngology and Maxillo-
1968.
facial Surgery, Northwestern University, Evanstown, Illinois.
Lore, J.M., Jr.: Head and neck surgery: The problem. Arch Otolaryng. Southwick, H.W: Presidential address. Eleventh annual meeting of the
78.842-843, 1963. Society of Head and Neck Surgeons. Amer. J. Surg. 110:499-501,
Lore, J.M., Jr.: Head and neck surgery: Proposed head and neck 1965.
training program. Arch. Otolaryng. 79:112-113, 1964. Wullstein, H.L.: A concept for the future of otorhinolaryngology.
MacComb, WS.: Future of the head and neck cancer surgeon. Amer. Ann. 0101., 77:805-814, 1968.
J. Surg., 118:651-653, 1969.
McCormack, R.M. (panel member): Panel discussion: Head and neck
surgical training. Medical Society of the State of New York Con-
vention, February 1972.
ACKNOWLEDGEMENTS
IN THE SECOND EDITION
As with the first edition, my prime indebtedness is to Alfred Davis, of the Medical Illustration Service of the
my wife Chalis, who single-handedly transcribed the Veterans Administration Hospital, Buffalo, New York.
changes in the first edition and all the new text for this Although many of their photographs do not appear in
expanded second edition. In addition to the manuscript, the atlas, they served as a guide for the artwork and the
she typed the bibliography with some help in classifi- text.
cation from my daughters Margaret and Joan. Thanks also go to Joan R. Bilger, R.N., of the Edward
The medical artist and illustrator is the same skilled J. Meyer Memorial Hospital, for help in preparing some
and dedicated one-Robert Wabnitz. Without him, this of the photographic arrangements and supplying other
atlas simply would not be. His persistence in accuracy technical data; and to Bette Stinchfield, my secretary at
and consistent drive for detail is obvious in the artwork. the Buffalo General Hospital, for aid in obtaining some
To him, also, am I deeply indebted. of the reference material.
Again, I am thankful to my mother for her encour- During the time between editions, many new tech-
agement and prayers. niques and modifications have reached the surgical
For his revisions and statistics relative to temporal arena, a significant number of changes have occurred
bone resection, I am thankful to John S. Lewis, M.D. and friends have lent their ideas and methods; how-
I wish to thank William R. Nelson, M.D., who has ever, one bit of philosophical admonition comes to
contributed a new section on pre- and postoperative mind-primum non nocere-first, do no harm. I know
care. He has been kind enough to condense a much not the originator of this phrase, but to Julius Pomerantz,
larger treatise of this aspect of head and neck surgery, a senior fellow physician from Good Samaritan Hospital,
which he originally produced in booklet form. Suffern, New York, I am indebted. It is to my residents
Gratitude is extended to James Upson, M.D., for his who have also contributed unwittingly to this endeavor
review of the section on surgery of degenerative vas- that I often pass on this thought in management of our
cular lesions and to John Bozer, M.D., as a consultant patients.
internist.
A great debt of gratitude is due the entire staff of the
I also wish to thank a number of photographers at W.B. Saunders Company for their unparalleled aid in
the various hospitals affiliated with the Medical School publishing this atlas. Their continuing help both as
at the State University of New York at Buffalo. They are publisher and personal friends makes an otherwise
Sheldon Dukoff and Charles Jackson, of the Edward J. burdensome task possible; their skill in the art of
Meyer Memorial Hospital; Joseph A. Dommer and publication makes it all worthwhile.
Dough Hanes, of Buffalo General Hospital; and Harold
C. Baitz, Theodore A. Scott and their secretary, Mrs.
JOHN M. LORE,JR.
xxxi
PREFACE
TO THE FIRST EDITION
The purpose and intent of this atlas is to encompass in reconstructive procedure or prosthesis has been omitted
one volume related regional procedures of the head purely through a lack of versatility. Obstructive vascular
and neck. It is actually a plea for a broader training disease affecting the intracranial circulation amenable to
program to reunite with basic general surgery the many surgical correction may have its center of trouble located
surgical specialties and subspecialies concerned in this either in the chest or neck or in both regions. The selec-
area. Surely, there will always be a need for such tion of the best-suited vascular procedure is enhanced
specialty groups alone but there is an even greater need by a working knowledge of general vascular surgery.
for the amalgamation and dissemination of their skills With anticipation of the criticism that such a con-
in the total treatment of problems of the head and cept would lead to a Jack-of-all-trades, master of none,
neck. The foundation upon which this concept is built one need but read the history of surgery. Many of the
is the basic principle that general surgery is the mother great surgeons of yesterday were first primarily general
and nurturer of all major surgery. The specialties are surgeons; with this basic knowledge they contributed
the fruits. Hence, general surgery as well as the special- lasting ideas both in the specialty fields and in general
ties of otolaryngology, plastic and reconstructive sur- surgery. Billroth was the master of gastrectomy and at
gery, maxillofacial surgery, neurosurgery, oral surgery the same time contributed to cleft palate repair by frac-
and thoracic surgery are involved. Disease knows not turing the hamulus of the pterygoid process, thus releas-
the man-made barriers that have been set up. ing the tensor veli palatini muscle. King, a general sur-
Each field can contribute to the others. One has only geon, made a significant contribution in the treatment
to reflect on the importance of mirror laryngoscopy of bilateral abductor cord paralysis of the larynx. Such
before and after thyroid surgery. Adequate examination examples are not intended to detract from the innu-
of the larynx is felt to be a sine qua non for any sur- merable contributions by the surgical specialists which
geon who performs a thyroidectomy just as a sigmoi- in their own fields outnumber these examples. Nor
doscopy should be performed by the surgeon who is the concept that is portrayed in this atlas intended
performs the abdominoperineal resection. For anyone to lessen or minimize in any way the need for the
who does major surgery in the neck, extension of specialist. Actually it supports the specialist and re-
resectability must not be hampered by a lack of famil- emphasizes the natural evolution of surgery.
iarity with thoracic surgery when the disease has John Henry Cardinal Newman in his classic The ldea
extended below the clavicles. This principle holds true of a University advocated a liberal education which
for both malignant disease and trauma. Major surgery would serve as the background for future endeavors.
on the larynx sooner or later will involve the cervical He pointed out that any student able "to think and to
esophagus and basic knowledge of bowel surgery will reason and to compare and to discriminate and to ana-
enhance the armamentarium of the surgeon and aid lyze, who has refined his taste, and formed his judg-
in his decision when selecting the most suitable type ment will not indeed at once be a lawyer, or a pleader,
of esophageal reconstruction. Procedures on the nose, or an orator, or a statesman or a physician ... but he
except the very simplest, can be refined and well select- will be placed in that state of intellect in which he can
ed only when the surgeon borrows from the orolaryn- take up anyone of the sciences or callings ... with an
gologist, the plastic and reconstructive surgeon and the ease, a grade, a versatility, and a success to which
general tumor surgeon. another is a stranger." So in the art and science of
The skills and tricks of one field are often applicable surgery, a liberal basic foundation is necessary. From
to another field. In the definitive treatment of malignant such a foundation and broad outlook, the field of head
tumors the details of an elaborate reconstruction proce- and neck surgery seems to have drifted. Reunification
dure are of little avail unless the primary disease has of all groups interested in the field of surgical problems
been handled correctly with full knowledge of the natural related to the head and neck is the intention, hope and
history of the disease. By the same token, radical surgical aim of this Atlas of surgical techniques.
treatment is incomplete if a suitable and adaptable JOHN M. LORE, JR.
xxxiii
ACKNOWLEDGEMENTS
IN THE' FIRST EDITION
.-,.-
I am deeply grateful to my wife, Chalis, for her sacrifice, been of considerable aid and have been a guide to
patience and able skill as an executive secretary. She personal experiences in this problem. Again to Alexander
has typed and retyped the manuscript under consid- Conte my thanks for supplying original photographs of
erable duress. his technique of cervical esophageal reconstruction.
My children, John III, Peter, Margaret and Joan, have During the two years of pressure to complete this
all felt the pressures and sacrifices resulting from the work, my surgical partner, Louis J. Wagner, M.D., has
loss of many happy hours together which have been unselfishly covered our practice to allow me the neces-
missed because of the time consumed in the prepara- sary undisturbed time. From him, I have also learned a
tion of this work. number of operative steps which have been successful
I am indebted to my mother for her encouragement in the solution of some technical problems.
and prayers. When this atlas was in its infancy, it was only through
Professionally, my indebtedness extends from books, the cooperation of John L. Madden and the administra-
journals and other collections of the surgical literature, tion of Saint Clare's Hospital, specifically the late Mother
through various opinions voiced at surgical meetings M. Alice, O.S.F, and her successor Sister M. Columcille,
(the authors of which I regret to say have slipped my O.S.F., that actual work began. At Saint Clare's Hospital
memory), to my recent and past teachers and associates. I met Robert Wabnitz, the sole illustrator of this volume,
All education is a compendium, and even more so sur- who since then has spent many hours in the operating
gical education. Hence many of the steps in this atlas room making sketches and at the drawing board com-
are the ideas, thoughts and work of surgeons under pleting the art work. Without his skills as an artist and
whom I have trained or worked. I owe much to my father his knowledge of anatomy, the illustrations would have
and to John J. Conley who were my early teachers. A been impossible. Both he and I are grateful to the Univer-
great many of the surgical procedures and techniques sity of Rochester where he now heads the Medical
concerned with the treatment of tumors of the head Illustration Department for allowing him time to com-
and neck either originated with or were developed by plete this work. If it were not for the skill in its repro-
Hayes Martin and other surgeons on the Head and Neck duction, the best of art work would be for naught. The
Service of Memorial Hospital. In the basic background W.B. Saunders Company has excellently completed this
of general surgery which forms an integral part of this endeavor. I am deeply indebted to the staff of the
atlas, I owe a debt of great magnitude to John L. Madden, Company for their advice, suggestions and patience. I
Director of Surgery at Saint Clare's Hospital. am grateful to my colleague William J. McCann, M.D.,
To make the decision after my father's death to con- for initiating this most fortunate association with the
tinue surgical training in general surgery after comple- Saunders Company.
tion of the first phase in otolaryngology presented a I wish also to acknowledge the cooperation of the
crisis. Two men convinced me and gave me advice of Administrator and Assistant Administrator of Good
immeasurable value. They are Michael Deddish, M.D., Samaritan Hospital, Sister Miriam Thomas and Sister
and Alexander Conte, M.D. Without them I never would Joseph Rita, as well as the Operating Room Supervisor,
have completed my surgical training and never would Miss Martha Henry, and the entire nursing staff for their
have come to realize the benefits of a multifaceted help and vision in the treatment and care of the patients
surgical background. with many of these operative and postoperative problems.
John S. Lewis, M.D., who is mainly responsible for I would be remiss if I did not add the aid of the admin-
the present technique of temporal bone resection in istration and staff of Tuxedo Memorial Hospital.
cancer of the middle ear, has kindly contributed to that My thanks to Anthony Paul for drawing many of the
section of the atlas. lead lines and some of the labels and to David Hastings
Edward Scanlon, M.D., has been kind in lending his for his care in photographing the x-rays in Chapter I.
original experiences and thoughts in colon transplants
for reconstruction of the esophagus. These ideas have JOHNM. LORE,JR.
xxxv
CONTENTS
The Role of Imaging in the Head and Neck 34 Other Untoward Events Associated With Endotracheal
Anesthesia 66
Detection of Perineural Disease at the Skull Base 35
Oblique Imaging of the Oral Pharynx to Avoid Dental BLINDNESS AND OPHTHALMIC COMPLICATIONS
Artifact 36 OF SURGERY OF THE HEAD AND NECK ....•................. 66
Multiplanar Techniques to Evaluate Tumor Location Daniel P. Schaefer and Arthur f. Schaefer
and Margins 37 Blindness ...............................................•..•.......................... 66
Three-Dimensional CT of the Inner Ear .............•.................. 39
xxxvii
CONTENTS
Basic Principles Relative to Bone and Cartilage Abandonment of the Patient With Neck Metastasis
Grafts and Implants 107 From an Undetectable Primary Tumor 128
Rib, Iliac, and Costochondral Grafts 107 Enucleation of Tumors of the Major Salivary
Glands and Thyroid Gland 128
Iliac Bone Graft-"Trap Door Type" 110
Treating a Patient With Antibiotics for an
Auricular Cartilage Graft 110 Extended Period of Time Without a Biopsy 128
Sural Nerve Grafts ......................•..................•....•........ 112 The Place for Chemotherapy in Management
Skin Incision ...........................................................•.......... 112 of Squamous Cell Carcinoma of the Head and Neck 128
Nonabsorbable Sutures for Mucosal Repair 112 Monica B. Spaulding
Preoperative and Postoperative Care 114 Recurrent or Metastatic Head and Neck Cancer .. 129
William R. Nelson and R. Lee Jennings Preoperative Chemotherapy, Uncompromised Surgery,
Preoperative Care .....................................•.•............... 114 and Selective Radiotherapy in the Management
of Advanced Squamous Cell Carcinoma of the
Postoperative Care 116
Head and Neck 132
John M. Lore, Jr., Sol Kaufman, Nan Sundquist,
and Kandala Chary
CONTENTS
Septal Flap for External Nasal Defect 334 Trigeminal Neuralgia (Tic Douloureux) 392
Laterally Based Chest Flap ...........................•...................... 438 Unilateral Cleft Lip Repair 494
Mutter (1842) Nape of Neck Flap 440 Triangular Flap Cleft Lip Repair: Tennison-Randall
Posterior Scapula Flap .........................................•.............. 442 Technique 496
Forehead Flap (Temporal Flap) ..............................•............ 444 Rotation Advancement Cleft Lip Repair 498
Reconstruction of Cheek with Forehead Flap .........•.•......... 446 Bilateral Cleft Lip Repair 500
Midline Forehead Flap ...........................................•.•.•....... 452 Basic Deformities of Cleft Lip (Bilateral Complete) 500
Fat Flip Flap ..............................•...........................•............ 454 Repair of Complete Bilateral Cleft Lip
(Straight-Line Closure) 502
Repair of Incomplete Bilateral Cleft Lip (Rotation-
• THE LIPS 458 Advancement Technique) 504
Cleft Palate ....................................................•................... 506
Lip Excision and Reconstruction 458
Types of Cleft Palate Deformities ...............•................. 506
Planing of Lip .................................•.•.......................... 458
Reconstructive Goals ................................•...•.............. 506
Shield Excision of Lower Lip .............•...•...................... 458
Optimal Age for Operation 506
Cupid's Bow 460
Repair of Complete Cleft of Secondary Palate 506
Elliptical Excision of Benign Lip Lesion 460
Repair of Incomplete Cleft of Secondary Palate 512
Distortion of Mouth Corrected by Z-Plasty 460
Repair of Complete Unilateral Cleft Palate 514
Excision of Large Benign Lesions of Upper Lip
Pharyngeal Flap in Cleft Palate Repair 516
with Nasolabial Flap 460
Pharyngeal Flap for Velopharyngeallnsufficiency 517
Repair of Large Vermilion Defects .............................•........ 462
Abbe-Estlander Lip Operation 464
Correction of Rounded Commissure of Lips 467
11 PERIORBITAL REGION 523
Plication of the Orbicularis Oris Muscle to Repair
Partial Paralysisof the Lower Lip 468 Anatomy 523
Modifications of Abbe-Estlander Lip Operation 469 Repair of Lids and Conjunctiva .........................•................ 523
Reconstruction of Center Lower Lip Defect 469 Wounds of the Conjunctiva ..........................•............. 524
Reconstruction of Upper Lip Defect 470 Repair of Lid Lacerations 524
Correction of Rounded Commissure of Lips 470 Management of Disruption of the Canaliculi 524
Reconstruction of Large Defects of Upper Lip 472 Reconstruction of Lids ................................................•....... 524
Reconstruction of Upper Lip with Cheek Flap 472 Reconstruction of Lower Lid 526
Fan Flap Reconstruction for Large Defects Resection of Large Basal Cell Carcinoma of Lower
of Upper Lip 474 Lid With Reconstruction Using Lateral Cheek
Excision and Repair of Large Lesions of Upper Lip 476 Flap 532
Gillies' Technique 476 Bridge Flap Repair of Large Upper Lid Defects,
Cutler-Beard Technique 542
Repair of Large Defects of Upper Lip 478
Resection of Large Basal Cell Carcinoma Involving
Bitemporal ("Visor") Flap for Large Upper Lip
Both Lids and Nose 544
and Cheek Defects 480
Excision of Superficial Basal Carcinoma in Region
Resection of Lower Lip with Bernard Reconstruction 482 of Lateral Canthus of Lower Lid 546
Reconstruction of the Lower Lip 484 Excision of Benign Lesion of Upper Lid 548
Reconstruction of the Lower Lip after the Reconstruction of Superficial Horizontal Defect
Extirpation of a Lip Cancer ..........................•........... 484 of Portion of Lower Lid 548
Reconstruction of the Upper Lip after an Eyelash Reconstruction ...........•.•.................................. 550
Operation of Lip Cancer 485
Eyebrow Reconstruction 550
Reconstruction of the Lower Lip from the Cheeks
after an Operation of a Lip 486 Excision of Lesions at the Medial Canthus 552
Cancer with the Resection of a Part of the Medial Canthoplasty and Repair of Related Injuries 554
Lower Jaw 486 Dacryocystorhinostomy 558
Correction of Scar Contracture of the Lids
and Ectropion 560
10 ClEFT LIP AND PALATE 493 Tarsorrhaphy 562
ROBERTJ. PERRYand JOHN M. LORE,JR. Lateral Permanent Tarsorrhaphy or Canthorrhaphy 562
Cleft Lip .................................................................•........... 493 Temporary Tarsorrhaphy 562
Types of Cleft Lip Deformities 493 Graft for Defect of Infraorbital Rim 564
Normal Anatomy 493 Decompression of the Orbit for Exophthalmos 566
CONTENTS
Resection of Benign Tumor of Lacrimal Gland 569 Repair of Large Mandibular Defects Utilizing
the DBDB Plate 618
Resection of Adenoid Cystic Carcinoma of the
Lacrimal Gland 570 Open Reduction of Depressed Fracture of Zygomatic
Arch With or Without Fracture of Body of Zygoma
(Gillies' Technique) 620
Open Reduction of Depressed Fracture of Zygoma
12 THE EAR 573 and Portion of Maxilla 622
Otoplasty 573 Early Reduction ........................•.•................................ 622
Cartilage Incision Technique ............................••......... 573 Late Reduction 622
Mattress Suture Technique (Correction of Early Reduction of Depressed Comminuted
Prominent or Deformed Ears) 576 Fracture of Anterior Wall of Maxilla 624
Surgical Treatment of Hematoma of the Auricle: Intraosseous Wiring for Facial Fractures 626
"Cauliflower Ear" 580 "Tent Peg" Method of Reduction and Fixation
Z-Plasty for Stenosis of External Auditory Canal 582 of Facial Bone Fractures 628
Excision of Small Malignant Tumor of Cartilaginous Open Reduction of Complete Fracture of Upper
Portion of External Auditory Canal · 584 Dental Arch of Maxilla (Le Fort I or Guerin) 630
Excision of Malignant Tumors of the Auricle 586 Suspensory Wire Technique 630
Excision of Hemangioma of the Face Involving Lobule Direct Intraosseous Wiring Technique 630
of the Ear 586 Internal Fixation of Fracture Through Middle Third
En Bloc Resection of the External Auditory Bony Canal 588 of Maxilla (Le Fort II or Pyramidal Fracture) 632
Total Resection of the Auricle With a Portion of the Open Reduction of Fractures Through Glabella, Orbit,
External Auditory Canal, Parotidectomy, and Zygomatic Arch (Le Fort III or Craniofacial
and Radical Neck Dissection for Recurrent Dysjunction) 634
Malignant Melanoma 590 Techniques of the Use of Miniplates in Le Fort I, II,
Technique 590 and III Fractures 636
Posterior Approach to the 7th (Facial) Nerve 590 Le Fort I-Basic ..................................................•........ 636
Final Pathology Diagnosis 592 Le Fort I-Complicated ................................•.......•...... 636
Le Fort II ..................................................•.................. 636
Le Fort III 637
13 FRACTURES OF FACIAL BONES 595 Internal Fixation of Fractured Hard Palate 638
JOHN M. LORE,JR.and DOUGLASW. KLaTCH Fractures Involving the Frontal Sinus 638
Basic Principles 595
Fractures of Floor of Orbit 640
Reduction of Fractured Nose 596
External Traction for Depressed Facial Fracture 646
Depression of Right Nasal Bone with Lateral Management of Zygomatic (Malar) Fractures 648
Displacement of Left Nasal Bone 597
Douglas W. Klotch
Depression of Nasal (Frontal) Process of Right Repair of Simple Fractures 649
Maxilla 598
Repair of Complex Fractures 650
Fractures of Mandible-Outline ..............................•.......... 599
Fracture of Condylar Process-Outline ..............•................ 600
Reconstruction of the Mandible Using Plates Buccal Wall lesions: Benign, Premalignant,
With or Without Free Autogenous and Malignant Squamous Cell Carcinoma 742
Nonvascularized Bone Grafts 675
Plan for Resection of Premalignant and Malignant
Resection and Second-Stage Reconstruction lesions of the Buccal Wall 744
of Anterior Portion of Mandible Using Iliac
Radical Resection of Buccal Wall With
Bone Graft 678
Mandibulectomy Associated With
Resection and Reconstruction of Major Portion Oropha~ngeal and Retromolar Trigone
of Body of Mandible With Bent Steinmann Pin Invasion: Advanced Squamous Cell Carcinoma 745
and Tie Wires and Forehead Flap 682
Reconstruction of Buccal Wall lesions 746
~=~ ~ Resection of Carcinoma of the Retromolar
Marginal Resection of Mandible, Partial Trigone and the Buccal Wall 747
Glossectomy, and Radical Neck Dissection for
Excisions of lesions of Soft and Hard Palate 752
Carcinoma of the Floor of the Mouth 688
Resection of Extensive Benign Minor Saliva~
Gland Tumors of the Soft Palate 760
Resection of Carcinoma of Soft Palate 764
t5 ORAL CAVITY AND OROPHARYNX 698
Excision of Ranula 766
Excision of Dysplasia (leukoplakia) and/or
Resection of Hemangioma and Neurofibroma
E~throplasia (Erythroplakia) of Tongue and
of Tongue 768
Buccal Mucous Membrane 698
Tonsillectomy and Adenoidectomy 770
Excision of Carcinoma In Situ or Small limited
Carcinoma of Tongue 700 Adenoidectomy 770
Excision of Small Midline Cancer of Anterior Third Salivary Duct Calculi 773
of Tongue 702 Repair of laceration of the Stensen Duct (Parotid) 773
Median labiomandibular Glossotomy (Trotter Reconstruction and Reimplantation of Stensen's Duct
Approach to Base of Tongue, Pha~nx, in the Buccal Wall 774
and Baseof Skull) 704 Pierre Robin Syndrome 774
Resection of Stage T1 Carcinoma of the Midline
of the Floor of the Mouth 708
Inlay Graft to Floor of Mouth for Carcinoma 710 16 THE NECK 780
Resection of Malignant Tumors of the Oral Cavity JESUSE. MEDINA and JOHN M. LORE,JR.
and Oropha~nx With Extension Above Into the Cervical lymph Nodes 780
Nasopha~nx and Below to the Hypopha~nx
With Cervical Metastasis With or Without Spinal Accesso~ Nerve 781
Involvement of the Mandible Including the Cervical lymph Node Metastatic Guide 781
Parapha~ngeal Space 714 Classification 786
Approaches 714 Radical Neck Dissection 788
Bone Involvement: Mandible ...........................•..•....... 716 Evaluation of Cervical lymphadenopathy
Guidelines 716 on Computed Tomography and Magnetic
Resection for Carcinoma of Tonsil, Soft Palate, Resonance Imaging 797
or Baseof Tongue by Mandibulotomy and Modifications of Radical Neck Dissections 797
Reconstruction 720 Parotid Extension of Radical Neck Dissection
Resection of Hemimandible, lateral Oropharyngeal (High Exposure of Internal Jugular Vein
Wall, and Portion of Soft Palate and and Internal Carotid Artery) 798
Hemiglossectomy With Reconstruction Modified Radical Neck Dissection Preserving
Using a Forehead Flap Versus Pectoralis Major Flap 724 the Spinal Accesso~ Nerve (Type I) 802
Combined Radical Neck Dissection, Partial Incision Modifications of Radical Neck Dissection 804
Glossectomy or Hemiglossectomy, and
Modified Radical Neck Dissection Preserving
Hemimandibulectomy Including Retromolar
the Spinal Accesso~ Nerve, the Internal Jugular
Trigone 726
Vein, and the Sternocleidomastoid Muscle
Base of Tongue 732 (Type III) 808
Anatomy of the Tongue 732 Selective Neck Dissections 811
Resection of Baseof Tongue 732 Extended Neck Dissections 814
Approaches to Base of Tongue 733 Resection of lower Margin of Mandible Combined
Resection of Baseof Tongue via Midline with Radical Neck Dissection 814
Mandibulotomy (Mandibular Swing) 734 Posterior Neck Dissection ...........................................•....... 818
Midline Mandibulotomy (Mandibular Swing) 736 Keun Lee
Resection of Baseof Tongue and Total Glossectomy 738 Excision of Thyroglossal Cyst and Sinus 824
Resection of lesions of the Buccal Wall 742 Resection of Submandibular Saliva~ Gland for Benign
Disease 828
CONTENTS
Section 3: Pearls and Pitfalls Regarding Stripping (De-Epithelialization) of a Vocal Cord 1074
Parathyroid Imaging 982 Endoscopic Removal of Congenital Cyst of Ventricle
Indications for Surgery in Primary in Newborn (Internal Laryngocele) 1076
Hyperparathyroidism 984 CO2 Laser in Laryngeal and Endobronchial Surgery 1077
Chemical Diagnosis of Hyperparathyroidism 984 Microlaryngoscopy Using the CO2 Laser 1077
CONTENTS
Simultaneous Radical Neck Dissection 1120 Free Skin Graft Over Tantalum Gauze 1196
Total Laryngectomy 1126 Resection for Cancer of the Cervical Esophagus 1199
Technique of Construction of Large Tracheal Stoma 1134 Gastric Pull-Up With Extrathoracic Esophagectomy 1200
FIGURE1-1
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-2
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-3
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1--4
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE1-4 Continued
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-5
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-6
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-7
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
The single-plane CT scans in Figures 1-8 to 1-10 and the Frontal Coronal Section in the Region of
three-dimensional reconstructed CT scans in Figures 1-11 the Second Molar Teeth (Fig. 1-8)
to 1-17 were prepared by David F. Hayes, MD, chairman
of the Department of Diagnostic Imaging at Sisters of
Compare this CT scan with the radiograph in Figure 1-5.
Charity Hospital, Buffalo, New York.
The magnetic resonance (MR) images in Figures b. Anterior ethmoidal sinus
1-18 to 1-24 are courtesy of Buffalo MRI, Buffalo, New c. Perpendicular plate of ethmoid
York (J. E. Gardner, AAS, RT, MR, chief technologist). d. Middle turbinate
The MR images in Figures 1-25 to 1-40 were prepared e. Inferior turbinate
by Scott Cholewinski, MD, Director of Magnetic Reso- f. Vomer bone
nance Imaging at Sisters of Charity Hospital, Buffalo, g. Maxillary sinus
New York. k. Mandible
n. Tongue
FIGURE 1-8
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-9
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-10
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-11
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-12
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-13
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-14
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-15
SECTIONAl RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-16
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-17
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Signal Intensity
Calcification,
Tl-Weighted T2-Weighted Overall Fibrosis, or Bone
Thmor Image Image Contour Appearance Fragments
FromSam PM, et al: Thmorsof the parapharyngeal space and upper neck: MRimagingcharacteristics.Radiologyt64:823, 1987.
SECTIONAl RADIOGRAPHIC ANATOMY AND SCANNING
Masseter
muscle
Medial
pterygoid
muscle
Facial vein
FIGURE 1-18
Thyroarytenoideus Sternocleidomastoid
muscle muscle Hypopharynx
Anterior
commissure
Aryepiglottic
Vocal cord
fold
Posterior
Vertebral
commissure
artery
Levator
scapulae
Pyriform
muscle
sinus
Mandible
Lingual
tonsil Maxillary
sinus
Oropharynx
Torus
tubarius
Medulla
oblongata
Internal Internal
jugular carotid
vein artery
FIGURE 1-22 Lateral Internal
pterygoid carotid
muscle artery
FIGURE 1-23
Retropharyngeal Lateral
space Odontoid Inferior pterygoid
Nasopharynx turbinate muscle
Torus
Tongue Masseter
tubarius
muscle
Fossa of
Rosenmuller Mandible
Vallecula
Internal
carotid Mastoid
artery air cells
Mandible
Larynx
Tongue
Uvula
Parotid gland
Palatine
tonsil
Facial vein
Parotid gland
External
carotid
Internal
artery
jugular vein
Longus
capitis Facial Masseter Odontoid
Jugular Internal Faucial muscle vein muscle process
vein carotid artery tonsil FIGURE 1-27
FIGURE 1-26
Vallecula
Submandibular
gland
Internal jugular
vein
Submandibular
gland
External
jugular vein
Internal
carotid artery
Anterior True
Sternocleidomastoid
commissure vocal cord
Thyroid gland Trachea muscle
Arytenoid
cartilage
Common
/-~
'fJI
.....
~.'~."
.
carotid artery
I ,.~.\..
' ..
Internal
"
•
. (. ", \-.~,':.-
.·~.....rr.;•.'. .
. jugular vein
" ....•
" '. '.''''''' ",' Esophagus
..... ~~. -- ".,.-'L .. _
Internal Sternocleidomastoid
Common Vertebral
jugular vein muscle
carotid artery artery
FIGURE 1-32
FIGURE 1-33
SECTIONAl RADIOGRAPHIC ANATOMY AND SCANNING
Ethmoidal
Medial sinus
pterygoid Optic nerve
muscle
Medial rectus
Internal muscle
carotid artery Maxillary sinus
Middle nasal
Levator
turbinate
scapulae
Inferior nasal
muscle
turbinate
Jugular vein
Inferior Tongue
Mandible Submandibular rectus muscle
gland FIGURE 1-37
FIGURE 1-36
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Internal jugular
vein
Parotid gland
Odontoid
process
Longus capitis
muscle
Detection of Perineural Disease There are several findings on CT that suggest perineural
at the Skull Base (Fig. 1-41) spread, including destruction of neural foramina, loss
of the normal fat pad adjacent to a foramen, excessive
In head and neck cancer, malignant cells may spread enhancement within the neural foramina, and excessive
along the neural sheath. Perineural spread may be abnormal enhancement or widening of the cavernous
asymptomatic, thus the importance of its detection. sinus, pterygopalatine fossa, or Meckel's cave.
The cranial nerves most often involved in perineural
tumor spread are the trigeminal and facial nerves.
The first division of the trigeminal nerve (oph- A An axialcontrast medium-enhanced CT scan shows
thalmic) with potential tumor carrying from the lacrimal tumor in the left pterygopalatine fossa (arrow). Note
gland, eyelid, and conjunctiva passes through the supe- the normal fat pad in the contralateral side (asterisk).
rior orbital fissure. The second division (maxillary) with
connections to the face, palate, and maxillary sinus B Coronal contrast medium-enhanced CT shows
traverses the pterygopalatine fossa and the foramen intracranial tumor extension into the left Meckel's cave
rotundum. The third division (mandibular), which can and cavernous sinus (arrows). Again note the normal
carry tumor from the lower face, oral cavity, and sub- fat pad in the contralateral side (asterisk).
mandibular and parotid glands passes through the fora-
men ovale. The facial nerve passes through the stylo-
mastoid foramen.
A B
FIGURE 1-41
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
A B
c D
FIGURE 1-42
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Multiplanar Techniques to
Evaluate Tumor Location and A Axial section shows a mass in the medial canthus
Margins (Fig. 1-43) region of the left eye (A) at the level of the inferior
rectus muscle (E). F, Inferior orbital fissure.
Thin sections and rapid helical scanning enable improved
B An enlarged left nasal lacrimal duct (arrow) is
localization of tumor margins and may give clues to
their origin. evident at the level of the petrous carotid arteries (G).
A B
FIGURE 1-43
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
E
FIGURE 1--43 Continued
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
B
FIGURE 1--44
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
A
FIGURE 1-45
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
B c
FIGURE 1--45 Continued
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
A B
c D
FIGURE 1--46
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Venous malformations of the face are frequently treated B Three-dimensional volume-rendered CT venogram
with sclerotherapy and percutaneous embolization. CT has increased transparency allowing views of vascular
venography helps the interventionist target these lesions. detail and bony landmarks. A, Zygoma; B, facial vein;
C, superficial temporal artery; D, external jugular vein
A Three-dimensional volume rendering of the skin (thin arrows: embolic material from previous treatment;
helps target the lesion (arrows) by providing enough thick arrow: residual venous malformation).
A B
FIGURE 1-47
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
B c
FIGURE 1--48
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Three-Dimensional CT Vascular
A This three-dimensional volume rendering of a large
Tumor Relationship (Fig. 1-49) squamous cell carcinoma shows neck vessels and bone.
A, Left common carotid artery; B, left internal carotid
Rapidly acquired contrast medium-enhanced CT can
artery; C, left external carotid artery; D, tumor; E,
be used for mapping tumor vessel relationships both in
innominate artery; F, right subclavian artery.
the neck and the brain. The following images show a
large neck mass with its relationship to the carotid
B A three-dimensional volume-rendered CT shows
arteries and other soft tissues. Any visible structure in
vessels and tumor on a soft tissue cut-away view. A,
the neck can be modeled in this way preoperatively,
Left common carotid artery; B, left internal carotid
from a single scan. artery; C, left external carotid artery' D tumor' G
thyroid gland; H, trachea. '" ,
A
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
A B
c
FIGURE 1-50
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
It is our hope that the detailed CT scans provided EXAMPLES OF MRI IN THE
here will begin to inform you of the potential that this SUPERIOR MEDIASTINUM
rapidly evolving technology has to offer the head and ______________ John M. Lore, Jr.
neck surgeon. From detailed anatomic assessment to
three-dimensional modeling of tumor/vessel relation- The following MR images (Figs. 1-51 to 1-57) of the
ships, advances in imaging technology will continue to mediastinum demonstrate the importance of viewing
provide maximum preoperative and perhaps even intra- this area of anatomy with MRI performed at an up-to-
operative information that will help the surgeon obtain date facility. The sagittal views are extremely important
the best possible outcome for each patient. to localize the mediastinal thyroid as to whether it is
anterior or posterior and its specific relationship to the
great vessels. This latter relationship is likewise con-
firmed with the usual axial and coronal views.
FIGURE 1-51 Sagittal MRI views of large cervical thyroid goiter with extension to the aortic arch. However, the
extension into the mediastinum appears to be minimal because of the high location of the aortic arch. AA,aortic arch;
DA, descending aorta; T, trachea; LMB,left mainstream bronchus; G, goiter. (From Lore JM Jr, Martin PT,Koch R], et al:
Approaches to the superior mediastinum for the head and neck surgeon: Operative techniques. Otolaryngol Head Neck
Surg 5:73-83, 1994.)
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-52 MRI sagittal and axial views show residual mediastinal tissue after previous surgery. Patient's chief
complaint was pain. Residual mediastinal tissue was removed via the supraclavicular route with transection of the
intraclavicular ligament and sternocleidomastoid and strap muscles. G, residual thyroid tissue; T, trachea; E, esophagus.
(From Lore JM Jr, Martin PT, Koch R], et al: Approaches to the superior mediastinum for the head and neck surgeon:
Operative techniques. Otolaryngol Head Neck Surg 5:73-83, 1994.)
FIGURE 1-53 Axial (T scans showing complete encirclement of the trachea in a patient with a multinodular
adenomatous goiter with marked deviation of trachea by mediastinal extension. The goiter was removed by
transclavicular resection. (From Lore JM Jr, Martin PT, Koch Rj, et al: Approaches to the superior mediastinum for the
head and neck surgeon: Operative techniques. Otolaryngol Head Neck Surg 5:73-83, 1994.)
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-54 Coronal and axial MRI views showing massive cervical goiter extending into the mediastinum with
compression of the trachea. In the axial view, extension into the posterior mediastinum behind the aortic arch is well
visualized. The goiter was removed by transclavicular resection. G, goiter; T, trachea; lA, innominate artery; AA, arch of
aorta. (From Lore JM jr, Martin PT, Koch Rj, et al: Approaches to the superior mediastinum for the head and neck
surgeon: Operative techniques. Otolaryngol Head Neck Surg 5:73-83, 1994.)
FIGURE 1-55 Compression of trachea and extension into posterior mediastinum (same patient as in Fig. 1-54). Close
relationship to all of the major vessels is seen with goiter extending from hyoid bone inferior and posterior to aortic
arch. It was removed by left transclavicular resection. HB, hyoid bone; AA, arch of aorta; LMB, left mainstream
bronchus; CH, chamber of heart; T, trachea; lA, innominate artery; CC, common carotid artery; IJV,left internal jugular
vein. (From Lore JM Jr, Martin PT, Koch Rj, et al: Approaches to the superior mediastinum for the head and neck
surgeon: Operative techniques. Otolaryngol Head Neck Surg 5:73-83, 1994.)
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-56 Sagittal MRI view shows a right posterior mediastinal adenomatous goiter removed by transclavicular
resection. The trachea is displaced anteriorly. The inferior extension of the goiter is close to the azygos vein. The
recurrent laryngeal nerve and the inferior thyroid artery cross over the anterior aspect of the goiter (G). (From Lore JM
Jr, Martin PT, Koch Rj, et al: Approaches to the superior mediastinum for the head and neck surgeon: Operative
techniques. Otolaryngol Head Neck Surg 5:73-83, 1994.)
FIGURE 1-57 Axial MRI view of same patient as in Figure 1-56 shows posterior mediastinal goiter behind the trachea
and juxtaposed to the vertebral bodies. G, goiter; L, left side. (From Lore JM Jr, Martin PT, Koch R], et al: Approaches
to the superior mediastinum for the head and neck surgeon: Operative techniques. Otolaryngol Head Neck Surg 5:
73-83, 1994.)
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-58
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-59
FIGURE 1-60
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-61
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
"These are typical costs. PETand SPECTare whole body imagingtechniques. The MRI and CT costs are per body region. Whole body MRI
or CT costs are comparable to those from whole body PET.
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
cellular function. Fluorine-18 incorporated into the associated with either clinical or structural imaging
radiotracer, fluorodeoxyglucose (FOG), is used to abnormalities. These indications include diagnosis of
measure how much of the cellular fuel, glucose, is mass lesion, localization of tumor, tumor grading,
used. This amount is altered by disease. FOG has staging, evaluation of metastases of unknown origin,
proved to be very useful in detecting and character- assessment of tumor therapy efficacy, distinction of
izing cancer. tumor recurrence or necrosis, restaging, and prognos-
tication. Because the principles underlying these indi-
cations are similar for all tumors of the head and neck
Role of PET in Oncology region, further discussion focuses on the two most
common head and neck cancers: squamous cell
FOG-PET is playing an increasingly important role in carcinomas and thyroid cancer.
oncology and is becoming a standard tool in the The published literature has been somewhat incon-
management of cancer patients. This results from the sistent in the assessment of the utility of FOG-PET in
high diagnostic accuracy of PET in most neoplasms. the management of patients with proven or suspected
Warburg and colleagues, in 1930, first demonstrated head and neck cancer (Assar et aI., 1999; Chisin, 1999;
that cancer cells have higher utilization of glucose than Keyes et aI., 1997; Myers et aI., 1998; Schechter et aI.,
regular cells (Warburg et aI., 1930; Warburg, 1956). This 2001). Reasons given for not using PET have included
elevated glucose utilization increases with increasing that it has marginal benefit from a high-cost test, that
grade of tumor malignancy. As such, FOG-PET has PET has poor anatomic localization as compared with
proven utility in the diagnosis, staging, and restaging that from CT or MRI, and that it provides little addi-
of cancer and in the evaluation of treatment effects tional information above physical examination and
(Gambhir et aI., 2001; Glaspy et aI., 1993; Andrich and endoscopy.
Neumann, 1994; Ichiya et aI., 1991; Hoh et aI., 1993). On the other hand, it is rare for patients to have CT
This is also evident in the wide array of indications that or MRI at a single anatomic position. Cost of PET
have been approved and are under consideration for becomes comparable to CT and MRI during a patient's
approval, by the Center for Medicaid and Medicare staging work-up (see Table 1-2). Furthermore, in our
Services (CMS) and by third party payers for reimburse- clinical practice we have witnessed potential diagnostic
ment. In a comprehensive literature review on upwards problems related to questionable FOG uptake and exact
of 18,402 patient studies, the average FOG-PET sensi- localization of uptake. Nevertheless, both of these PET
tivity and specificity across all oncology indications and diagnostic conundrums can be corrected or minimized
applications was 84% and 88%, respectively (Gambhir with imaging methodologic changes. The significance
et aI., 2001). This high diagnostic accuracy translated of questionable FOG uptake can be made more certain
into an average management change in 30% of patients. by using two methods. First, much of the PET literature
FOG-PET not only can characterize the behavior of the is based on a measurement technique called the stan-
primary tumor but also has repeatedly been shown dard uptake value (SUV), which is regional activity
efficacious in identifying unsuspected metastatic disease normalized to injected dose and body mass. In our
(Gambhir et aI., 2001; Hoh et al., 1993). Changes of experience, a more reliable measurement method is one
staging from that derived by conventional methods, in which lesional activity is normalized to the regional
both upstaging and downstaging, has also been demon- activity of a reference tissue, called relative uptake
strated. FOG-PET is proving invaluable to the assess- value (RUV). Second, we have found that measuring
ment of treatment effects, including surgery, radiation the temporal behavior of the FOG uptake of lesions is
therapy, and chemotherapy (Andrich and Neumann, a helpful discriminator. Both methods facilitate distin-
1994; Gambhir et aI., 2001; Ichiya et aI., 1991). Positive guishing neoplasm from inflammatory or desmoplastic
therapeutic responses, reflected in improved clinical changes, the principal differential diagnostic consider-
outcomes, are associated with decreases of tumor ation when foci of FOG activity are seen. In terms of
glucose utilization. anatomic localization, a new generation of PET instru-
mentation allowing near-simultaneous PET with CT or
MRI and their spatial co-registration is appearing in
Role of FDG-PET in Head and Neck clinical practice. Even without this capability, however,
Cancer anatomic localization of FOG uptake is achievable by
cross-correlation of FOG uptake (from emission PET)
There are a number of potential indications for the use with tissue density images (from transmission PET).
of FOG-PET in head and neck cancer. These occur Both sets of data are routinely obtained during a PET
principally in three clinical settings: initial or early scan session. These low-grade CTs (i.e., transmission
presentation; after tumor therapy; and evaluation for scan images) provide sufficient contrast to ascertain
possible tumor recurrence during follow-up, usually compartmental and geometric position within the head
SECTIONAl RADIOGRAPHIC ANATOMY AND SCANNING
Diagnosis 298 93 66 70 56 87 58
Staging 591 87 62 89 73 88 67
Diagnosis/staging 360 88 69 83 85 88 73
Recurrence 511 93 54 83 74 87 65
Treatment response 169 84 60 95 39 96 54
'Key data extracted from Gambhir ss. Czernin J, Schwimmer J, et al: A tabulated summary of the FOG PET literature. J Nucl Med 42:
1S-93S, 2001.
and neck region, as well as elsewhere in the body. (Myers et aI., 1998). The increased concentration of FOG
These simple methods correct many of the problems by cancer cells facilitates definitive diagnosis of sus-
leveled at PET but unfortunately are currently pected nodal metastases and detection of unsuspected
employed by few PET facilities. nodal metastases (Fig. 1-62).
The criticisms against the use of PET listed earlier FOG-PET can dramatically alter patient management
have been applied to the initial or early clinical presen- by the detection of remote disease. Although metastatic
tation. Most authors agree on the utility of FOG-PET in involvement of the thorax can be seen with squamous
the post-therapy setting. However, when the findings of cell carcinoma of head and neck origin, if metastases
multiple publications are collated together, FOG-PET are present it is typically local or regional disease. How-
appears to have applicability in each of the three ever, for other types of cancer involving the head and
clinical settings listed earlier. Gambhir and associates neck, including lymph node metastases, lymphoma,
have published a landmark paper that provides a tabu- and more rare tumors, there often is disease in other
lated summary of FOG-PET patient studies published body regions. FOG-PET is particularly useful in staging
from 1993 to 2000 (Gambhir et a!., 2001). FOG-PET had because imaging can easily be performed in the same
high sensitivity and specificity and resulting diagnostic session not only of the head and neck region but
accuracy in all three clinical settings of diagnosis/ typically also of the thorax as well as more rostral and
staging, treatment response, and recurrence/restaging caudal aspects of the body. Detection of remote
(Table 1-3). The utility of FOG-PET is reflected in the metastatic disease is particularly important in thyroid
impact PET had on patient management. Both for carcinoma either in the neck or to the lungs or bone
diagnosis and staging and for recurrence or restaging, (Fig. 1-63). With metastatic thyroid cancer, scans with
FOG-PET had a 33% management change effect based iodine-131 often show no or equivocal uptake. The
on IS patient studies. primary histologic types where this occurs is with tall
Although it is true that physical examination with cell papillary carcinomas and Hiirthle cell carcinomas,
endoscopic examination accompanied by CT/MRI is as well as with anaplastic carcinomas. FOG-PETcan be
likely to adequately diagnose and stage many patients particularly useful in these cases in identifying iodine
presenting with head and neck tumors, often these non-avid metastases.
findings may be equivocal or indeterminate. It is in this Cancer often presents itself as metastases of unknown
situation that FOG-PET can be of benefit. The differ- origin (MUD). Asymptomatic cervical adenopathy in
ential diagnosis of lesions identified by these diagnostic patients older than 40 is often either lymphoma or
methods can be narrowed by characterizing their meta- carcinoma. Controversy exists in the literature on the
bolic attributes. Inflammatory lesions, such as reactive utility of FOG-PET for head and neck MUD (Greven et
lymphadenopathy, can be distinguished from neoplasm a!., 1999; Jungehulsing et a!., 2000; Keyes et a!., 1997;
based on FOG uptake characteristics. Size and distri- Stokkel et a!., 1999), despite its documented ability to
bution of the primary neoplasm and local nodal and identify the primary tumor (Bohuslavizki et a!., 2000).
remote metastatic spread are the most important Because FOG-PET is performed as a whole body scan,
staging, and thus prognostic, factors for head and neck its ability to find additional unknown and unsuspected
cancers. Nodal involvement is particularly important, metastatic sites is important in the definition of the
with the S-year survival of patients with node disease total body tumor burden (Lonneux and Reffad, 2001)
less than half that of those without nodal tumor spread (Fig. 1-64). Knowledge of the primary site and the total
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-62 A 54-year-old man presented with a history of left tonsil moderately differentiated squamous cell
carcinoma, status post tonsillectomy and recent left cervical lymphadenopathy. FOG-PET revealed multilobulated,
hypermetabolic lesion in left deep anterior cervical triangle (arrow). The FOG uptake characteristics were consistent
with high-grade malignancy in confluent jugulocarotid lymph nodes. No residual neoplasm was seen at the palatine
tonsil region, and no other metastatic lesions were identified either locally or remotely. PET images are three-
dimensional projection views of the body rotating in space to the right 68 degrees from the anterior projection to nearly
the left lateral projection.
FIGURE 1-63 A 69-year-old man presented with a history of thyroid cancer, status post thyroidectomy, and one
course of 30 mCi 1311 approximately 1.5 years before PET.The patient presented with new-onset seizure disorder. Whole
body FOG-PETreveals a metastatic lesion in the brain as the cause of the seizure (rostral arrow) but also reveals multiple,
unsuspected mediastinal and lung metastases (thoracic arrows). PETimage format is as in Figure 1-62.
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
P00831
FIGURE 1-64 A 59-year-old woman with a 1-week history of left face weakness and numbness with questionable left
skull base MRI signal changes. FDG-PETrevealed widely metastatic disease with over 50 lesions identified affecting soft
tissue and bony skeleton. Two metastases were identified by PETin the left skull base (bottom row, lateral projection
arrow) causing compressive cranial neuropathies. The primary lesion was identified by PETas a right upper lobe, non-
small cell lung cancer (top row: anterior projection arrow). PETimage format is as in Figure 1-62.
POO924
FIGURE 1-65 A 54-year-old man presented with squamous cell carcinoma of the left auditory meatus status post
radical mastoidectomy and fractionated radiation therapy that ended 3 months before PET.CT was unrevealing. PET
shows hypermetabolic focus in the petrous portion of the skull base, infra-auricularly and in the subjacent soft tissue,
consistent with poor radiotherapeutic response in residual/recurrent neoplasm (arrow). PET image format is as in
Figure 1-62. Whole body images have been cropped to zoom into the head and neck region.
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
body burden can add prognostic information. The initially, have been successfully treated for head and neck
number of metastatic sites has been shown to be a cancer. In this post-therapy setting, distortion of normal
major prognostic variable (Le Chevalier et aI., 1988; architecture and scarring by surgery and radiation ther-
Nieder et aI., 2001). Given that conventional work-up apy confounds physical examination and endoscopy
methods for MUO are often unsuccessful and costly, and limits the accuracy of structural imaging with CT
PET may help target subgroups of patients for the most and MRI (Chisin, 1999). FOG-PET has a very high,
appropriate treatment (Hainsworth and Greco, 1993; 93 %, sensitivity for recurrence detection, in contrast to
Schapira and Jarrett, 1995). 54% for CT (see Table 1-3). 1t is in this setting that all
1t is with treatment response evaluation that PET authors agree as to the utility of FOG-PET (Fig. 1-67).
may have its most unique impact. By measuring cellular The published results for the diagnosis and staging
metabolism, PET is essentially measuring the biologic of thyroid cancer have been slightly less impressive
behavior of the tumor. Effective therapy, manifested than those for head and neck squamous cell carcinomas,
with decreased tumor cell number or decreased cellular with an overall diagnostic accuracy of 84% (Gambhir
activity, will be reflected in decreased FOG uptake. et aI., 2001). However, in the context of disease recur-
These changes can occur in the total absence of any rence and restaging, FOG-PET is proving to be of con-
structural changes within the tumor bed. Thus, the diag- siderable value in thyroid cancer. Based on 601 patients,
nostic accuracy for FOG-PET is near perfect, whereas FOG-PET had a sensitivity of 77%, specificity of 91%,
CT showed an accuracy little better than a flip of the and an overall diagnostic accuracy of 86 %. This results
coin (see Treatment Response in Table 1-3). This ability in a highly significant management change effect of
to accurately gauge treatment response is seen with 53 %. Thus, the indications for which FOG-PET can play
radiation therapy (Peng et aI., 2001; Stokkel et aI., 1998) a key role in thyroid cancer are in assessment of recur-
(Fig. 1-65), chemotherapy (Haberkorn et aI., 1993), or rences, therapeutic effects, and staging, particularly of
combined radiochemotherapy (Gambhir et aI., 2001) tumors with low avidity for iodine-131, and in detect-
(Fig. 1-66). ing remote metastatic disease.
Evaluation for the presence of recurrent disease is a An inherent property of measuring the biologic
major element in the follow-up of patients who, at least behavior of neoplasm is the ability to grade tumors, to
LAO
P01003
FIGURE 1-66 A 57-year-old man presented with squamous cell carcinoma of the tongue base, stage IV T4NOMO,
status post chemotherapy and high dose fractionated radiation therapy. Laryngoscopy reveals diffuse swelling consis-
tent with edema. CT shows diffuse ill-defined attenuation changes. PETreveals a bilobed hypermetabolic lesion in the
tongue base at the tumor site on the pretreatment CT. Patient was downstaged to stage III T3NOMObased on PET.
PET image format is as in Figure 1-65.
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Anterior
/
LAO
POl 046
A
Lateral
P0194l
B
FIGURE1-67 A 61-year-old woman presented with Hurthle cell thyroid carcinoma initially diagnosed 15 years before,
status post total thyroidectomy and then bilateral radical neck dissections with multiple metastatic nodes found. Two
ablative iodine-131 therapies were given before the first PETstudy (A) and one iodine-131 therapy before the second
PET study (B). Twenty months separate the two PETs. Physical examination and CT were unrevealing owing to
postoperative changes and scarring. A less than 1-cm focus is seen in the medial supraclavicular, anterior periscalene
region. This shows increased uptake from the first to the second PETand is consistent with a lymph node metastasis.
Supraglottic FDG localization on the first PET(A) was likely related to radiation-induced inflammation. PETimage format
is as in Figure 1-65.
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
determine their degree of malignancy and aggressivity Oi Chiro G, DeLaPaz RL, Brooks RA, et al: Glucose utilization of cere-
(Chisin, 1999). Although this capability has not been bral gliomas measured by (l'F]fluorodeoxyglucose and positron
emission tomography. Neurology 32:1323-1329, 1982.
used to any great extent in oncology for body cancers,
Di Chiro G, Fulham MJ: Virchow's shackles: Can PET-FOGchallenge
it has been known since the early 1980s for primary tumor histology? Am J NeuroradioI14:524-527, 1993.
brain tumors (Di Chiro et a!., 1982; Di Chiro and Fulham, Gambhir SS, Czernin J, Schwimmer J, et al: A tabulated summary of
1993). This ability to grade tumors is used in our daily the FOG PET literature. J Nuel Med 42:1S-93S, 2001.
clinical practice for assisting neuro-oncologists in the Glaspy JA, Hawkins R, Hoh CK, Phelps ME: Use of positron emission
tomography in oncology. Oncology 7:41-55, 1993.
management of their patients. The capability of grading
Greess H, Nomayr A, Tomandl B, et al: 2D and 30 visualization of
tumors and determining proliferative activity does exist head and neck tumours from spiral-CT data. Eur J Radiol 33:
for head and neck tumors (Minn et aI., 1988). Prognos- 170-177,2000.
tication directly flows from grading and staging infor- Greven KM, KeyesJW Jr, Williams OW III, et al: Occult primary tumors
mation (Minn et al., 1997; Patronas et al., 1985). Patient of the head and neck: Lack of benefit from positron emission
tomography imaging with 2-[F-18]fluoro-2-deoxy-d-glucose. Cancer
management must be rationally designed for each
86:114-118, 1999.
individual patient based on the array of diagnostic and Greyson NO, Noyek AM: Radionuelide salivary scanning. J Otolaryngol
prognostic information available. (SuppllO)11:1-47,1982.
Haberkorn U, Strauss LG, Oimitrakopoulou AO, et al: Fluorodeoxyglu-
cose imaging of advanced head and neck cancer after chemother-
apy. J Nuel Med 34:12-17,1993.
Conclusion
Hainsworth JD, Greco FA: Treatment of patients with cancer of an
unknown primary site. N Engl J Med 329:257-263, 1993.
FDG-PET is a functional imaging modality in which the Hillsamer P, Schuller 0, McGhee R, et a]: Improving diagnostic accu-
regional concentration of FDG provides an index of racy of cervical metastases with computed tomography and magnetic
glucose utilization. Because neoplasm has heightened resonance imaging. Arch Otolaryngol Head Neck Surg 116:1297-
1301, 1990.
glucose utilization, FDG-PET has many uses in the
Hoh CK, Hawkins RA, Glaspy JA, et al: Cancer detection with whole-
management of head and neck cancer patients. There body PET using 2-[l'F]fluoro-2-deoxy-d-g]ucose. J Comput Assist
are indications for its use in three different clinical set- Tomogr 17:582-589,1993.
tings: initial presentation/early work-up; after therapy Holgate RC, Wortzman G, Noyek AM, Flodmark CO: Angiography in
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North Am 11:477-499,1978.
detection of disease recurrence. The indications for
Hudgins PA, Gussack GS: MR imaging in the management of extracra-
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of tumor, tumor grading, staging, evaluation of metas- 159:161-169,1992.
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restaging, and prognostication. The diagnostic accuracy
Jungehu]sing M, Scheidhauer K, Oamm M, et al: 2[F]-fluoro-2-deoxy-
of FDG-PET has been recognized by the CMS and other o-glucose positron emission tomography is a sensitive tool for
third party payers, with authorization for payment for the detection of occult primary cancer (carcinoma of unknown
the diagnosis, staging, and restaging of head and neck primary syndrome) with head and neck lymph node manifestation.
cancer. Thyroid cancer is currently in evaluation for Otolaryngol Head Neck Surg 123:294-301, 2000.
Keyes JW Jr, Watson NE Jr, Williams OW Ill, et al: FOG PET in head
clinical reimbursement by the CMS. In the future, the
and neck cancer. AJR Am J RoentgenoI169:1663-1669, 1997.
capability of FDG-PET of grading neoplasms and in Laine F, Braun t Jensen M, et al: Perineural tumor extension through
prognostication may play a greater role in the man- the foramen ova]e: Evaluation with MR imaging. Radiology 174:
agement of head and neck cancer patients. 65-71, 1990.
Le Chevalier T, Cvitkovic E, Caille P, et al: Early metastatic cancer of
unknown primary origin at presentation: A elinical study of 302
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Bohuslavizki KH, Klutmann S, Kroger S, et a]: FOG PET detection of Lore JM: Deep infections of the neck: Applied anatomy. Laryngoscope
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Minn H, Joensuu H, Ahonen A, Klemi P: Fluorodeoxyglucose imaging: to nasopharyngeal carcinoma by positron emission tomography with
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108:1592-1598, 1998. Sataloff RT, Grossman CE, Gonzales C, Naheedy MH: Computed
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Neuroradiol 19:701-706, 1998. Schechter NR, Gillenwater AM, Byers RM, et al: Can positron emis-
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2 EMERGENCY
PROCEDURES
65
EMERGENCY PROCEDURES
The diagnosis and successful treatment of MH require 2. An endotracheal tube inserted in the right mainstem
that every patient be monitored to determine his or her bronchus can have a fatal outcome if not recognized
oxygen saturation, exhaled carbon dioxide levels, and and corrected.
temperature. Because the characteristic feature of an MH 3. Insertion of an esophageal cardiac monitor without
reaction is a hypermetabolic response to the offending care may perforate Zenker's diverticulum.
agent, tachycardia, increasing expired carbon dioxide, and
decreasing oxygen saturation occur early. The development
of an elevated temperature may be delayed until the BLINDNESS AND OPHTHALMIC
problem is well developed, and the absence of fever in COMPLICATIONS OF SURGERY
the presence of other signs should not delay treatment. OF THE HEAD AND NECK
Spasm of the masseter muscles after administration Daniel P. Schaefer and Arthur J. Schaefer
of succinylcholine should alert one immediately to the
possibility that the patient is susceptible to the Periocular, facial, sinus, and cranial surgeries are
development of MH. commonly performed for the treatment of infections,
The surgical care of patients who are known to be neoplasms, cosmesis, and other conditions. Generally
MH susceptible can be safely accomplished by avoiding these procedures are relatively safe, but serious ocular
the known triggering agents: the halogenated inhalation complications may and do occur. Comprehensive and
agents and succinylcholine. The prophylactic adminis- detailed knowledge of orbital, periorbital, nasal, and
tration of dantrolene may also be advised. A presurgical sinus anatomy and of the pathophysiology of compli-
consultation with an anesthesiologist familiar with MH cations is mandatory for a complete understanding of
is certainly warranted. the mechanisms of injury, the significance of clinical
findings, and the main way to prevent and treat these
Highpoints complications. In addition, meticulous surgical tech-
nique is essential to minimizing these potential surgical
1. When MH presents unexpectedly during a surgical complications. Combined teams of ophthalmology,
procedure the procedure should be terminated as otolaryngology, and/or neurosurgery often facilitate
soon as possible. surgery.
2. The administration of any halogenated anesthetic Because of the proximity of the orbits to the nose
must be terminated immediately. and paranasal sinus cavities, ophthalmic complica-
3. Intravenous access if not established previously tions may occur in association with sinonasal surgery.
should be accomplished by whatever route is These include infection, hemorrhage, epiphora,
immediately available. diplopia, ptosis, eyelid defects, nasolacrimal duct
4. Hyperventilation with 100% oxygen should be obstruction, visual compromise, or even the devas-
started immediately. tating ocular complication of a complete and perma-
5. Intravenous fluids including sodium bicarbonate nent loss of vision. The orbital structures at greatest
must be administered as soon as possible. risk are those structures closest to the area that is being
6. Measures to cool the patient must be instituted. operated on. The reported incidence of orbital compli-
7. Dantrolene must be immediately available in the cations secondary to sinus surgeries varies from 2.8 %
operating suite along with all of the necessary items to 47%.
to prepare it for administration. A large placard
displaying the treatment protocol should be present
in each operating room. Dantrolene must be Blindness
administered according to the protocol.
8. After resolution of the initial crisis, the patient must Blindness, whenever it occurs, is an obvious calamity.
be followed closely in a fully monitored setting for at When it is iatrogenic it becomes such a serious sequela
least 24 hours. of any surgical procedure that the axiom primum non
nocere is most pungent.
Therefore, care must be taken even while prepping
Other Untoward Events Associated the patient. Accidental exposure to solutions such as
With Endotracheal Anesthesia Hibiclens has resulted in a permanent decrease in
vision, owing to its corneal toxicity. Hibiclens will cause
The following complications may also occur with corneal epithelial defects or corneal edema that may
endotracheal anesthesia: take more than 6 months to resolve or may progress to
a bullous keratopathy, corneal opacification, vascu-
I. Dislocation of arytenoid cartilage may mimic vocal larization, thinning, or ectasia, which may require a
cord paralysis (see Chapter 20). corneal transplant.
EMERGENCY PROCEDURES
Operations that have been complicated by blindness a lateral canthotomy and cantholysis of the inferior crus
are too numerous to present a complete list here. Fortu- and, occasionally, the superior crus, and of the lateral
nately, these are infrequent occurrences. Some of the canthal tendon is performed.
surgical procedures that may be associated with blind- Treatment is as follows, especially when there is prop-
ness include the following: tosis and a tight orbit, which is evident by a marked
increased resistance to retropulsion of the globe:
1. Ethmoidal surgical procedures, especially those
injuring the lamina papyracea 1. Remove sutures if present, open the wound, evacu-
2. Endoscopic sinus surgery late the clot, and obtain hemostasis.
3. Reduction of fractures involving the periorbital region 2. If the first step is not successful, a lateral canthotomy
4. Surgical procedures involving the contents of the orbit: and then a cantholysis of the superior and inferior
a. Lacrimal gland resection crus of the lateral canthus is required.
b. Any intraorbital tumor resection 3. If the second step is not successful, a decompression
c. Release of entrapped intraocular muscles of the bony orbit can be done.
5. Blepharoplasty 4. For intermediate cases, treat as follows:
6. Ligation of ethmoidal vessels for epistaxis a. 500 mg of acetazolamide and/or I to 1.5 g/kg body
7. Simultaneous or staged radical neck dissection (very weight delivered at 3 to 5 mL/min of 20% mannitol
rare, but it can occur) intravenously, or 1 to 1.5 g/kg body weight of
glycerol orally if not considering general anesthesia.
Table 2-1 lists numerous mechanisms that can lead b. head elevation, steroids, and intermittent ice
to blindness or a loss of vision as a result of surgery. applications.
These causes are obviously overlapping, but the main
reason for blindness appears to be the interruption of Optic Nerve Injury
the blood supply to the optic nerve. Treatment is initi-
ated as soon as possible to lower the intraocular pres- Direct injury or damage to the optic nerve has little in
sure, and to restore the posterior ciliary artery circulation. the way of promising treatment. These complications
Mannitol, acetazolamide, topical antiglaucoma medica- must be avoided through meticulous knowledge of the
tions, and high-dose steroids are administered when anatomic variations in the relationship between the
indicated. Hypotension, anemia, and other abnormal optic nerves and ethmoidal sinus. Chronic infection
systemic conditions must be corrected. If there is orbital and inflammation makes recognition of the anatomy in
swelling, hemorrhage, or proptosis creating a "tight orbit," this area difficult, and thickened mucosa, polyps, scar
tissue, and hemorrhage add to the problem. Even
polypectomies can result in orbital injury.
TABLE 2-1 Mechanisms Leading to Vision
Impairment After Surgery Orbital Walls and Soft Tissue Damage
--'-
Frontal sinus surgery can lead to injury of the superior
1. Hemorrhage into the orbit
2. Compressionof the optic nerve and its vascular oblique muscle, tendon, and trochlea or even to the
supply from various causes fourth cranial nerve. Even extensive manipulation of
3. Stretchingor shearing forces to the optic nerve the orbital fat around these structures can result in
4. Optic nerve ischemia postoperative scar tissue formation and restriction. When
5. Packing the maxillaryantrum with oxidized the orbital wall is violated, this can result in entrap-
cellulose ment of muscle and orbital tissue. For the extraocular
6. Frontal sinus irrigation muscle to be involved, orbital contents must be pulled,
7. Any sinus surgery that violates the orbital walls cut, or torn, which will result in complications secondary
(e.g., an antral trocar that is directed superiorly) to the direct effect on the muscle, causing more scarring
8. Inappropriate or no ocular protection for the patient and reaction than that seen with traumatic orbital frac-
(and also the operating room personnel) when
tures. The creation of a larger defect of the orbital walls
using the various lasers
9. Sustained intraoperative or postoperative pressure can result in enophthalmos.
on the eye A most frustrating complication to the patient and
10. Microembolism the physician is ocular motility problems. Persistent
11. Pulmonary venous gas emboli with the use of diplopia can be extremely disabling, and treatment can
neodymium:yttrium-aluminum-garnet(Nd:YAG) be very frustrating. Transient diplopia can result from
laser for endobronchial lesion multiple causes, including orbital hemorrhage or orbital
12. Severeedema of face and neck fractures, or secondary to postoperative swelling and
infections. Permanent ocular motility problems may
EMERGENCY PROCEDURES
result from direct muscle or nerve injury, orbital frac- As described previously, treatment is initiated as soon
tures with entrapment, and postoperative scarring. It as possible to lower the intraocular pressure and restore
may take up to 6 months for some transient motility the posterior ciliary artery circulation. The use of man-
complications to resolve. It is important to determine if nitol, acetazolamide, topical antiglaucoma medications,
there is significant restriction secondary to scarring by and high doses of corticosteroids should be administered
performing forced adduction testing. When restriction when indicated. The correction of hypotension, anemia,
is significant, exploration of the muscle with possible and other abnormal systemic conditions must be per-
lysis of the cicatricial tissue is indicated. formed. If orbital swelling, hemorrhage, or proptosis
When paralysis is significant, the correction should creates a "tight orbit," which is evident by a marked
be performed using the standard techniques. Injuries of increased resistance to retropulsion of the globe, then
the orbital floor should be treated similar to traumatic surgical intervention is indicated.
orbital floor fractures. Often these patients are not The optimal period of time in which to observe the
referred to someone familiar with proper treatment patients under treatment and the time window in which
until weeks after the injury and the opportunity for an successful surgical treatment may be performed are
early and possibly more successful repair may be lost. unknown. No light perception vision is not necessarily
If the patient is examined months after the injury, it a contraindication but is actually an indication for
may be difficult to differentiate between the scarring, aggressive medical and surgical treatment. One must
entrapment, or injury secondary to muscle injury. never hesitate to take the appropriate steps to preserve
Direct laceration or damage to the extraocular muscle the sight of the affected eye.
itself may result in much more severe scar tissue Most orbital hemorrhages after blepharoplasty or
formation and restriction than entrapment does. eyelid procedures are caused by bleeding from vessels
within the orbital fat or from diffuse bleeding of the
Orbital Hematoma orbicularis muscle. Hemostasis must be achieved
intraoperatively but will not eliminate the possibility of
Another mechanism that can cause a loss of VISIOn late hemorrhage. Traction on the orbital fat should be
during ethmoidal surgery is orbital hematoma or avoided to decrease this complication from occurring.
hemorrhage, which needs to be managed with urgent Patients should be instructed to call immediately if they
control of the hemorrhage. Severe periocular and orbital develop pain, proptosis, or visual loss, especially in the
edema and hematomas may occur if adequate hemo- early postoperative period. Treatment of a post-
stasis is not obtained during surgery, clotting mechanisms blepharoplasty orbital hemorrhage is an ophthalmologic
are impaired, the patient has a severe coughing spell, emergency. Decompression of the hemorrhage is the
or the patient performs a Valsalva maneuver postopera- most effective means of eliminating the orbital com-
tively. If the hematoma is localized in the lid, it can partment syndrome (see Highpoints). Corticosteroids
often be drained through the incision or through a and osmotic and ocular hypotensive agents are not
small stab incision with a No. 11 Bard-Parker blade. If effective as primary therapy.
the hematoma dissects into the orbit, intraorbital pres- If the orbital pressure is not extremely severe, and
sure can be increased as a result of the edema or there are no signs of visual impairment (e.g., decreased
hemorrhage, which may be sufficient to produce an visual acuity or pupillary defects), temporizing measures
orbital compartment syndrome. The increased orbital may be instituted (e.g., ice, prednisone, head elevation,
pressure extrinsic to the globe produces a compression intermittent pressure). If the patient develops any signs
of the optic nerve and the vessels supplying the nerve of visual compromise or progression of the hematoma
and globe. This can compromise vision from compres- or hemorrhage, or when the increased orbital pressure
sion of the optic nerve and the vascular supply to the compromises the globe or optic nerve, then emergency
globe. If an orbital hematoma occurs in a patient who measures are required to reduce the orbital pressure
has had a tight pressure dressing applied, the risk of (see Highpoints). Heroic measures must be instituted
loss of vision is greater owing to the increased orbital at the first sign of any progressive hematoma or hemor-
pressure that is generated in this confined space. rhage, reduced vision, pupillary defects, or sign of a
Severe postoperative pain should alert the surgeon central artery occlusion.
to the possible development of an orbital hematoma or
hemorrhage, corneal abrasion, or a glaucoma attack. Highpoints
Pressure bandages should be avoided, owing to the
possibility of masking and/or augmenting the effects of Table 2-2 describes surgical intervention.
orbital hemorrhage, because this can add to the intra- Paracentesis of the eye has been advocated by some
orbital tissue pressure, obscure lid and conjunctival signs as a treatment of visual loss secondary to an orbital
of retrobulbar bleeding, and hinder the monitoring of hematoma or hemorrhage, but we do not recommend
pupillary reactions. this because the pathogenic mechanism that must be
EMERGENCY PROCEDURES
highly myopic eyes (anteroposterior axis greater than ventricular arrhythmias, and the prompt initiation of
24 mm) can increase the incidence of globe perforations rhythm and oximetry monitoring.
during orbital injections. Scleral perforations due to injec- The two components of emergency cardiac care are
tion can manifest with immediate ocular pain, intraocular basic life support (BLS)and advanced cardiac life support
hemorrhage, restlessness, or hypotony of the globe. The (ACLS).Cardiopulmonary resuscitation (CPR) is an inte-
planned surgery should be discontinued immediately gral part of both. BLS is intended to prevent inadequate
and the patient evaluated by a vitreoretinal surgeon. or arrested circulation or respiration and to provide cardio-
In children, care should always be taken to avoid the respiratory support of the arrested patient through CPR.
development of amblyopia (deprivational amblyopia). ACLSincludes BLSplus the use of adjunctive equipment
Prolonged occlusion of the eye (secondary to patching to support ventilation (e.g., intubation, the establishment
or swelling of the periocular structures and eyelids), of intravenous access), the administration of drugs, cardiac
induced paralysis of one or more extraocular muscles, monitoring, and arrhythmia control including defibril-
or even the development of secondary cataracts may lation and the arrangement of care after resuscitation.
lead to a severe amblyopia, especially in children younger In a patient with cardiorespiratory arrest, if CPR is
than 5 years of age. initiated within 4 minutes, and ACLS including defib-
Complications of orbital decompression surgery for rillation where appropriate is initiated within 4 minutes
thyroid-related orbitopathy are infrequent but can be thereafter, the chances of full recovery are excellent. If
serious. Postoperative hemorrhage, infection, exacerba- CPR is initiated after 6 minutes, brain damage will
tion of Graves' inflammatory reactions, and damage of almost always occur.
the infraorbital nerve and artery or the nasolacrimal
drainage system are generally avoided with good visuali-
zation and knowledge of the anatomy. Contraction scar- Sequence of BLS (Fig. 2-1)
ring or keloid formation may result from skin incisions,
and fistulas may develop with mucosal approaches. When faced with an unresponsive patient an orderly
Comprehensive and meticulous knowledge of sequence of steps should be followed. CPR should not
orbital, periorbital, nasal, and sinus anatomy and be initiated until a proper assessment has been made and
the pathophysiology is mandatory for a complete the need for resuscitation established. Unresponsiveness
understanding of the mechanisms of injury, the should first be established, followed by the determina-
significance of clinical findings, and the main way to tion of breathlessness, and pulselessness, the so-called
prevent and manage complications. ABC sequence of BLS (Airway, Breathing, Circulation).
the long axis of the heel parallel to the long axis of the The rescuer providing ventilation should check the
sternum. The other hand should be placed parallel over carotid pulse periodically for adequacy of compression
the first. The shoulders should be positioned directly and pause every 1 to 2 minutes for spontaneous return
over the sternum and the elbows locked and the finger of pulse. If pulse is restored, spontaneous ventilation
kept off the chest. The sternum should be depressed should be assessedand ventilatory support continued
1.5 to 2 inches with each compression. With two if necessary.
rescuers, one breath should be administered for every
five compressions, and with one, two breaths after ACLS measures should be initiated as soon as effective
each 15 compressions. Chest compressions should be CPR has been established and ACLS-trained personnel
maintained at a rate of 80 to 100 per minute. arrive.
A. Determine Unresponsiveness
B. Determining Breathlessness
C. Determining Pulselessness
D. Chest Compression
FIGURE 2-1
EMERGENCY PROCEDURES
FIGURE 2-2
EMERGENCY PROCEDURES
FIGURE 2-3
EMERGENCY PROCEDURES
E Using the Kelly clamp as a guide in the stab I After a sufficient length of the catheter has been
wound, a multi-holed No. 26 to No. 30 French plain inserted-at least until all the holes are within the
rubber catheter is inserted in the thoracic cavity. thoracic cavity-the trocar is gradually removed.
A straight hemostat is used to grasp the catheter and When the catheter is visible at the skin margin, a
passit in through the stab wound. clamp grasps the catheter to prevent it from being
withdrawn. After the trocar is completely removed,
F Silk sutures are used to close the stab wound the catheter is connected to the underwater drainage
tightly and are wound snugly around the catheter to system, as shown in Figure 2-5. In infants and children
help hold it in place. A small dressing of petrolatum similar results can be achieved by inserting plastic
and plain gauze with supporting adhesive completes tubing through the lumen of a large-bore needle that
the dressing. The catheter is unclamped after it is has been inserted into the pleural space. The needle
connected to the tubing from the underwater can then be removed by withdrawing it along the
drainage system (see Fig. 2-5). tubing. Such smaller tubing, however, may become
plugged.
G When a large-bore trocar with cannula is available,
an intercostal catheter is easily inserted. The technique J Minithoracentesis: Pictured is a simple self-
is similar to the method described in the previous contained intercostal catheter with an attached needle
plate. The trocar is kept close to the superior border of (after Algird, 1966).
the rib. A clamp is placed on the catheter before
insertion.
FIGURE2-3 Continued
EMERGENCY PROCEDURES
J
FIGURE 2-3 Continued
EMERGENCY PROCEDURES
A B
FIGURE 2-4
EMERGENCY PROCEDURES
FROM
PATIENT
D
FIGURE 2-5
EMERGENCY PROCEDURES
Highpoints • Hemorrhage
• Chondritis
1. Procedure is utilized in emergency glottic or • Subglottic and/or glottic stenosis
supraglottic airway obstruction or electively by
some thoracic surgeons after midline sternotomy,
when there may be an associated airway problem. A With the head and neck extended, palpation of
Next to intubation, this is one of the fastest methods the cricothyroid ligament is usually quite easy. It is at
of establishing an airway. this point that the airway is mos't superficial. A short
2. Obstruction must be ascertained to be above the horizontal skin incision is preferred. There is little to be
level of the cricoid cartilage. gained by a vertical incision, because vessels can be in
3. Either a horizontal or vertical skin incision is made, horizontal and/or vertical planes. In addition, a vertical
with the former preferred. incision carried too deeply may involve the cricoid
4. A midline separation of strap muscles is done. and/or thyroid cartilages.
5. A horizontal incision is made through the
cricothyroid membrane. B The anatomy of the cricothyroid membrane with
6. Bleeding may occur from the cricothyroid artery, blood vessels that may cause significant bleeding is
which is a branch of the superior thyroid artery. shown. The arteries are branches of the superior
7. Conversion to a standard tracheostomy is done as thyroid artery, while the veins drain into superficial
soon as possible except when the procedure is used thyroid veins and/or the median cervical veins. The
electively, in which case the tube should be removed exposure depicted is for anatomic purposes; the actual
as soon as possible, within a maximum of 5 to 7 surgical exposure is limited to the immediate area of
days. Antibiotics should accompany the cricothy- the cricothyroid membrane.
roidotomy during this period of time.
C The sternohyoid muscles may require retraction
Comment for additional exposure of the cricothyroid ligament. A
horizontal stab incision is made through the ligament
Although this procedure was condemned by Chevalier with cognizance of the blood vessels.
Jackson in the early 1900s because of related
complications of chondritis and glottic and subglottic D The stab wound is widened either with a clamp or
stenosis, the procedure is justifiable and very useful. with a tracheal dilator. The clamp may have to be
When reviewing Jackson's original articles, it becomes rotated 90 degrees to separate the cricoid cartilage
apparent that the procedure was often extended to farther from the thyroid cartilage. Care must be taken
include an incision through the cricoid and/or thyroid not to injure either cartilage or the vocal cords, located
cartilages. These extensions contributed significantly to superiorly. A standard tracheostomy tube is inserted.
the complications listed here. In addition, in the early The skin edges are loosely approximated. The
1900s there was a preponderance of infectious disease cricothyroidotomy should be converted as soon as
causing glottic obstruction. Antibiotics, of course, were possible to a standard tracheostomy.
not available at that time.
The immediate conversion to a standard tracheostomy
except in patients with laryngeal trauma has been Contraindication
challenged by some authors (Boyd et aI., 1979), who
emphasize that the complications of stenosis occur • Malignant neoplasm of larynx
when the tube is left in place for 1 week.
EMERGENCY PROCEDURES
PYRAMIDAL LOBE
CRICOID CART.
,
~
(IRSTTRACHEAL CART.
c
" f
FIGURE 2-6
EMERGENCY PROCEDURES
Management of Acute Respiratory leak by the cuff. This ensures that the cuff is not over-
Emergencies inflated and can prevent damage to the tracheal mucosa
and possibly the tracheal cartilages. Such complication
When medical management, including antibiotics with leads to tracheal stricture and stenosis. It must be
or without corticosteroids, racemic epinephrine mist, and emphasized that with this method there exists the
ultrasonic aerosol therapy, fails in the management of inherent possibility of temporary or permanent damage
acute croup, epiglottitis, and laryngotracheobronchitis, to the vocal cords as well as subglottic stenosis.
mechanical intervention to establish an emergency airway Problems associated with the care of acute respira-
is necessary. The indication for this kind of interven- tory emergencies in which selective operative interven-
tion is progression of the symptoms characterized by tion is necessary include the following:
supraclavicular retraction, cyanosis, substernal retrac-
tion, and a general picture of increased air hunger. 1. Pneumothorax, tension and nontension, unilateral
The types of mechanical intervention for the and bilateral
emergency establishment of an airway include: 2. Airway obstruction from any cause
3. Respiratory arrest and cardiac arrest
1. Insertion of an endotracheal tube 4. Tension pneumoperitoneum
2. Placement of a laryngeal-mask airway. The laryngeal 5. Mediastinal emphysema
mask airway is recommended as the second most 6. Perforated gastroduodenal ulcers in infants leading
desirable way to establish an airway under to tension pneumoperitoneum associated with
emergency conditions because it can be successfully aerophagia
inserted at times when endotracheal intubation fails 7. Hemorrhage following neck surgery that compresses
because of anatomically related difficult intubating the airway (e.g., thyroidectomy). The operative wound
conditions or the presence of secretions or blood, must be immediately opened and the larynx examined.
which make visualization of the glottis difficult. 8. Bilateral abductor vocal cord paralysis
Once it is properly placed it is an efficient means for
providing ventilation and may provide a passageway Emergency Establishment of Airway
for suctioning and placement of a smaller caliber
endotracheal tube (ASA Task Force, 1996). Airway obstruction and severe hemorrhage are two of
3. Insertion of a bronchoscope the most important and life-threatening emergencies
4. Percutaneous insertion of a large-bore needle into facing the head and neck surgeon. The important facet
the tracheal lumen in the emergency establishment of an airway is to
5. Nasotracheal intubation using virtually any type of ascertain the location of the obstruction. This can have
tubing available, for example, a portion of any of the following locations:
stethoscope tubing
6. Tracheostomy (see Fig. 19-1) 1. Oral cavity
7. Cricothyroidotomy (see Fig. 2-6) 2. Oropharyngeal
8. Oropharyngeal airway 3. Hypopharyngeal
4. Supraglottic-epiglottic or ventricular bands
After the emergency establishment of an airway (if 5. Glottic
tracheostomy has not already been carried out), a 6. Subglottic
tracheostomy is performed over the endotracheal tube, 7. Tracheal
bronchoscope, percutaneous needle, or nasotracheal 8. Bronchial
tube. If there is any doubt about the presence of any
significant amount of retained tracheobronchial secre- It is obvious that the location of the obstruction and
tions or the possibility of a retained foreign body, the etiology of the obstruction govern the methodology
bronchoscopy is then performed under topical, basal, of management. When appropriate, endotracheal
or general anesthesia. At the same time a careful intubation through either the oral or the nasal route or
evaluation of the larynx is done by direct fiberoptic or use of a nasal oropharyngeal airway is usually the
rigid laryngoscopy. fastest. Nasal intubation can be achieved "blindly" with
A variation of this generally accepted method involves any available tube having the correct diameter (e.g., a
the continuation of the use of the endotracheal tube relatively stiff section of stethoscope tube inserted with
without tracheostomy for a number of days in conjunc- the head and neck extended). The next method is the
tion with antibiotics, corticosteroids, and ultrasonic placement of a laryngeal-mask airway for supraglottic
aerosol therapy. When on a respirator the cuff on the and glottic obstruction. Other methods are bronchoscopy
endotracheal tube should usually be adjusted to and the percutaneous insertion of a large-bore needle
"minimal leak," thus allowing a small amount of air to into the trachea. To discuss this entire problem and
EMERGENCY PROCEDURES
method of management would be a treatise in itself. Gordon AS, Palich WE, Fletcher EE: Emergency heart-lung resus-
The previous figures depict cricothyroidotomy, which citation and external defibrillation. Presented before the Scientific
is a very rapid and satisfactory method for establishing Exhibit at 39th Congress of International Anesthesia Research
Society, Washington, DC, March 1965.
an airway when the obstruction is located at the glottic Greenfield LJ, Bruce TA, Nichols NB: Transvenous pulmonary
level or above. A number of instruments are available embolectomy by catheter device. Ann Surg 174:881-886, 1971.
that are useful for a cricothyroidotomy and can be Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency
carried by any physician in the shirt or coat pocket. Cardiovascular Care: Circulation (Suppl 8) 102:1255-1290,2000.
"Anterior cricoid split" in infants and children to Hayreh SS: Blood supply of the optic nerve head and its role in optic
atrophy, glaucoma, and edema of the optic disc. Br J Ophthalmol
avoid tracheostomy after extubation has been reported 53:721-748,1969.
by Holinger and colleagues (1987) as well as Cotton Hayreh ss: Posterior ischemic optic neuropathy. Ophthalmologica
and co-workers with a 77 % success rate (1980). An 182:29-41, ]981.
anterior incision is made through the thyroid cartilage Holinger LD, Stankiewicz JA, Livingston GL: Anterior cricoid split:
commencing 2 mm distal to the thyroid notch and then The Chicago experience with an alternative to tracheotomy.
Laryngoscope 97:19-24,1987.
through the cricoid cartilage and the first and second Hybels RL: Venous air embolism in head and neck surgery.
tracheal rings. A wedge of thyroid cartilage can then be Laryngoscope 6:945-954, 1980.
inserted at the site of the split in the cricoid cartilage. Jackson C: High tracheotomy and other errors: The chief causes of
When airway obstruction is associated with possible chronic laryngeal stenosis. Surg Gynecol Obstet 32:392, 1921.
James PM, Myers RT: Central venous pressure monitoring. Ann Surg
cervical spine injury, either secondary to trauma or
175:693-701, 1972.
congenital osseous defects (e.g., Hallermann-Streiff Johnson J, Kirby CK: Surgery of the Chest, 2nd ed. Chicago, Year
syndrome), any procedure that involves hyperexten- Book Medical, 1958.
sion of the cervical spine must be avoided. Hence, the Jude JR, Kouwenhoven WB, Knickerbocker GG: A new approach to
types of mechanical intervention as listed earlier that cardiac resuscitation. Ann Surg 154:311-319, 1961.
could be used are Nos. 3 to 8. Jude JR, Tabbarah HJ: Otolaryngological aspects of cardiac arrest.
Ann Otol 79:889, 1970.
Kanter MA, Geelhoed GW: How to manage cardiopulmonary arrest.
BIBLIOGRAPHY Resident Staff Physician 30:28-36, 1984.
Keenan RL, Boyan CP: Cardiac arrest due to anesthesia. JAMA
Algird JR: A technique for thoracentesis utilizing a disposable catheter 253:2373-2377,1985.
unit. Cancer 19:281-283, 1966. Kiers K, King 10: Increased intracranial pressure following bilateral
American Heart Association: Basic Life Support for Health Care neck dissection and radiotherapy. Aust NZ J Surg 61:45B-61B,
Providers. Dallas, American Heart Association, 1994. 1991.
ASA Task Force on Management of the Difficult Airway: Practice Kimmelman CP, Weisman RA, Osguthorpe JD: The efficacy and safety
Guidelines for management of the difficult airway and the ASA of trans antral ethmoidectomy. Laryngoscope 98:1178-1182,1988.
difficult airway algorithm. Anesthesiology 84:688-699, 1996. Kirimli B, Kampschulte S, Safar P: Resuscitation from cardiac arrest
Borja AR, Lansing AM: Technique of selective pulmonary embolec- due to exsanguination. Surg Gynecol Obstet 129:89-97, 1969.
tomy without bypass. Surg Gynecol Obstet 130:1073-1076, 1970. Kotani J, Nitta K, Sakuma Y, et al: Effects of bilateral jugular vein
Boyd D, Romita MC, Conlan AA, et al: A clinical evaluation of ligation on intracranial pressure and cerebrospinal fluid outflow
cricothyroidotomy. Surg Gynecol Obstet 149:365, 1979. resistance in cats. Br J Oral Maxillofac Surg 30:171-173,1992.
Brantigan CO, Grow JB Sr: Cricothyroidotomy: Elective use in respira- Kouwenhoven WB, Jude JR, Knickerbocker GG: Closed-chest cardiac
tory problems requiring tracheotomy. J Thorac Cardiovasc Surg massage. JAMA 173:1064-1067, 1960.
71:72,1976. Lindskog G, Liebow AA: Thoracic Surgery and Related Pathology.
Britt BA, Kalow W: Malignant hyperthermia: A statistical review. Can New York, Appleton-Century-Crofts, 1953.
Anesth Soc J 17:293-315, 1970. Lore JM Jr, Gordon SG, Gordon EW: Successful use of hypothermia
Carey JS, Mohr PA, Brown RS, Shoemaker WC: Cardiovascular func- following cardiac arrest in twelve-day-old infant. NY J Med
tion in hemorrhage, trauma and sepsis: Determinants of cardiac 60:278-279, 1960.
output and cardiac work. Ann 5urg 170:910-921, 1969. Lucas eE, Ledgerwood AM: Pulmonary response of massive steroids
Chillar RK, Farbstein M, Ellington DB, et al: Use of right atrial catheter in seriously injured patients. Ann Surg 194:256-260, 1981.
for prolonged IE support in cancer patients. Cancer Treat Rep 64: Lundberg GD, Mattei IR. Davis CJ, Nelson DE: Hemorrhage from
243-246, 1980. gastroesophageal lacerations following closed-chest cardiac
Chutkow JG, Sharbough FW, Riley FC: Blindness following simulta- massage. JAMA 202:195-198,1967.
neous bilateral neck dissection. Mayo Clin Proc 48:713-717,1973. McCabe BF: Hemorrhage in otolaryngologic surgery. Trans Am Acad
Cole SL, Corday E: Four-minute limit for cardiac resuscitation. lAMA Ophthalmol Otolaryngol 72:23-24, 1968.
161:1454-1458,1956. McLaughlin JS: Physiologic consideration of hypoxemia in shock and
Cotton RT,Seid AB: Management of the extubation problem in the pre- trauma. Ann Surg 173:667-679, 1971.
mature child: anterior cricoid split as an alternative to tracheotomy. Machiedo GW, Rush SF Jr: Comparison of corticosteroids and
Ann Otol Rhinol Laryngol 89:508-571, 1980. prostaglandins in treatment of hemorrhagic shock. Ann Surg
Fell T, Cheney FW: Prevention of hypoxia during endotracheal suction. 190:735-739,1979.
Ann Surg 174:24-28, 1971. Madden JL: Atlas of Techniques in Surgery. New York, Appleton-
Fischer JE, Turner RH, Herndon JH, Riseborough EJ: Massive steroid Century-Crofts, 1958.
therapy in severe fat embolism. Surg Gynecol Obstet 132:667-672, Mauney FM Jr, Ebert PA, Sabiston DC Jr: Postoperative myocardial
1971. infarction: A study of predisposing factors, diagnosis and mortality
Flanagan JP, Gradisar I, Gross RJ, Kelly TR: Air embolus: A lethal com- in a high risk group of surgical patients. Ann Surg 172:497-503.
plication of subclavian venipuncture. N EnglJ Med 281:488-489,1969. 1970.
EMERGENCY PROCEDURES
Millikan JS, Moore EE, Steiner E, et al: Complications of lube Schechter DC: Role of the humane societies in the history of resus-
thoracotomy for acute trauma. Am J Surg 140:738-741, 1980. citation. Surg Gynecol Obstet 129:811-8IS, 1969.
Morain WD: Cricothyroidotomy in head and neck surgery. Plasl Stankiewicz JA: Complications of endoscopic intranasal ethmoidec-
Reconstr Surg 6S:424, 1980. tomy. Laryngoscope 97:1270-]273,1987.
Newmark SR, D1uhy RG: Hyperkalemia and hypokalemia. JAMA Stankiewicz JA: Blindness and intranasal endoscopic ethmoidec-
231:631-633,1975. tomy: Prevention and management. Otolaryngol Head Neck Surg
Pad berg FT, Ruggerio J, Blackburn GL, Bistrian BR: Central venous 101:320,1989.
catheterization for parenteral nutrition. Ann Surg 193:264-270, Sweeney PJ, Breuer AC, Selhorst lB, et al: Ischemic optic neuropathy:
1981. A complication of cardiopulmonary bypass surgery. Neurology
Pappelbaum S, Lang TW, Bazika V, et al: Comparative hemodynamics 32:S60-563, 1982.
during open vs. closed cardiac resuscitation. JAMA 193:6S9-662, Sweet RH: Thoracic Surgery. Philadelphia, WB Saunders, 1950.
1965. Thompson OS, Eason CN: Hypoxemia immediately after operation.
Parker MM, Parrillo JE: Septic shock. JAMA 250:3324-3327, ]983. Am J Surg ]20:649-6S1, ]970.
Phinney RB, Mondino BJ, Hofbauer JD, et al: Corneal edema related Tisi GM, Twigg HL, Moser KM: Collapse of left lung induced by arti-
to accidental Hibiclens exposure. Am J Ophthalmol 106:210, 1988. ficial airway. Lancet 1:791-793, 1968.
Pierce WS, Tyers Fa, Waldhausen JA: Effective isolation of a Trunet P, LeG all JR, Lhoste F, et al: The role of iatrogenic disease in
tracheostomy from a median sternotomy wound. J Thorac admissions to intensive care. JAMA 244:2617-2620,1980.
Cardiovasc Surg 66:34], 1973. Twigg HL, Buckley CE: Complications of endotracheal intubation.
Puryear GH, Osborn JJ, Beaumont JO, Gerbode F: The influence of AJR Am J Roentgenol 109:4S2-454, ] 970.
adjuvant ventilators in the respiratory effort of acutely ill patients. Vernon S: The ideal initial infusion in unexpected shock. Surg Gynecol
Ann Surg 170:900-909, ] 969. Obstet 13]:748-749, 1970.
Randall HT: American College of Surgeons Manual of Preoperative Weale FE, Rothwell-Jackson RL: The efficacy of cardiac massage.
and Postoperative Care. Philadelphia, WB Saunders, 1967. Lancet 1:990-992, 1962.
Riker WL: Cardiac arrest in infants and children. Pediatr Clin North Yee ES, Verrier ED, Thomas AN: Management of air embolism in
Am 16:661-669, 1969. blunt and penetrating thoracic trauma. J Thorac Cardiovasc Surg
Salyer JM: Management of spontaneous pneumothorax or pneumo- 85:66]-668, ]983.
mediastinum in the newborn. Surg Gynecol Obstet 131: 11S-1I6, Zimmerman JE: Respiratory failure complicating post-traumatic
1970. acute renal failure: Etiology, clinical features and management.
Samuel JR, Beaugie A: Effect of carbon dioxide on the intraocular Ann Surg 174:12-18, 1971.
pressure in man during general anesthesia. Br J Ophthalmol
58:62-67, 1974.
3 BASIC
CONSIDERATIONS
Needle Biopsy Techniques over the material, which may crush the cells and make
it very difficult for the cytologist to identify the charac-
There are two techniques of needle biopsy: needle aspi- teristic of the cells. When aspirating a thyroid nodule,
ration biopsy and core needle biopsy. hyperextension is at times helpful; this is achieved by
placing a pillow under the patient's shoulders. Care must
Needle Aspiration Biopsy be taken to avoid puncturing the great vessels and the
trachea.
Needle aspiration biopsy is a special method of biopsy
that is not to be used indiscriminately and hence deserves Large-Needle Aspiration Biopsy (See Fig. 3-')
some clarification of its role. There are basically two
types of needle aspiration biopsy: fine-needle aspiration This technique is primarily of historical interest. Large-
biopsy and large-needle aspiration biopsy. needle aspiration uses an IS-gauge needle with a stylet
and a large syringe. A small amount of local anesthesia
Fine-Needle Aspiration Biopsy is usually utilized, and a No. 11 blade knife is used to
puncture the skin, thereby avoiding withdrawal of any
Fine-needle aspiration (used almost exclusively by this squamous cells from the epidermis or dermis. Negative
author) requires a 22- to 25-gauge needle without a pressure is applied when working the needle back and
stylet and a small syringe. No anesthetic is used. The forth in the mass. The negative pressure is usually con-
aspirant is usually not drawn or is minimally drawn into tinued as the needle is withdrawn, and the aspirate is
the syringe unless the mass is cystic. Negative pressure collected on the base of the plunger and barrel and then
is applied only while the needle is working back and removed with a small "rake" and smeared on the slides.
forth at various angles in the mass, and then the needle The specimen is primarily in the syringe and possibly
is withdrawn without negative pressure. Ideally, the in the needle as well. This minimizes the question of
specimen is thus retained in the needle. The contents implant along the needle tract. Again, the fixation of
of the needle are then spread on glass slides by first the slides depends on the wishes of the pathologist.
removing the needle from the syringe and filling the
syringe with air. This prevents the aspirate from being Core Needle Biopsy
drawn into the syringe. The slides are fixed and/or air
dried, depending on the wishes of the pathologist. At Core needle biopsy requires, for example, a Silverman
times some blood is aspirated into the syringe. When needle or Tru-Cut needle. The core is then fixed in for-
spreading the material it may well be that the last amount malin and sectioned as a histologic specimen. Silverman
in the syringe has a concentration of the cells in ques- needle biopsies and Tru-Cut biopsies in the head and
tion. Hence, care should be taken when ejecting the neck are very seldom used and never in any vascular
last amount of material from the syringe. To remove any structure, for example, a thyroid gland, unless the lesion
residual aspirant in the hub of the needle, use a dispos- is extremely hard and avascular on a fine-needle aspi-
able interdental brush (Sunstar Butler GUM Proxabrush ration. Details of the utilization of the Tru-Cut biopsy
Trav-Ler Model 1614) inserted in the hub and smear on technique are supplied by the manufacturer, which is
slides. Another technique (described by the French) Baxter Healthcare Corporation.
when the aspirate is blood is to insert the needle a
second time with the barrel of the syringe attached but Discussion
without the plunger. The material is then more likely to
be retained in the needle. After the needle and barrel of Various types of needles have been devised as well as
the syringe are removed from the area aspirated, the various syringe devices. Close cooperation with the
plunger is reinserted in the syringe and the material is concerned pathologist is most important. Some centers
spread on glass slides. When spreading the materials, have the pathologist present at the time or even have the
spread as one would do a blood smear. The end of the pathologist perform the actual biopsy. If at all possible,
slide is used to spread rather than facing another slide the site of the needle puncture should be in a line of
87
BASIC CONSIDERATIONS
possible surgical excision for the definitive surgery. At nodes reveals thyroid tissue, the diagnosis of metastatic
times it is worthwhile to mark the needle site with India cancer of the thyroid is virtually certain, realizing the
ink to facilitate excision of the entire needle tract. This extremely low incidence of normal thyroid tissue in cer-
is considered mainly when aspirating a lymph node in vicallymph nodes. When aspiration of a lateral cervical
the neck and not in thyroid aspiration. Success of needle lymph node reveals pinkish, dark, or yellowish cystic
aspiration depends on both the surgeon's and the fluid, or even frank, slightly thickened blood (be sure not
pathologist's knowing its restrictions and limitations. in vessel), the surgeon must first think of metastatic
Only after a complete head and neck examination should carcinoma of the thyroid even though no thyroid mass
it be considered as an aid in determining the nature of is palpable. Black or murky aspirants are suggestive of
the mass in the neck, if its main use is for tumefactions a branchial cleft cyst or metastatic thyroid carcinoma.
in the neck when metastatic squamous cell carcinoma is Murky aspirant with slightly blood-tinged material is
suspected, or when a primary lesion cannot be found. suggestive of a necrotized metastatic squamous cell
A fine-needle aspiration biopsy of the thyroid offers carcinoma.
the physician an opportunity to obtain a histologic diag- Some surgeons question whether a fine-needle aspi-
nosis of thyroid pathology but has definite limitations. ration of the thyroid is indicated when the clinical diag-
It is performed with neither special equipment nor local nosis is very suspicious of carcinoma. The patient will
anesthesia and usually permits a prompt interpretation. likewise question the rationale of fine-needle aspiration
Its reliability depends on the expertise and competence under the circumstances. Nevertheless, fine-needle
of the surgeon and cytopathologist. Fine-needle aspira- aspiration does serve several purposes, if it is positive
tion of thyroid masses that may be difficult to palpate for carcinoma:
but that appear on a radionuclide iodine thyroid scan
and/or a sonogram can be performed by using high- I. Ability to discuss the various aspects of the diagnosis
resolution ultrasound. This is accomplished with a small and management of thyroid cancer with the patient
transducer placed laterally to the thyroid and directed and the family and make plans accordingly. On the
medially and is a great help not only in locating the mass other hand, some surgeons will say that if the fine-
but also in directing the fine needle. The needle itself may needle aspiration fails to reveal malignant cells, then
or may not be visible on the screen, but, for example, the patient might defer surgery. If this is so, this may
its deflection of the anterior and posterior walls of a be a serious calamity when the clinical diagnosis
cyst is clearly visible. Ultrasound thyroid imaging is also points to malignant neoplasm.
useful in following the size of the thyroid mass when 2. If fine-needle aspiration is positive for malignant cells,
the patient is on suppression therapy. then computed tomographic (CT) scanning and/or
Limitations of cytologic diagnosis include difficulties magnetic resonance imaging (MRI) of the neck and
in interpretation of follicular lesions and Hiirthle cell mediastinum is indicated to further evaluate the pres-
lesions and in trying to discriminate between benign and ence of cervical lymphadenopathy, which may not
malignant lymphocytic lesions. Fine-needle aspiration be clinically palpable.
of a follicular neoplasm cannot distinguish whether the
neoplasm is benign or malignant. The latter diagnosis It also can aid in the differentiation of a solid from a
is based on histologic findings of vascular invasion and cystic lesion.
capsular invasion. If the fine-needle aspiration of a thy- In lymphoma, needle aspiration usually cannot facili-
roid mass reveals clear fluid or slightly xanthochromic- tate a definitive diagnosis (only a suggestion) and open
colored fluid, then the diagnosis is almost certainly a biopsy is necessary. In tumors of the salivary glands,
parathyroid cyst (see section on fine-needle aspiration needle aspiration is used only in very selective situations,
in Chapter 18). An example of fine-needle aspiration is particularly when a positive diagnosis of a malignant
the difficulty, if not impossibility, of differentiating a tumor would significantly change the operative approach
micro follicular pattern cytology, whether benign or malig- or if the mass is suspected to be a lymph node. If there
nant. Under these circumstances most surgeons would is diffuse swelling of a major salivary gland, fine-needle
recommend lobectomy, isthmectomy, and frozen section. aspiration may yield some diagnostic information (e.g.,
Well-documented studies indicate the reliability of posi- lymphoepithelial disease [Godwin's disease)). If a
tive interpretations to be about 95%, whereas negative chemodectoma is suspected, fine-needle aspiration using
interpretations are only 75 %. In the final analysis, needle a 22- or 25-gauge needle can usually be performed with
aspiration, if it is utilized, must not be the sole method- minimal morbidity. Either frank blood may be obtained
ology in making the diagnosis but most be correlated or, in fact, a smear with an adequate number of cells will
with the other clinical and laboratory findings as well facilitate the diagnosis. Obviously, a pulsatile mass-to
as the important facets of the history. It is, however, of be distinguished from transmitted pulsations-should
distinct value when enlarged cervical lymph nodes not be aspirated. Apart from needle aspiration, CT with
accompany a thyroid mass. When aspiration of such enhancement, magnetic resonance angiography (MRA),
BASIC CONSIDERATIONS
or MRI can lead the clinician to the definitive impres- vessel. Otherwise the aspiration can be done under
sion that a paraganglioma is present. These are nonin- sonography because the needle can be seen and thus
vasive studies and offer a distinct advantage over the avoid the vessel. In addition, clearance between the
arteriogram. However, once CT, MRA, or MRI is positive, node and the vessel may be visualized with a sonogram.
a bilateral arteriogram is usually indicated to obtain Another application of fine-needle aspiration is aspira-
more detailed anatomy of the vessels. Paraganglioma tion of the lung in conjunction with CT.
can be bilateral (see Chapter 22).
An acellular or "negative" needle aspiration should
not be interpreted as a definitive diagnosis of a nonma- Large-Needle Aspiration Biopsy
lignant lesion. The limitation of fine-needle aspiration (After Martin, 1934) (Fig. 3-1)
biopsy cannot be overemphasized under such circum-
stances. On the other hand, when it is certain that the
aspiration needle is in fact inserted into a mass, and A With a local anesthetic injected into the overlying
clear material is obtained (not cystic fluid), a lipoma is skin and using a No. 11 blade, a small stab wound is
to be suspected. The cytology report usually states that made in the skin directly over the mass. Only the skin
the material is acellular. A report of an acellular aspirate is entered, not the mass itself. The stab wound should
in a very hard mass may also indicate a neurofibroma be placed so that it can easily be included in the
or traumatic neuroma (e.g., a small, sometimes tender, standard neck dissection incision if operation becomes
movable mass in the region of a transected cervical sen- necessary.
sory nerve following a radical neck dissection). These
are not to be construed as certain diagnoses but simply B A large-bore needle (No. 17 is ideal) with stylet is
suspicious impressions. inserted through the stab wound into the mass, with
A not uncommon problem is the palpation of a the index finger holding the stylet in place. The
lymph node overlying and suspected to be fixed to the purpose of the stab wound and stylet is to facilitate
bifurcation of the carotid artery or the internal carotid ease of insertion and to avoid picking up cells from the
artery. If the estimated thickness of the node is close to skin and other overlying tissue.
or over 1 em, then insertion of the fine needle in a hori- Continued
zontal or oblique plane is done to avoid the underlying
FIGURE 3-1
BASIC CONSIDERATIONS
o E
Commonly Used Terminology for 9. TTF-I: Used to differentiate thyroid and lung tumor
Squamous Epithelium from other tumors.
Ashok Koul
Z-Plasty (Continued) (Fig. 3-2) becomes less than 30 degrees and hence reduces
practicability of the Z-plasty.
Technique of Basic Z-Plasty 3. A word of caution regarding the use of an extensive
Z-plasty in the primary closure of a wound for a malig-
Highpoints nant lesion: Margins must be free of disease for fear
of implantation of tumor cells along the transposed
1. Optimal flap angle is 60 degrees. This will rotate scar flaps.
or incision 90 degrees (A and Al). 4. Tip necrosis may occur. Wilkinson and Rybka (1971)
2. Be sure resultant rotated scar is in or in line with the have shown experimentally that glue or tapes prevent
natural skin crease. The base ends of the lateral tip necrosis.
arms should be in the line of the natural crease (A 5. Too much lateral tension occurs with larger flaps in
and Al). tight surrounding tissue.
3. Realize effect of changes of flap angle to gain in length 6. Strangulation of blood supply with suture may
of scar line and the degree of rotation of scar line. occur.
The smaller the angle, the less the gain in length and
the smaller the amount of rotation (H and I).
4. The smaller the flap angle, the greater the danger of A The scar, web, or linear contracture extends along
tip necrosis (points X and Y of A); the larger the flap the line X-V (central arm). An incision or excision of a
angle, the more tension on surrounding tissue. small amount of skin is made along the line X-YoFrom
5. Carefully place sutures to avoid strangulation of points X and Y two other incisions (lateral arms), each
blood vessels. of equal length to the line X-Yare made to Xl and V',
6. Each lateral arm should be the same length as the respectively, at a 60-degree angle (flap angle) (range is
central arm in the classic Z-plasty. 30 to 90 degrees). Points Xl and Y' are along the
7. As a check for correct planning of the classic Z- natural skin crease.
plasty with 60-degree flap angles, an imaginary line
(natural skin crease) connecting the base ends (points B The flaps formed by X and Yare widely under-
XI and yl of Al) of both lateral arms should pass mined with extreme care to preserve both arteries and
through the midpoint of the central arm. veins. Small skin hooks or fine nylon sutures are used
8. It may be advantageous to have a set of dividers and to handle the flaps. Trauma must be minimal. The
protractor in the sterile field. transposition is begun by rotation of Y to Y'.
Limitations and Complications C X is rotated to X'. Sutures of 5-0 or 6-0 nylon are
usually used. These sutures are placed slightly obliquely
1. Dog-ears are likely to form near the base of the trans- to relieve tension along central arm after closure.
posed flaps. If these require excision, they cannot be
excised toward the base but rather away from the D, D1 Rotation is completed. The scar line (central
base (see Fig. 3-4A to C). arm) has been rotated 90 degrees, and the distance
2. When an angle formed by a scar with a natural skin between points 1 and 2 has been increased 75%. These
crease is progressively less than 50 degrees, the geometric figures refer to a flap angle of 60 degrees.
angle of the tip of the transposed flap of the Z-plasty Continued
BASIC CONSIDERATIONS
y'_.
FIGURE 3-2
BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2) The flap angle can be varied from a range of 20 to
90 degrees, with the most variable range around 60
degrees. The smaller the flap angle, the less percentage
E TO G If a parallelogram is outlined around the rate of increase in the length of the release (McGregor,
corners of the Z-plasty, some interesting theoretical 1962):
measurements are obtained:
The short diagonal of the parallelogram before the • 30-Degree angle yields 25% increase in length.
Z-plasty (which is the length of the scar contracture) • 45-Degree angle yields 50% increase in length.
between points 1 and 2 in E becomes the long diagonal • 60-Degree angle yields 75% increase in length.
of the parallelogram after the Z-plasty (points 11 and
2' in F). These diagonals approximately maintain their
respective lengths when rotated; hence the distance H, I The smaller the flap angle, the lower the
gained in any classic Z-plasty between points 1 and 2 number of degrees the central arm or "scar" line is
corresponds to the long diagonal minus the short rotated. This is important in planning the resultant
diagonal (G). Expressed in another way, the total length arm to lie in a natural skin crease (dotted line).
desired between points 1 and 2 after the Z-plasty can Variations of flap angle end in various positions of the
be easily achieved by constructing a parallelogram resultant central arm, which is the long diagonal of the
before the Z-plasty whose long diagonal is equal to parallelogram. This demonstrates how a Z-plasty is
the final desired length and the direction of the final or varied so that the resultant central arm can rest along
resultant central arm. a natural skin crease. This is further shown in the
The shaded triangle in E corresponds to one rotated following steps.
Continued
flap of a Z-plasty, the base being the dotted line, which
is shown transposed in F. The nons haded triangle is
the corresponding flap in the Z-plasty, the dotted line
being the base. Points A and B refer to the tips of the
respective triangular flaps, which are transposed.
BASIC CONSIDERATIONS
60'
E ,<
B
SCAR 2 NATURAL
TO BE EXCISED SKIN CREASE
LENGTH
TO BE INCREASED
SHORT DIAGONAL
(CENTRAL ~RM)
I LONG DIAGONALI
I
NATURAL INCREASED
SKIN CREASE l' LENGTH l'
\ I
I
\ I
I
I
GAIN I
I
I
I
I
I
LONG DIAGONAL
SHORT DIAGONAL
F
2' 2 2'
SCAR
LINE
I ...
FIGURE 3-2 Continued
BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2) The smaller the flap angle, especially less than 30
degrees, the greater the danger of tip necrosis. The larger
the flap angle (especially over 90 degrees), the greater
J TO L First select the length of the central arm that the tension on the surrounding tissue, with too much
may equal the entire length of the scar or a part thereof. borrowing from each side. These larger angles tend to
If the scar is long, multiple Z-plasties are necessary (see result in larger dog-ears at the base of the triangle.
5 and T). The midpoint of the central arm should lie on Clinically, a GO-degree flap angle has been shown to
the natural skin crease (J), and the base end of each be the largest angle that will allow transposition of
lateral arm must be located on the natural skin crease triangular flaps while achieving the greatest increase of
(K). Each lateral arm is equal in length to the central length along the central arm or line of contracture. With
arm. A protractor can be of aid in the determination of this angle the central arm is rotated 90 degrees. As the
these measurements. L demonstrates the final result. central arm length is increased, the greater is the per-
(To achieve a more pleasing result, the lateral arms can centage increase in length. Depending on the relative
be slightly curved.) position of scar to natural skin crease, the two flap
angles may be of unequal size (Ql. This is also referred
to as half Z when one of the angles is 90 degrees.
M, N The direction of linear scars or webs or linear 0, P Scar across nasolabial fold is converted
contractu res is changed from vertical to horizontal in to lie in and along the natural skin crease of the
scars of the neck. The size of the Z-plasty is large for nasolabial fold.
clarity's sake. In actual practice multiple Z-plasties with Continued
a long scar are preferred (see Sand T) or a slight
curvature of the lateral arms.
BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2) arms are usually short, as used in the face or neck.
This technique is useful for large scars of the cheek,
where, as in the latter case, the surrounding tissue is
Q I ncrease the length between the ends of the tight or has lost its elasticity. A single Z-plasty in a long
original scar contracture, for example, lengthening of scar would be impractical and almost devastating on
the contracted tissue causing upward distortion of the the cheek.
upper lip. 4. S-plasty (see W)
5. W-plasty (Borges, 1959) (see X and Y)
R Release and redistribution of tension along linear
contracture breaks up unsightly scars of cheek and Continuous Types (Entire Scar Excised)
thus returns some elasticity, aiding in normal facial
expression. This is accomplished either by multiple Z-
plasties (see Sand T), by opposing Z-plasties (see U 5 Depicted is a series of continuous Z-plasties in which
and V), or by W-plasty (see X and V). all the arms are equal, all the angles are 60 degrees,
and all the lateral arms are parallel. The entire scar con-
tracture is excised in a continuous line. The lengthening
Types and Modifications of of the scar contracture is obvious.
Z-Plasty 51 Depicted is a similar type of continuous Z-plasties,
except that the lateral arms are independent with a
1. Single Z-plasty (M and N). The single or basic Z-
space between each Z. '
plasty has multiple applications as previously
described. By and large, however, it is limited to
relatively short scars. It can be useful in longer scars Interrupted Types (Portions of Scar
only when the surrounding tissue is very loose, as, Excised)
for example, in the neck.
2. Half Z-plasty (Q and R). This is actually a variant of
T Depicted is a series of multiple Z-plasties of equal
the angles of a basic Z-plasty. It simply means that
size similar to those in Sl except that intervening por-
an increase is made at right angles to a wound into
tions of the linear scar between each Z are not excised.
which is transposed one triangular flap (Q). This is
The length of the remaining portion of the scar varies
useful in the elongation of a wound, especially the
according to the desired result.
short side of a curved defect (R).
3. Multiple Z-plasties (5 and T, 51 and Tl) (Davis and
T1 This series of interrupted multiple Z-plasties differs
Kitlowski, 1939; Limberg, 1963; Morestin, 1914).
from those in T in that two are opposite. These are the
Multiple Z-plasties are two or more Z-plasties in
so-called opposing Z-plasties.
either a continuous series or interrupted series, with
Continued
a number of other modifications. Of necessity the
BASIC CONSIDERATIONS
T TI
FIGURE 3-2 Continued
BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2) good match of color, texture, sensation, hair, and sweat
and sebaceous glands. The dermis becomes thinner but
may revert to normal after the prosthetic balloon is
U, V Depicted in steps U and V is an example of the removed. Collagen synthesis is increased in the papillary
excision and reconstruction of a scar on the side of the dermis secondary to fibroblast formation. Myofibroblasts
cheek. This technique is very useful in upsetting the develop. Hair follicles remain the same in structure and
tension of contractu res, especially on the cheek (after number and become separated. Adipose tissue is decreased
Converse, 1964). in thickness, probably permanently. Muscle becomes
thinner, but there is no loss of function. Blood vessels
W S-Plasty. The lateral arm of a basic Z-plasty may proliferate; increased vascularization of the skin with
curve in a convex arc. This aids in preserving the blood distention of capillaries and an increase in the number
supply, especially in burn scars in which the blood of arterioles becomes evident within several days. Because
supply is compromised. The full application of this of the dense vascular pattern, viability and survival of
modification is in the neck, where a large S-plasty is expanded tissue is similar to that of delayed flaps.
performed. This is possible because of the laxity of the
surrounding tissue.
Effects of Tissue Expansion (Cherry et aI.,
1983)
Tissue Expansion (See Fig. 3-2Wl)
Tissue expansion permits an increase in the length of a
Versaci and Balkovich (1984) reviewed the history of flap as compared with nondelayed random flaps (dermal
tissue expansion dating back to 1905. The technique and subdermal plexus) and improves random flap
was revived by Neumann (1957), and important recent survival by increasing vascularity. Skin is not simply an
contributions have been made by Radovan (1982, elastic membrane but has dynamic properties responding
1984), Austad and associates, (1982), Sasaki and Pans to the tissue expander. This response allows many
(1984), Argenta and associates (1984), and Kabaker applications in terms of modifications in flap design,
and colleagues (1986). length, and overall size (Sasaki and Pans, 1984). After
implantation a dense fibrous capsule develops on the
Anatomic Physiology implant due to elongated fibroblasts. This capsule
becomes thinner when the implant is removed.
The epidermis undergoes no significant decrease in
thickness during tissue expansion. There is usually a
U
FIGURE3-2 Continued
BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2) at a second stage or (2) utilize short-term expansion
(Sasaki) intraoperatively by expanding tissue for
Device (After Radovan) reconstruction for a period of 15 to 30 minutes. This
technique can facilitate closure of defects of up to 3 or
A silicon balloon is inserted via a silicon tube to which 4 cm without long delay and can minimize the possible
is attached an injection port. As shown in the photo- complications of infection and prolonged deformity at
graph (Wl), various sizes and shapes of balloons are the donor site. Avoid resection of surplus skin over
available. dead space; these areas usually contract eventually.
Anesthesia is usually local plus basal. The incision is Tissue expansion can be used for defects secondary to
made as small as possible, just large enough to insert trauma, congenital lesions, and resection for carcinoma.
the empty balloon, alongside or near the tissue to be Sites include the scalp, forehead, and face. Tissue
expanded. Injection ports are kept away from the tissue expansion can be used before random flaps and free
to be expanded and are buried under the skin by blunt flaps and in excision of cicatricial deformities with
dissection so that they are easily accessible for injec- closure by advancement or transposition flaps. Other
tion of saline solution. For scalp expansion a 250-mL potential applications have been suggested by Argenta
balloon is inserted in the subgaleal plane. and associates (1984).
The balloon is expanded using sterile saline with
gentamicin. The balloon is partially filled immediately Complications and Potential Problems
after the initial incision, and systemic antibiotics are given
for 5 to 7 days. After 10 to 14 days additional injections • Infection, avoided by strict sterile technique
of 10 to 30 mL, depending on the size of the balloon, • Skin necrosis
are given at 3- to 5-day intervals (some surgeons inject • Patient reluctance due to swelling of the expander.
every 7 to 10 days) usually over a period of 6 to 8 weeks. Explain that this technique will usually result in a
If pain does not subside within 5 to 10 minutes, the smaller number of surgical procedures for large
saline solution is withdrawn. defects that ordinarily would require several staged
Another technique is rapid injection over a period of operations.
24 to 48 hours to blanching of the skin and then with-
drawal of some of the sterile saline solution.
Careful monitoring for pain and skin necrosis is most W-Plasty (See Fig. 3-2X and Y)
important. Avoid any dead space, and thus avoid the
use of drains. However, suction drains may be necessary
if dead space or significant dog-ears appear. x, Y The W-plasty is a method of excising a scar to
Occasionally two or three balloons can be used break up a straight line by removing small
simultaneously in two areas. If there is insufficient interdigitating triangles on either side of the scar line.
expansion of the skin when the balloon is removed, the It is useful in depressed linear scars of the cheek when
process can be repeated. no lengthening of the line of contracture is necessary.
The diseased area is resected when the balloon is The W-plasty, unlike the Z-plasty, does not gain length.
removed, and the defect is closed by advancement or A metal template or bent flap metal strip modeled to
rotation flaps of the expanded skin. If the lesion is correspond to small equal triangles is useful to mark
malignant, the delay necessitated by the usual technique the area for the line of excision (X). McGregor (1962)
of tissue expansion is obviously not possible. TWooptions has demonstrated modification of the W-plasty for the
are available: (1) temporarily cover the defect with a closure of an oval wound (Y).
split-thickness skin graft and then use tissue expansion
BASIC CONSIDERATIONS
~2
Rhombic Flap (After Limberg, 1963; 3. The short diagonal of the flap should parallel as closely
Modified After Gunter, 1983; Bray, as possible the lines of maximum extensibility (LME).
1983) (Fig. 3-3) These lines are at right angles (perpendicular) to the
natural skin folds referred to by Borges (1959) as the
The rhombic flap is based on the mathematic shape of relaxed skin tension lines (RSTL). This principle is
a rhombus, which is an equilateral parallelogram in demonstrated in Figure 6-21H and I, where the short
which all sides are equal in length and the opposite sides diagonal of the flap is at right angles to the naso-
are parallel. There are two equal obtuse angles opposite labial fold.
one another and two equal acute angles opposite one 4. Although the flap closes the defect, the donor site is
another. The basic Limberg rhombus has two 120-degree closed by undermining and mobilizing the skin that
obtuse angles and two 60-degree acute angles. It is forms the outer margin of the donor site, line E-F in
important to understand this basic mathematic calcu- C. Hence, the flap must be planned so that transpo-
lation to utilize this flap as well as minor modifications sition of line E-F will not cause distortion. Other-
of it. A rhomboid, on the other hand, is a parallelogram wise, the vector of tension (VaT) (D) will be changed,
in which the pairs of opposite sides are either longer or and distortion of other structures will occur. At times,
shorter in length than the pairs of the other side. compromises may be necessary. This should all be
calculated before the flap is actually incised.
Highpoints 5. Exact geometry is not always necessary if there is
sufficient mobility of surrounding skin.
Basic geometry of the perfect or ideal rhombic flap: 6. Modifications will be necessary if frozen sections
indicate inadequate margins in the resection of a
1. All sides are equal. malignant lesion.
2. Opposing angles are equal.
3. The ideal acute angle is 60 degrees; the ideal obtuse
A The shaded area is the ideal defect, planned
angle is 120 degrees.
primarily to resect all disease with adequate margins
4. The flap is exactly the same geometric size, shape,
and four possible juxtaposed donor sites. The choice of
and angles as the defect, including the length of the
the donor site should be such that the donor site short
short diagonal and the long diagonal of the
diagonal is parallel to the LME.The long diagonal of
parallelogram.
the defect equals the length of the long diagonal of
5. The long diagonal (B, line A-El) of the flap forms a
the donor site, both represented by the dashed lines;
60-degree angle with the long diagonal (B, line A-C)
the short diagonals are likewise equal, both repre-
of the defect in any of the four possible (A and B)
sented by the dotted lines. Point A is the pivot point
donor sites of the flap. Both long diagonals are the
with a 60-degree angle formed by both long diagonals.
same length and are represented as the line with
The base of the flap is the line represented by dashes
dashes in A.
and dots and obviously left intact. This is the space
6. The short diagonal (B, line D1.F) of the flap equals
between points A and F in Band C.
the short diagonal (B to D) of the defect, and the two
are represented by the dotted lines.
B The donor site has been chosen, again empha-
7. The pivot point, the point on which the flap turns,
sizing that both defect and donor site are geomet-
is A, whereas Dl, El, and F are the mobile or rotated
rically identical. The short diagonal line B-D of the
points (el.
defect equals the length of the short diagonal of the
donor flap as well as the side line Dl-E' of the flap. 0'-
Planning the Flap
E' is a straight line continuation of the short diagonal
line B-D.
1. The flap is outlined on the side of the defect that has
the most relaxed and available skin.
2. The flap site must avoid areas that, if mobilized, would
create additional defects; that is, avoid a donor site
that might distort the ala nasi or the lower eyelid.
BASIC CONSIDERATIONS
B E
A F A
B C o
FIGURE 3-3
C Mobilization of the flap. Ideally, this is accom- then requires widening the flap along the line Dl_F,
plished by rotating the flap on the fixed point A, with which can be accomplished if the skin of the donor site
point F mobilized and being moved to point D, which has sufficient elasticity, a factor that should be
is relatively fixed. This results in a vector of tension evaluated before the choice of the donor site.
(VaT), as depicted in D. If, on the other hand, point D
must be moved toward point F to effect closure of the D The ideal closure demonstrates the ideal vaT.
donor site, then the vaT changes toward point B. This Examples of this type of flap with modifications are
in turn lengthens the width of the defect B-D. This depicted in Figure 6-21 E to I.
BASIC CONSIDERATIONS
A The dog-ear has resulted from unequal lengths of Dog-ears can also be prevented by a modified W-
each side of the repair. plasty, as depicted on 3-2X and y.
A 3 c 2
FIGURE 3--4
BASIC CONSIDERATIONS
Bone, Cartilage, and Nerve Grafts preserve perichondrium when possible and when curling
(See Figs. 3-5 to 3-8) is not a detriment.
In an animal experiment preserving the perichondrium
Basic Principles Relative to Bone and in free cartilage grafts Duncan and co-workers (1984)
Cartilage Grafts and Implants concluded: "The results obtained strongly suggest that
(After Schuller, 1980) perichondrium responds briskly to repair injury and
that the breaking load is greater in the presence of
See also the discussion of osseous microvascular free perichondrium and increases with time. It is suggested
grafts in Chapter 24. that perichondrium be included with free cartilage grafts
for optimal survival and intercartilaginous healing."
Bone Grafts The question has been raised whether the experiments
should be repeated using costochondral cartilage, as this
TYpesof bone grafts include autologous bone and homolo- experiment was done with ear cartilage. Tardy (1985),
gous preserved bone (implant). Bone is a specialized however, does not believe that the perichondrium is
type of connective tissue covered by periosteum, which necessary for cartilage graft survival.
in turn is a specialized form of connective tissue. The Gibson, in 1957, introduced the principle of "balanced
bone is made up of (I) cortical bone, an outside firm cross sections of cartilage." This concept stems from
compact layer that provides rigidity, and (2) cancellous the fact that the cartilage has a subperichondrial layer
bone, an inside layer coupled with marrow and a spongy of flattened chondrocytes that maintains the inner zone
component that has the greatest osteogenic potential of the cartilage taut. Interruption of the balance of
for growth and thus prevents reabsorption of the bone these peripheral cells on one side will make the carti-
graft. Bone grafts in turn require two important items lage warp toward the opposite side. Strict adherence to
for success: (I) a good blood supply in the recipient bed the principles of balanced cartilage carving as stated by
and (2) mechanical stress (e.g., muscular contraction). Gibson will result in implanted cartilage grafts that will
Hence, the ideal bone graft should, if feasible, include not warp (e.g., Gibson selects cartilage and shapes the
both cortical and cancellous bone regardless of where' cartilage graft by trimming equal portions on each
and how the graft is utilized. side). This, of course, means that the perichondrium will
be sacrificed. When utilizing thin strips of peripheral
Donor Sites cartilage, gentle morsulization or cross hatching of the
subperichondrium will break the spring effect and
The choice of the donor site depends on the type of prevent warping.
reconstruction intended and includes the following:
Implants
• Rib
• Iliac crest 1. Alloplastic materials
• Septum-vomer and perpendicular plate of the a. Problem of rejection
ethmoid b. Migration
• Anterior wall of the maxilla c. Infection
2. Homologous bone and cartilage grafts
Cartilage Grafts a. Problem of rejection
b. Questionable vascularization
TYpes of cartilage grafts include autologous cartilage c. Infection
and homologous preserved cartilage (implant).
Rib, Iliac, and Costochondral Grafts
Donor Sites (Fig. 3-5)
• Costochondral Highpoints
• Nasal septum
• Auricular concha (see Fig. 6-26A to L) 1. Preserve periosteum with cortical bone graft or peri-
chondrium on at least one surface. There is some
The problem with cartilage grafts is that they tend to difference of opinion regarding this suggestion, with
curl with the concavity toward the perichondrium, if it more unanimity regarding the periosteum and the
is preserved. Despite this problem the author prefers to perichondrium in children.
BASIC CONSIDERATIONS
E A Doyen elevator completes the periosteal sepa- I A rectangular block is then excised with the aid of
ration posteriorly. If this is carefully performed, the a right-angle knife (Beaver Blade No. 64).
pleural cavity is not entered. When the pleural cavity is
inadvertently opened, it is necessary to use underwater J The excised block of cartilage with anterior layer of
drainage (see Fig. 2-5A to C) or to close the chest with perichondrium intact is shown. The wound is closed in
the lung fully expanded. layers.
BASIC CONSIDERATIONS
Neurovascular
hundle
rletal pleura
FIGURE 3-5
BASIC CONSIDERATIONS
1. Avoid injury to the lateral femoral cutaneous nerve. A Depicted is the incision for harvesting the auricular
Hence, the incision is made lateral and oblique to cartilage. The incision is made along the inner edge of
the iliac crest. the anthelix (see Fig. 6-26), maintaining a broad base
2. If the edge of the crest is not necessary for the for the skin flap. The perichondrium is included (one
reconstruction, utilize a segment beneath the crest, or both sides) in adults, but at least one layer of
the so-called trap door technique. perichondrium is left at the donor site in children. The
3. Use a medial bone approach if possible. skin flap is returned and approximated with 6-0 nylon
4. Replace the crest. sutures using cotton impregnated with antibiotics, or
povidone-iodine (Betadine) as a gentle compression
Complications dressing over the donor site.
FIGURE 3-6
B
FIGURE 3-7
BASIC CONSIDERATIONS
Sural Nerve Grafts (Fig. 3-8) If a single horizontal incision following a natural skin
crease does not give adequate exposure as, for example,
The sural nerve, which is on the posterolateral aspect in a thyroglossal cyst that lies at the level of the thyroid
of the lower extremity, accompanies the lesser saphe- gland or in a branchial fistula, multiple horizontal inci-
nous vein. It is formed by a junction of the medial sions in stepladder fashion solve the problem admirably.
cutaneous sural nerve and the anastomotic ramus of A skin incision made along the anterior border of the
the common peroneal nerve. This is a sensory nerve sternocleidomastoid muscle is entirely unnecessary
that supplies the skin of the posterior surface of the except in an extreme emergency. Even in an emergency
lower leg and the region of the lateral malleolus. tracheostomy, the horizontal incision is preferred.
There are exceptions to any rule of thumb. The expo-
sure for a radical neck dissection is the main exception.
Figure 3-8 depicts the anatomy of the sural nerve and Although multiple horizontal incisions (MacFee) can be
its formation from the two nerves, as just mentioned. used in this operation, the exposure and time consumed
This nerve branches and may be used as a nerve graft raise some questions (see Fig. 16-6A to F).
either in its branched form or in its single trunk form. Another exception may be a total laryngectomy for
Its terminal portion, the lateral dorsal cutaneous malignant disease in an individual with a long, thin
branches, is preferred for facial nerve reconstruction. neck, in whom two horizontal incisions may extend too
This nerve is distributed over the lateral portion of the far laterally and thus enter an area of later metastatic
foot. It can be obtained by two or more short hori- spread. This exemplifies a basic principle in operations
zontal incisions and can be carefully removed from its for malignant disease: avoid skin incisions for cosmetic
bed alongside the lesser saphenous vein. purposes and the use of skin flaps for reconstructive
purposes in and from regions to which metastatic
disease may later spread. This dictum eliminates the
use of the so-called sternocleidomastoid muscle flap in
Skin Incision reconstructive procedures associated with neoplastic
disease except in the rarest circumstances. Scars in
All skin incisions in the neck, with few exceptions, such areas will delay an early detection of metastases
should follow the natural skin creases. This is important and often make later radical surgery difficult.
from a functional as well as a cosmetic point of view.
Adequate exposure is accomplished by the development
of upper or lower skin flaps, which include the platysma Nonabsorbable Sutures for
muscle. The superior-based cervical flap in neck dissec- Mucosal Repair
tion has the best blood supply, and the posterior flap
has the poorest. After adequate skin flaps are elevated, Although nylon and Prolene suture materials have been
the deeper fascial incision may be changed as the shown to result in minimal tissue reaction and are uti-
exposure dictates. lized in repairs of mucous membranes of the oral cavity,
Skin incisions for operations in the superior cervical their use involving the mucosa in oropharyngeal, laryn-
regions should be 3 to 5 cm below the horizontal ramus geal, and hypo pharyngeal surgery has been found to be
of the mandible to avoid injury to the mandibular not as satisfactory. The problem is that loose loops, ends,
branch of the facial nerve. For operations in the inferior and knots are sites for the collection of debris, mucus, and
cervical region, the skin incision usually should be at food and are very difficult if not impossible to remove.
least 2 to 3 cm above the clavicle, because incisions If the sutures are totally buried, nonabsorbable suture
placed lower will tend to drop over the clavicle in time materials (nylon, prolene, or silk) are ideal; otherwise an
and become unsightly. An exception is the upper inci- absorbable material is recommended. Chromic gut is
sion for a deltopectoral flap, which lies close to the preferable, rather than Vicryl; the Vicryl appears to have
level of the clavicle. a longer than necessary absorption rate on mucosal repair.
BASIC CONSIDERATIONS
PERONEAL
ANASTOMOTIC N.
LESSER
SAPHENOUS V.
FIGURE 3-8
BASIC CONSIDERATIONS
may frighten an already apprehensive patient. 7. All apparently malnourished patients require
Preoperative visits by previously operated patients nutritional evaluation pretreatment by the hospital
mayor may not be wise, depending on the disfigure- nutrition team. Nasopharyngeal or nasogastric tube
ment or dysfunction present and the patient's own feedings may be advisable preoperatively in patients
personality and state of anxiety. After surgery plagued with severe nutritional deficiencies and
when the individual is recuperating, a visit by one swallowing problems; however, this method has
of these veteran patients may be extremely helpful. been replaced in many centers by percutaneous
The local chapter of the Lost Chord Club or the endoscopic gastrostomy (PEG) tube placement
International Association of Laryngectomees should (Fig. 3-9) (see also Chapter 21). This method is
be contacted about each new laryngectomy case so better tolerated, may be continued postoperatively
that a visit by one of these laryngectomees can be for as long as needed, and avoids having a tube
scheduled. Speech therapy must be arranged through across suture lines. Complication rates may be less
this organization or through a professional speech and survival rates improved when the nutritional
therapist. For those patients who are candidates for status is more nearly normal. Nutritional support is
a Blom-Singer procedure, such surgery can be provided to patients undergoing preoperative
planned when indicated. chemotherapy or radiation therapy.
Gastrostomy
tube
B
A
FIGURE 3-9 A, B, and D show the PEG tube; C is the Moss type placed at laparoscopy.
BASIC CONSIDERATIONS
TRACHEOSTOMY CARE
SEPARATE
STERILE
TRACHEAL
CATHETER
FOR
EACH
SUCTIONING
STOMA CLEANED
2x DAILY
-
NOTTHIS! BUTTHIS!
FIGURE 3-10
BASIC CONSIDERATIONS
catheter during each insertion and withdrawal to tracheal tube inserted at the end of the operation is
prevent trauma to anyone area of tracheal mucosa. normally deflated. Just before this, however, the
The thumb should be repeatedly placed over the nurse must be prepared to suction the remarkable
open end of the V-tube and removed during the pro- quantity of secretion that gathers above the inflated
cedure. Avoid prolonged and continuous suctioning cuff. This mucous material usually drops quickly
to prevent dangerous oxygen desaturation. An oxygen into the trachea on deflation. Never discontinue a
saturation monitor should be in use during suctioning. tracheostomy until it is certain that the patient has a
Hyperventilation with 100% oxygen is recommended satisfactory airway. Mirror or fiberoptic laryngoscopy
before suctioning, and brief oxygen inhalation while allows evaluation of the subglottic, glottic, and supra-
suctioning is used as needed. glottic airway. In spite of some criticism of this method,
Instill sterile normal saline solution with an eye- half- and full-corking is a satisfactory technique of
dropper or syringe without needle in 1- to 2-mL "weaning" the patient from a tracheostomy. However,
amounts every 2 to 4 hours and remove by suctioning one must be certain that the tracheostomy tube does
to prevent dry tracheitis. Detergents or enzymes may not fill the lumen of the trachea when corking is
be helpful locally in cases of severe dry tracheitis attempted! By gradually decreasing the size of the
with crusting. Remove and clean the inner cannula tracheostomy tube (from the standard NO.7 for men
of the tracheostomy at least every 4 hours. Remove, to NO.6 or No.5), the surgeon can then cork with
clean, and replace the entire tube every 1 or 2 days ease and finally remove the tube. Examine the
after the tracheostomy is well established (usually in larynx before corking or removing the tube. At times
5 to 6 days). Large crusts may require removal by tube removal aids in deglutition.
forceps (with the entire tube out if a solid tract is The patient must be able to pull the cork at any
present). If large crusts or obstructing crusts occur in time if breathing becomes difficult. Of course, the
a laryngectomy tube and cannot quickly be removed corked, inner cannula must be removed and cleansed,
from the tube, then remove the entire tube stat. Use just as previously described, until final discontinuance
extreme care when changing a tracheostomy tube in of the tracheostomy. When oral or laryngopharyngeal
an infant. Carry out the first change in the operating surgery with tracheostomy has been performed,
room or intensive care unit with a bronchoscope and remove the feeding tube when the patient is swal-
an endotracheal tube available. lowing with ease. The tracheostomy tube must be
A cuffed tracheostomy tube allows positive-pressure left in place as a "safety valve" in case aspiration
breathing when required. A low-leak technique will occurs. The surgeon must then carefully test the
minimize injury to the trachea, thus preventing tra- swallowing function to be certain that ingested liquid
cheal stenosis. Otherwise, the traditional noncuffed is not being aspirated before final termination of the
metal tube with inner cannula is desirable. The dis- tracheostomy. Here, food coloring added to liquid or
posable, cuffed plastic tube (without inner cannula) puree diet aids in evaluating aspiration.
has become popular with many thoracic surgeons in After partial laryngostomy, removal of the tra-
patients requiring very brief tracheostomies. This cheostomy tube may be necessary to initiate the act
tube has not been generally satisfactory in our hands of swallowing. Close observation for aspiration is
because of its large outer diameter and the lack of an necessary, and, if significant, the tracheostomy tube
inner cannula for cleaning purposes. The Shiley should be reinserted.
cuffed tube does have an inner cannula and is the 3. Laryngectomy stomata need care similar to that for
preferred product in our hands but is also difficult to tracheostomies (see Fig. 3-10). The entire laryngec-
insert and prone to tearing of the cuff. Some sur- tomy tube must be removed, carefully cleansed, and
geons (JML) prefer the Portex tubes with inner replaced at least twice daily by the surgeon, a member
cannula. The cuffed tube-if needed-is easier to of the house staff, or other trained personnel. At this
insert. The tube is made in various models, some of time the suture line is meticulously cleared of crusts
which are flexible. The low-pressure cuff is relatively with saline solution (if necessary with cautious appli-
atraumatic; and when it is inflated, only enough air cation of diluted peroxide to loosen any dried material).
should be injected to prevent leakage between the Avoid the use of peroxide within the stoma. It can
cuff and the wall of the trachea. When patients are cause obstruction in both the tracheostomy or laryn-
learning to swallow after extensive procedures with gectomy tube, as well as in the suction catheter.
preservation of the larynx, cuff inflation prevents Antibiotic ointment is then applied to the skin/mucosal
aspiration but is ordinarily contraindicated, because edge before tube reinsertion. If there is ulceration or
this merely hides evidence of aspiration of swallowed persistent erythema, tincture of benzoin may be
liquid and pureed foods. When the patient returns applied carefully to the edge of the stoma and to the
from surgery to the recovery room and respiratory surrounding skin. Most patients are allowed to go
assistance is no longer needed, the cuff of the endo- without the laryngectomy tubes for increasing periods
BASIC CONSIDERATIONS
during the waking hours after the first 2 to 3 days. and neck dissection, or operation through radiated
The patient should be taught self care as convales- tissue), a cephalosporin is administered beginning
cence continues, the goal being independence in care preoperatively for 24 hours.
on hospital discharge. Many surgeons prefer to keep Clean contaminated cases are those in which the
the tube in place at night until it is certain that a large surgical field is exposed to mucosal secretions (com-
rigid stoma has developed. In dry climates, prolonged bined oral and neck procedures, pharyngeal, sinus,
laryngectomy tube use and home humidification are and laryngeal procedures). Here, the wound is exposed
necessary to avoid dry tracheitis. Plastic "buttons" or to both aerobic and anaerobic bacteria and higher
stoma rings (especially the Helsper button) are help- wound infection rates are expected. Some proce-
ful in preventing stenosis when stomata are small and dures, such as skull base surgery, in which the
in treating stenosis (by dilatation with larger and larger central nervous system is exposed to pharyngeal
rings). A "bib" of porous gauze (without cotton filling), secretions and in which abdominal flap harvest is
moistened frequently with water, should be placed utilized, would be impossible without perioperative
loosely over the stoma at all times. If a plug becomes antibiotic use. In these cases, antibiotic administra-
lodged at the distal end of the laryngectomy tube, the tion is started preoperatively in full dose and discon-
entire tube must be removed STAT by anyone! This is tinued 24 to 48 hours postoperatively. In simpler
a life-saving procedure, since the author (JML) knows clean-contaminated cases (radical neck dissection
of one patient who died because of this incident. with oral or pharyngeal resection and free flap repair
4. Narcotic requirements are usually minimal after head or laryngeal surgery), 24- to 48-hour cephalosporin
and neck procedures compared with after abdominal coverage is used. Other surgeons use ampicillin
and orthopedic procedures. Adequate pain control is sodium/sulbactam (Unasyn), 1.5 g, intramuscularly
to be ensured in the immediate postoperative period or intravenously every 6 hours unless the patient is
with intravenous narcotics provided via patient- allergic to penicillin. This is given as a single dose
controlled analgesia (PCA) according to the protocol preoperatively and continued postoperatively for 24
used in each hospital. Patients who have had proce- to 48 hours. Some surgeons use clindamycin 1% as
dures that require the harvest of microvascular flaps a mouthwash one to three rinses per day before the
involving muscle and bone require longer use of operation and continued 24 to 48 hours postopera-
PCA analgesia, whereas patients with neck dissection tively. Ototoxicity and nephrotoxicity may occur. In
require minimal narcotic analgesia. Nonsteroidal anti- more extensive procedures (skull base surgery or
inflammatory analgesics, such as ibuprofen 600 to mandibular resection cases in which hardware is
800 mg via feeding tube or orally every 6 hours, are used), perioperative cephalosporin and aminogly-
usually adequate for minor pain as recovery con- coside antibiotics are used for 48 hours. Still, there
tinues. The use of tranquilizers for anxiety or rest- is little evidence to recommend anyone drug com-
1essness is important. Alcoholics who require large bination over another as long as the antibiotics are
doses of tranquilizers should be cared for in the inten- effective against oral gram-positive aerobic and
sive care unit until stable. Oversedation with resultant anaerobic bacteria. In any cases, antibiotics will not
respiratory depression should be avoided in any prevent infection where poor surgical technique
patient who might aspirate. Serious consequences allows continued postoperative salivary wound con-
have been observed in patients with partial airway tamination. Watertight closure of suture lines with-
obstruction, such as in a patient with a posterior out tension is mandatory.
nasal pack placed for nasal hemorrhage control who 6. Irrigate the oral cavity at least four times daily when
was oversedated. All postoperative head and neck suture lines are present. (Tube feedings should
procedure patients should receive prophylactic med- replace oral intake during the postoperative healing
ication to avoid gastritis and gastric hemorrhage. phase in all except the smaller, intraoral resection
Effective medications for gastric hemorrhage preven- cases.) Hydrogen peroxide/saline solution adminis-
tion include H2 receptor blockers such as ranitidine tered by power atomizer, Asepto syringe, or Water
(Zantac), 50 mg intravenously every 8 hours or Pik, is useful in keeping the operative site clean.
150 mg via feeding tube every 12 hours. Aspiration of the irrigating solution is best managed
5. Perioperative antibiotic use along with improved sur- by a tonsil tip attached to a portable or wall suction
gical techniques has resulted in very low postoperative apparatus (Fig. 3-11A). The patient should be placed
infection rates. In clean surgical procedures (major in a sitting position for this treatment to prevent the
salivary gland resection, thyroid and parathyroid aspiration or the swallowing of the irrigating solution.
resection, cyst removal, and radical neck dissection) As recovery progresses, the patient can be a valuable
there is no evidence that antibiotic administration ally in wound care. Patients who become self suffi-
decreases the already low infection rate. In longer, cient in their care also have less anxiety and seem to
clean cases (free flap repair, combined parotidectomy have a more comfortable postdischarge recovery.
BASIC CONSIDERATIONS
7. Frequent wound cleansing with peroxide is advisable the suction drains. Kling is the best material to secure
to reduce wound contamination by tracheal secre- the pressure gauze (see Fig. 3-11B) but there should
tions and serum crusting. Stents over skin grafts are be no pressure over any type of transposed flap.
kept in place for periods varying from 4 to 5 days for Vacuum apparatus of Hemovac or Jackson-Pratt types
mucosal defect skin grafts and up to 6 to 7 days for is generally satisfactory for wound drainage, the
skin defect grafts. Pressure dressings are not required, latter being preferred by this author (WRN) because
because fluid accumulation can be prevented and less clotting is experienced. Avoid drainage sets with
skin flaps made to adhere nicely to deeper structures hard catheters. Large-sized catheters (10 mm) are best
with the use of properly managed vacuum wound for larger cases and small (7 mm) for less extensive
catheters. Some surgeons use pressure dressing over cases. Clotting will occur in any tubes inserted into
the parotid salivary gland after radical neck dissec- wounds and must be evacuated. Tube stripping or
tion to prevent edema and swelling of the parotid "milking" is helpful in removing clots. Again, the
salivary gland, which can be permanent. Pressure patient can assist with this procedure. A word of
dressings are also occasionally utilized along with caution regarding these tubes needs to be made.
POSTOPERATive _ 1_
CARE
ALWAYS
PROTECT
THE EAR!
FIGURE 3-11
BASIC CONSIDERATIONS
They must not cross the carotid vessels nor be located by care personnel. Bulky dressings can hide the rare
too closely to a microvascular anastomosis, because but dangerous postoperative hematoma and do little
there is danger of pressure necrosis or microvascular to protect the operative site. With pectoralis major
anastomosis failure. One or two fine, absorbable, flaps no pressure dressing is used. In microvascular
loosely placed sutures are used to keep the tubes in free flap cases wound exposure is mandatory for
the desired location. observation and Doppler checks of vascular flow.
Antibiotic ointment may be applied over exposed Here, any pressure over the site of vascular anasto-
suture lines. Some physicians prefer a quick-drying mosis may result in flap loss (Fig. 3-12).
liquid dressing administered by spray to these skin All tubes and drains are possible sources of
closures. It is acceptable to leave neck wounds uncov- ascending infection, and appropriate precautions to
ered postoperatively. This allows frequent inspection prevent this should be taken. The neck wound should
,
\,
Pectoralis
major rotation
A flap
FIGURE 3-12 Avoid dressings or tracheostomy ties around the neck that could compress rotation flap or
microvascular flap blood supply. (A modified from Ritchie WP Jr, Steele G Jr, Dean RH: General Surgery. Philadelphia, JB
Lippincott, 1995, Figure 2-15.)
BASIC CONSIDERATIONS
be carefully examined daily for any evidence of fluid Your hospital may have an enteral feeding protocol,
accumulation. Prompt evacuation is imperative. Late but a simple sample protocol follows:
accumulations often herald the development of pha-
ryngeal suture line disruptions. (Foul-smelling, mucus- 1. Confirm accurate tube placement by radiography
containing material is diagnostic of such a compli- or air injection and auscultation. Small-bore tubes
cation.) If Proteus infection is suspected clinically or require radiographic confirmation of position.
by laboratory tests, use the appropriate antibiotic. If 2. Elevate the head of the bed or place the patient in
necessary, dilute solutions of acetic acid used locally a chair at the bedside.
may resolve the problem. If infection persists, widely 3. Check gastric residual. If it is greater than 100 mL,
open the overlying skin flaps and .start irrigation and withhold feeding and check hourly until less than
packing after adequate drainage of any pockets. 100mL.
Loosely and temporarily applied saline/hydrogen 4. Start feeding by pump with dilute (half-strength)
peroxide packs after each irrigation will clear up any product at 50 mL/hr. Check residual every 4 hours.
anaerobic infections and stimulate formation of granu- Discontinue feeding if residual is more than 100 mL
lation tissue. These packs should be changed fre- and restart when residual is less than 100 mL.
quently. Antibiotic coverage is restarted when culture 5. Advance to full strength after 12 hours if residual is
results are available. less than 100 mL.
Carotid artery exposure (which is usually pre- 6. Advance rate of feeding 25 mL/hr every 12 hours
vented during the operation by muscle flap coverage when full-strength formula is tolerated until the
or dermal graft; see Figs. 22-35 and 22-36) necessitates desired rate is achieved (caloric requirement
extremely vigorous local wound care. Ligation may calculated by the nutritional team).
become necessary if granulation does not quickly 7. Convert to interval feedings in five divided doses
cover the vessel. The appearance of a pale, avascular when the desired rate is tolerated.
area in the arterial wall indicates an impending rup- 8. Discontinue feedings and check residual if patient
ture. If the wound is clean proximally and distally an complains of nausea or gastric discomfort.
elective arterial bypass graft could be performed 9. Flush the tube with 30 mL of water before medica-
through clean surgical fields (see Chapter 22). tion administration and with 60 mL of water after
8. When needed, feeding tube placement can be by the interval feedings.
preoperative PEG tube method or by a large bore 10. Give supplemental water according to the osmolarity
nasogastric tube placed during surgery. The former of the feeding formula.
method is preferred except where tube feeding require- 11. Check electrolyte levels frequently until stable.
ments are only a few days and preoperative nutrition 12. Diarrhea may be treated by tube-feeding adjust-
is adequate. If not placed preoperatively, the feeding ment or medication.
tube must be inserted by the anesthesiologist, espe-
cially when the procedure is a laryngectomy. Here, Complications
the tube insertion must be completed before pharyn-
geal wall closure to prevent possible perforation of Complications in nutritional support are related to the
the suture line. Some surgeons prefer the PEG tube delivery method. Properly adjusted TPN solution seldom
(see Fig. 3-10) in a laryngectomy in the hope of causes electrolyte imbalance, but central venous line
decreasing the incidence of fistula formation. In any infections are common, particularly when a tracheostomy
event, do not reinsert an accidentally removed feed- is present. Central venous line placement complications
ing tube after pharyngeal or esophageal closure before should be rare and include pneumothorax and bleeding.
wound healing, because the reinserted tube can dis- Nasogastric feeding tube complications include the
rupt the suture line. Postoperative chest radiography avoidable misadventures of lung placement, nasal
confirms proper placement of the tube before use. cartilage necrosis, and esophageal perforation on tube
Postoperative consultation with the nutrition team placement, especially if a tube with wire stylet is used.
allows calculation of caloric requirements and method PEG tube complications tend to occur at the time of tube
of product administration. Administer high-caloric placement and are rare. There have been two instances
liquid feedings by tube after nausea and gastric atony of postoperative implantation of squamous cell carci-
have subsided. Clear surgical liquids or DsW may be noma at the PEG site reported. Any enteral feeding
given by tube in the interim. Commercial products method may cause reflux and aspiration (more common
for tube feeding are now numerous, and specific with large-bore nasogastric tubes) and diarrhea due to
recommendations are not possible because a hospital the osmotic effect of the product. All methods of nutri-
will usually have one product line available. Choose tional support can cause electrolyte imbalance and are
the appropriate product after consultation with the more difficult to manage in patients with diabetes,
dietitian. congestive heart failure, and hepatic and renal failure.
BASIC CONSIDERATIONS
These brief preoperative and postoperative sugges- better expressed in negative rather than posltlve
tions should serve as a guide in the management of terms-what should not be done or pitfalls to avoid. It
patients undergoing head and neck surgery. Meticulous would of course be impractical to attempt any kind of
attention to details of patient care will help to decrease exhaustive listing of departures from sound practice;
morbidity and mortality in these surgical cases involv- however, a few that stand out as perhaps too often seen
ing complex anatomic areas. are itemized below for easy reference and discussed
more extensively in the following section.
Nasoesophageal Feeding Tube (Fig. 3-13)
Unsound Practices
When and if this type of tube is indicated, extreme care
must be followed if performed, for example, before • Open biopsy of a lump in the neck before performing
surgery or if necessary postoperatively. a complete head and neck and general physical
The patient's head should be flexed forward so that examinations
the best opportunity to insert the tube in the esophagus • Inadequate incisional biopsy of an oral cavity lesion
is achieved. Hyperextending the head and neck will • Inadequate excisional biopsy of a suspicious oral
tend to place the tube in the larynx and trachea, which cavity lesion
can end up in a very serious aspiration and death. • Failure to review previous histopathology slides
After the tube is inserted, the end is placed in a cup • Permitting a single histopathologic benign diagnosis
of water to be certain that there are no bubbles. If there to override a clinical diagnosis of carcinoma
are bubbles, then the tube is most likely in the trachea. • Biopsy of the larynx, hypopharynx, nasopharynx,
Examination with a laryngoscopy is sometimes necessary esophagus, or trachea before radiologic studies and
to confirm mislocation of the tube. imaging when such studies are indicated to aid in
the evaluation of the extent of disease
Common Departures From Sound • Lack of multidisciplinary approach, when indicated
Management-"Pitfalls" (From Lore • Tailoring the scope of surgical resection to the ability
and Shedd, 1979)* of the surgeon rather than to the objective requirements
imposed by the lesion
Sound clinical management, as collectively developed • Compromise of the ablative phase of surgery to
over years of accumulated experience, is sometimes accommodate limited reconstructive skills
noma of a salivary gland, it is crucial to know whether Biopsies of the larynx, Hypopharynx,
it is low grade, intermediate grade, high grade, or very Nasopharynx, Esophagus, or Trachea
high grade. This grading not only influences prognosis Before Radiologic Studies and Imaging
but also is most important in the type of surgical Techniques
management.
Prevention. Request submission of all histologic slides Discussion
and, if necessary, blocks for further evaluation. The
results may even indicate that an additional biopsy Biopsies of these organ sites will often cause edema
should be performed. and/or distortion of the neoplasm as far as its extent
and size are concerned. Hence, radiologic studies, either
Permitting a Single Histopathologic in the form of plain soft tissue radiographs, CT, MRI, or
Benign Diagnosis to Override a Clinical contrast studies, can be erroneously interpreted, if
Diagnosis of Carcinoma performed after such biopsies.
Prevention. If at all anticipated and practical, radio-
Discussion logic studies and imaging techniques are best performed
before biopsy of the areas in question to avoid distortion
At times, the clinical diagnosis of a malignant neoplasm in the interpretation.
is not substantiated by biopsy and histologic evaluation.
The problem may lie with the choice of the location of lack of Multidisciplinary Approach When
the biopsy site. For example, if the biopsy is taken in an Indicated
inflammatory area surrounding a neoplasm, in the
center of a necrotic area, or in the far periphery where Discussion
only epithelial dysplasia is present, the specimen will
lead to a histologic diagnosis of a nonmalignant lesion. A primary care physician has the tremendous respon-
Another problem may result from the paucity of histo- sibility of the initial referral for definitive care of the
logic sections taken through the block of tissue, thus patient with a head and neck neoplasm. At times these
causing the malignant cells to be missed. referrals are to other physicians who, although quite
An example of this pitfall is a single punch biopsy capable in their own disciplines, are not well versed in
of a whitish patch involving, for example, the major the multidisciplinary aspects of the management of
portion of the vocal cord. It is better to strip the head and neck malignant neoplasms.
entire vocal cord. The specimen thus would include Prevention. Obviously, lesions frequently present with
the entire suspicious area for serial histologic sections. a choice of management that is clear cut, but in the
Staining with toluidine blue may be of help in select- patient's best interest even the slightest reservation should
ing sites of biopsy, for example, in the oral cavity, be subjected to a broader scrutiny. Use of multidiscipli-
oropharynx, larynx, or hypopharynx. The whitish nary consultations or conferences should be stressed. The
patch (leukoplakia, a term best discarded by the primary care physician must be cognizant of this multidis-
examining physician because it has implications of a ciplinary aspect and be sure that the physician chosen to
malignant lesion) can be due to atypism, dysplasia, manage the patient is also cognizant of this multidiscipli-
cancer in situ, invasive cancer, Candida, or lichen nary approach. This latter physician in basic training
planus and may be related to smoking, irritation by a may have sufficient knowledge of the disciplines involved
denture, or chewing tobacco or betel nuts with or or may in fact wish for an additional consultation.
without slacked lime.
Prevention. A skilled clinician's impression on Tailoring the Scope of Surgical Resection
physical examination is more often right than wrong. to the Ability of the Surgeon Rather
The clinician, thus, must be wary of a benign diagnosis Than to the Objective Requirements
in the histologic evaluation for the previously men- Imposed by the lesion
tioned reasons. Repeat biopsy or total excision of the
lesion must be performed with explicit understanding Discussion
by the pathologist that, if necessary, many serial sections
should be performed. It may also be necessary to have When making a decision about the feasibility of surgical
recourse to one or several repeat biopsies. Then, should management of an extensive neoplasm it is a serious
all biopsy specimens prove to be benign, such patients error to render a verdict of nonresectability because the
should be followed at close intervals until the diag- physician or surgeon making the decision does not have
nostic discrepancy is adequately resolved. Additional the expertise or background to carry out the necessary
consultation may be advisable. operation.
BASIC CONSIDERATIONS
Furthermore, in surgery; tailoring the scope of excision Performing the Right Operation on the
to the ability of the surgeon, rather than to the objective Wrong Patient
requirements imposed by the character, location, and
extent of the lesion, is inexcusable. Discussion
Prevention. Although there is often a wide divergence
of opinion regarding resectability, the physician making This pitfall is closely allied with earlier items men-
the decision must be well versed in the various options tioned in certain respects but primarily concerns itself
and fully aware of what can and cannot be resected with with the definition of resectability versus operability. A
reasonably satisfactory results. Clear-cut knowledge of neoplasm may be technically resectable utilizing a spe-
the natural history of the disease is as important as cific surgical technique, yet the operation is not suited
knowledge of the surgical technique in making this to the patient or the patient may not be in such physical
decision. condition to tolerate the operation or the consequences
of the operation (e.g., cardiac and pulmonary diseases).
A Compromise of the Ablative Phase of Actually, in head and neck surgery, there are very few
Surgery to Accommodate Limited general medical or general surgical problems that totally
Reconstructive Skills interdict surgical management, yet there are contingen-
cies that influence the selection of a surgical procedure;
Discussion for example, a supraglottic laryngectomy may well be
suited to the carcinoma of the larynx but not suited to
When the ablative surgery is modified to such an extent the patient who is elderly with chronic pulmonary insuf-
that adequate resection with reasonable free margins ficiency. The same principle may also well apply to the
is jeopardized to accommodate wound closure, a sur- use of a nondelayed flap in a patient with diabetes and
gical error is committed. The surgeon must be well severe arteriosclerosis.
versed in both the ablative phase and the reconstruc- Prevention. Careful evaluation of the total patient in
tive phase of surgical management. Otherwise, the regard to all vital functions being certain that the
likelihood of cure is compromised or the patient is patient can tolerate not only the operation but also the
disabled. The reconstructive phase must at times take anesthesia as well as the sequelae of both is essential.
somewhat of a "back seat" to the ablative phase but
never vice versa. Assessing the Degree of Success or
Prevention. Complete training of the head and neck Failure of Radiation Therapy on the Basis
surgeon in all phases of ablative and reconstructive of the Response of the lesion During or
surgery is necessary. Immediately on the Completion of
Treatment
Compromise of Surgical Margins Because
Radiation Therapy or Chemotherapy Was Discussion
or Is to Be Given
There is a tendency among some physicians to decide
Discussion prematurely that radiation therapy has failed when
disease is still present on completion of this modality.
It is a sore temptation to limit the area of surgical Along the same line is the error of deciding that the
resection because of a false sense of security deriving neoplasm under treatment will not eventually have a
from a favorable radiation therapy and/or chemotherapy successful outcome when, early or midway through the
result that has either already occurred preoperatively or treatment, the response has been slow. Conversely, a
is anticipated postoperatively. rapid response during radiation therapy is sometimes
Prevention. If radiation therapy and/or chemother- improperly used as a justification to reduce total dosage.
apy are utilized in combination with surgery, it is A high rate of response of a neoplasm does not have
important that the surgery encompass the same area implications for the dose needed to sterilize the tumors.
that would have been resected had it been the sole Prevention. The physician must realize that response
treatment modality. Careful record keeping of the size to radiation therapy is varied during the course of
and extent of the primary neoplasm (at times with treatment and that this may not necessarily indicate the
the use of tattoo and photographs) as well as the final outcome. On completion of the planned full course
metastatic disease is most important to prevent this of treatment, a 4- to 6-week interval should lapse
error. before biopsy is performed again.
BASIC CONSIDERATIONS
On completion of the planned full course of radio- may be in the chest, breast, abdomen, pelvis, ovaries,
therapy treatment, continued response may extend up urinary bladder, or elsewhere.
to 3 months and even possibly 4 months. Early re-biopsy Prevention. In addition to a complete head and neck
is indicated if there is clinical evidence of changes examination, a complete physical examination is a sine
indicating either a regrowth of the tumor or increase of qua non for diagnosis and must be performed before
the size of the original mass. commencement of definitive management of a head
After radiation therapy or chemotherapy, the over· and neck neoplasm. This examination should include
lying mucosa may be intact, giving a false impression digital rectal and pelvic examination as indicated.
of a complete response (see section on chemotherapy).
There may be viable tumor cells deep to the intact mucosa. Prolonged Watch-and-Wait Attitude in
Deep biopsy through edematous mucosa after radiation the Face of an Asymptomatic Mass
therapy is challenging and may not be productive.
Discussion
Failure to Realize the Implication of the
"Condemned Mucosa" or Multiple All too often either the patient or the primary care
Primary Syndrome physician may delay the evaluation of a mass in the
head and neck that is causing no pain or interference
Discussion with the patient's normal function. This delay could
well be a disaster.
Especially in patients with multiple areas of leukoplakia Prevention. Any abnormal mass must be promptly
and/or erythroplakia, multiple primary tumors are not and completely evaluated, and it is then usually
only a possibility but are also actually a probability. Even removed, depending on the findings and diagnosis.
in the absence of these possible precancerous lesions,
multiple primary tumors are a distinct possibility in a Inadequate Search for an "Occult"
patient who already has one squamous cell carcinoma of Primary Tumor
the head and neck. This clinical entity is more common
in the heavy tobacco and/or alcohol user. These are the Discussion
patients who demonstrate the condemned mucosa. A
tendency to "zero in" on the site of the first or original There are patients seen who have histologically proven
lesion in follow-up examination is only natural, and involvement of cervical lymph nodes by squamous cell
often a follow-up and repeat complete head and neck carcinoma without an apparent primary lesion. Such a
examination is bypassed, thus causing other lesions to patient should not be placed in this unknown primary
be all too frequently overlooked. category until after a completely adequate diagnostic
Prevention. A complete head and neck examination work-up has been done.
must be performed at frequent intervals in all patients who Prevention. The only admonition for this problem is
have demonstrated a primary squamous cell carcinoma to repeat complete head and neck and general physical
of the head and neck. A recommended regimen for examinations with diagnostic studies including
follow-up is reexamination every month for the first radiographs of the paranasal sinuses, nasopharynx,
year, every second month for the second year, and so esophagus, and chest. Depending on the histologic
on, up to 6 years. Beyond 6 years, follow-up is suggested findings on aspiration of the metastasis, other radiologic
every 6 months. Cell type and extent of the original studies should be performed as indicated. Areas to scru-
lesion could modify this regimen. tinize extremely carefully if the metastases are squamous
cell carcinoma are the nasopharynx (vault, lateral walls,
Failure to Perform a Complete General and posterior choanae, including posterior edge of
Physical Examination as Well as a septum), tonsils, base of the tongue, pyriform sinuses,
Complete Head and Neck Examination and inferior portion of the laryngeal surface of the
epiglottis. If open biopsy is necessary after all else has
Discussion failed, it may well be performed in the operating room
with frozen sections, so that, depending on the
Unfortunately, the division of human anatomy into circumstances and histologic diagnosis, a radical neck
various regions, for example, head and neck, chest, dissection can then be performed without delay.
abdomen, and pelvis, is not respected by neoplastic At times, the location of the cervical metastasis may
disease or, for that matter, by infectious disease or trauma. give an indication of the location of the primary tumor
A mass in the neck may not necessarily represent pri- (e.g., posterior triangle node, nasopharynx [vault], sub-
mary disease above the clavicle. The primary disease digastric node; floor of the mouth, tongue, oropharynx,
BASIC CONSIDERATIONS
hypopharynx, larynx, maxillary sinus, sphenoidal sinus, nerve and/or loss of the parathyroid glands. (2) A
and posterior portion of nasal septum). Nevertheless, second nodule, which was not perceptible, may be left
remember the possibility of skipped metastasis. behind. This latter nodule has on occasion proved to be
the carcinoma.
Abandonment of the Patient With Neck Prevention. With all tumors of the salivary glands
Metastasis From an Undetectable and thyroid gland, the operation of choice is total
Primary Tumor lobectomy. With the parotid salivary glands, exposure of
the seventh nerve is important. With the thyroid gland,
Such a patient should not be abandoned but should be exposure and preservation of the recurrent laryngeal
given the benefit of definitive treatment. If the cancer nerve and preservation of the parathyroid glands and
in the neck node is well differentiated and if the node external branch of the superior laryngeal nerve are
is situated in the midportion of the lateral neck, it may important.
possibly represent a so-called bronchogenic carcinoma, In relation to thyroid lobectomy, the word "total" is
although there has been uncertainty about the exis- stressed, because it is suspected that all too often the
tence of this entity. In such an instance, radical neck surgeon calls an operation a total lobectomy when in
dissection is indicated, with careful subsequent follow- fact a subtotal lobectomy has been performed. A portion
up in a continued search for a hidden primary tumor. of the thyroid lobe is likely to be left behind the pos-
In some patients, the long-term repeat examinations terior suspensory ligament (Gruber, Henle, Berry) of
will eventually disclose the primary tumor, it is hoped, the thyroid, if meticulous care is not exercised.
at a treatable stage. If the node shows undifferentiated
squamous carcinoma and if the node is at the periphery Treating a Patient With Antibiotics for an
of the usual neck dissection, the management is more Extended Period of Time Without a
controversial. Some clinicians would advise neck dis- Biopsy
sections, whereas others would advocate radiation
therapy. When the neck is irradiated in such circum- Discussion
stances, a judgment is necessary as to whether the ports
should encompass the sites of a possible undisclosed It is not at all uncommon to see patients with tumors
primary tumor, for example, nasopharynx or base of of the head and neck in whom the initial physician
the tongue (refer to the earlier discussion Failure to assumed an inflammatory lesion was present and
Perform a Complete General Physical Examination as prescribed antibiotics for extended periods of time.
Well as a Complete Head and Neck Examination for Prevention. Often, in such circumstances, after a
additional suggestions). Despite the ominous situation reasonable period of no response to antibiotics, a more
of the undiscovered primary tumor, a significant number careful examination of the lesion would mandate a
of such patients do achieve cure by a combination of biopsy and thereby avoid an unwarranted delay in
surgical and radiotherapeutic approaches. beginning definitive treatment of cancer.
More recently, there has been a great deal of interest has a predictable dose-limiting side effect of irreversible
in utilizing chemotherapy as part of the initial treat- pulmonary fibrosis. S-FU has been known to have
ment plan in patients who present with advanced stage activity in head and neck cancer since early studies as
III and IV disease. The rationale for chemotherapy use well. Both drugs (S-FU given by continuous infusion)
is to improve the overall treatment results of standard have been utilized primarily in locally advanced disease
therapy. Chemotherapy can be given as a neoadjuvant as part of drug combination and combined modality
treatment, to shrink the tumor before surgery and/or programs.
radiation therapy. Concurrent chemotherapy can be given The biggest breakthrough in the management of
with radiation therapy, so that the patient receives head and neck cancer was the development of cisplatin
chemotherapy daily, weekly, or less often while receiving (formerly cis-platinum) as a chemotherapeutic agent.
daily radiation. Chemotherapy can be administered as The recognition that cisplatin was active in head and
an adjuvant, after completion of standard treatment, or neck cancer has had a major impact on therapy of this
"sandwiched" as a treatment between surgery and tumor. As a single agent, it has higher response rates
irradiation. Finally, the utilization of chemotherapy as than methotrexate; however, it does require careful atten-
an initial treatment modality has led to a proliferation tion to hydration and has more side effects. Because its
of "organ preservation" trials in which the standard toxicity profile is different than other available chemo-
surgical treatment is eliminated or modified in the face therapy, it is an ideal drug to include in drug combi-
of a good response to chemotherapy. nations for treating head and neck cancer. Most active
drugs cause myelosuppression and stomatitis, but the
dose-limiting toxicity of cisplatin is renal impairment, a
Recurrent or Metastatic Head and Neck problem that can be overcome by administering large
Cancer volumes of fluid and, if necessary, diuretics, to ensure
good renal output. Carboplatin, a platinum analogue,
Single-Agent Therapy also has activity in head and neck cancer and does not
cause renal impairment, but dosing is limited by myelo-
The goal of chemotherapy in patients with locally toxicity, particularly a reduction in the platelet count.
recurrent disease or metastatic disease is palliation. There are new drugs undergoing phase II trials that
Head and neck cancer may recur locally in the head offer significant promise in head and neck cancer.
and neck area and be associated with pain, bleeding, Paclitaxel (Taxo!) was developed from the bark of the
difficulty swallowing, or obstruction of the respiratory yew tree and has proved to be active in a variety of
tract or may be widely disseminated involving lung, solid tumors. Its has a unique mechanism of action that
bone, and liver. The first chemotherapy demonstrated also makes it a logical drug to include with others in
to have significant activity against head and neck cancer combination. As a single agent, its response rate is as
was the folate analogue methotrexate. Methotrexate high as 40% in patients with recurrent or metastatic
remains the standard against which all other drugs need head and neck cancer, making it one of the most active
to be tested. It has a response rate varying between drugs available for head and neck cancer (Cortes-Funes
10% and 30%, is relatively inexpensive, can be given and Aisner, 1997). Its use can be limited by neurotox-
in the outpatient department by a bolus injection, and icity, which can be severe and unpredictable, although
has predictable toxicity consisting of mucositis and also quickly reversible. Docetaxel has the same mecha-
myelosuppression. The mucositis is self-limited, lasting nism of drug action and seems to have the same degree
only 2 to 3 days, and is dose dependent. Reducing the of activity in head and neck cancer, although the studies
dose reduces the degree of mucositis so that even its are more limited. Both drugs can cause significant
toxicity is easy to manage. myelosuppression with neutropenia; however, the use
Methotrexate can be given in higher doses followed of growth factors appears to ameliorate this problem.
24 hours later with leucovorin, a folate analogue, which Sepsis and other forms of infection are uncommon.
protects normal cells from toxicity. In spite of the Mucositis has not been noted. Gemcitabine, an
leucovorin rescue, the risk of toxicity is greater with the antimetabolite, has undergone evaluation in a number
higher dose regimens, but there is no significant increase of tumors including head and neck cancer. The drug
in the response rates or the duration of response with has a relatively low response rate but is well tolerated
any of these studies. Other drugs shown to have signifi- and may be useful in combination therapy. Like many
cant activity in head and neck cancer over the next of the other agents, it appears to have synergistic
decade were bleomycin and S-fluorouracil (S-FU). activity when used with radiation therapy, and studies
Bleomycin, although having a measurable response rate of its use with radiation therapy are ongoing. Other
of approximately 20 %, was limited by its toxicity. It is drugs with significant activity in head and neck cancer
not myelosuppressive but does cause mucositis and are cyclophosphamide, hydroxyurea, and vinorelbine.
BASIC CONSIDERATIONS
Of the 10 options, 6 include various forms of 1. Highest superior and lowest inferior neck dissection
chemotherapy used in various techniques. nodes positive
The preference of one of us (JML) is. preoperative 2. Margins positive on permanent section
chemotherapy, uncompromised aggressive surgery, and 3. Tumor extending through the lymph node capsule
selective radiotherapy. (extracapsular spread)
4. Extension of disease beyond the fascial planes of the
Highpoints neck
5. Invasion of the deep cervical musculature
I. Preoperative chemotherapy: Two to three courses as 6. Recurrence within 6 weeks
tolerated are suggested based on response and tolera- 7. Inclusion of patients who had multiple cervicallym-
tion. Advance from two courses to three courses phadenopathy. This was later modified according to
2. Surgery un compromised by any response to the the extent and location of the multiple cervical
chemotherapy lymphadenopathy. That is, all patients with multiple
3. Selective radiotherapy positive nodes did not receive postoperative
radiotherapy.
Treatment Criteria
The protocol commenced in 1979, and the latest
Before Chemotherapy evaluation was done in 1999. The protocol is still used
with modifications of the chemotherapy plan, increasing
1. A careful and complete evaluation of disease is the number of courses to three whenever there was a
based on clinical, CT, MRI, and, at times, PET favorable response and the first two courses were well
examinations. tolerated. Also, other chemotherapeutic agents were used,
2. The extent of the disease is documented using tattoo, mainly paclitaxel (Taxo!), when the response to the
drawings, photographs, and description. original protocol was not as favorable. The 5- to 20-year
3. The planned operation is outlined in detail. follow-up results of this protocol were presented at the
BASIC CONSIDERATIONS
5 Years 10 Years
Group No. Absolute (%) Relative (%) Absolute (%) Relative (%)
Totalgroup 82 60 66 45 58
RegimenA (bleomycin) 45 46 50 36 44
RegimenB (5-fluorouracil) 37 77 83 46 64
Comparison of regimens A and B (P value) .004 .003 .5 .3
From Lore JM Jr, Kaufman S, Sundquist N, Chary KK: Carcinoma of the head and neck: A 5- to 20-year experience with preoperative
chemotherapy, uncompromised surgery, and selective radiotherapy. Ann Surg Oncol 10:645-653, 2003, with permission.
BASICCONSIDERATIONS
....J 100
~
>
a:
:::>
(f)
UJ
Percent fo-
Absolute :::>
....J
Survival 40 o
(f)
ell
«
f0-
20
rD 20
()
o a:
UJ
o 5 10 15 c.. 0
TIMEFROMENTRY(YEARS) o 5 10 15
FIGURE 3-14 Estimated absolute survival for total TIME FROM ENTRY (YEARS)
study group (N = 82) with 95% confidence bounds. FIGURE3-15 Estimated absolute survival in regimens A
(Reprinted from Lore JM Jr, Kaufman S, Sundquist N, and B. (Reprinted from Lore JM Jr, Kaufman S, Sundquist
Chary KK: Carcinoma of the head and neck: A 5- to 20- N, Chary KK: Carcinoma of the head and neck: A 5- to
year experience with preoperative chemotherapy, 20-year experience with preoperative chemotherapy,
uncompromised surgery, and selective radiotherapy. Ann uncompromised surgery, and selective radiotherapy. Ann
Surg Oncol1 0:645-653, 2003, with permission.) Surg Oncol 10:645-653, 2003, with permission.)
Regimen
TABLE 3-4 Distant Metastasis (N - 12) TABLE 3-5 Comparison of Clinical and
(15%) Histologic Data Relative to Neck Metastasis
DOD, dead of disease; DOC, dead of other causes; LFU, lost to follow-up.
Reprinted from Lore JM Jr, Kaufman S, Sundquist N, Chary KK: Carcinoma of the head and neck: A 5- to 20-year experience with
preoperative chemotherapy, uncompromised surgery, and selective radiotherapy. Ann Surg Oncol 10:645-653, 2003, with permission.
Four patients had positive margins on frozen section at using a regimen similar to regimen A, it was reported
the primary site and underwent resection. Of these 4, that the surgical complications were no greater and
only 1 had positive frozen sections on permanent section actually less when compared with historical data of
and only I patient died of disease. surgery alone than when combined with preoperative
In a previous clinical trial (Lore et aI., 1989) evaluating chemotherapy and selective radiotherapy. Evaluation of
the surgical complications after preoperative chemotherapy surgical complications were as follows:
Additional Comments
therapy but no radiation. In summary, Mary is an 1. Careful and complete evaluation of the extent of
outstanding-outcome patient who has achieved, I disease
am sure, a cure without the long-term indignities of a. Primary tumor
radiotherapy effect." b. Neck metastasis
c. Distant metastasis
All these data, even though some are anecdotal, indicate 2. Recording of the extent of disease (recording
that surgery, uncompromised, carefully planned, and all modalities: tattoo, written description, diagram,
encompassing, is the important modality in the manage- photographs)
ment of not all but most malignant lesions. Chemotherapy a. Primary tumor
and radiotherapy require fine tuning, and each has a i. Size
significant part in the overall planning of the treatment ii. Ulceration
of squamous cell carcinoma of the head and neck. ili. Mass
iv. Induration
Organ Preservation v. Edema
b. Neck metastasis
Most of the data regarding organ preservation are related I. Levels/zones
to the larynx, with 5-year survival figures scarce. Failure 11. Size
of that treatment and the surgical salvage with its com- lll. Multiplicity
b. Annual chest radiograph-preferably CT with the vast experience of a senior surgeon with expertise
mediastinum in search for metastasis and a in the field of head and neck surgery."
second primary tumor
c. Images-CT and/or MRI of the head and neck; Conclusions
frequency depends on the clinical history, find-
ings, and final pathology, specifically in relation • Improved survival: regimen B: absolute 76.7%, relative
to number of nodes positive in the neck 83.4%
d. Complete head and neck examination to search • Low incidence of distant metastasis: 5 % regimen B
for possible second primary tumors, even after • No neck recurrence: regimen B
8 to 10 years' survival following first primary • Recurrence at the primary site: 5% regimen B
tumor • Surgery is a mainstay in the treatment of advanced
squamous cell carcinoma of the head and neck.
Comments on the Previous Data by a Reviewer Chemotherapy and radiotherapy are important
(Reviewer Unknown to the Authors) adjuncts that require fine tuning.
disciplines plus all other germane disciplines and services 5. Involvement may occur through neurovascular
numbering over 20. The main purpose is to render the foramina.
best possible patient care, to attract the best-qualified
physicians and other professionals, thus sifting out the There is paramount concern regarding the mandible
dabblers, and to promote an academic atmosphere. This in the absence of direct gross invasion of the perios-
oncology service functions as an autonomous service teum and cortex when there is a malignant juxtaposed
with the cooperation and support of the chairman of neoplasm. This is an increased concern when there are
Surgery and Internal Medicine. The service, however, is varying degrees of fixation and extent of fixation to the
not a separate department and has no representative on mandible.
the executive committee of the hospital. The service is Decisions regarding mandibular resection are based
responsible for its own quality review data, which is sup- on the following:
plied to the Continuous Quality Improvement Hospital
Committee. Outpatient, inpatient, speech and swallowing 1. Juxtaposed neoplasm fixed to the bone
clinic, and laboratory, physician's, fellow's, nurse clini- 2. Imaging
cian's offices, as well as oncologic dentistry and oral a. Routine standard radiographs, as well as CT, will
facial medicine, conference rooms, library and nutri- only demonstrate a grossly ulcerative lesion of
tionist's office and microsurgical laboratory are all con- the cortex.
tiguous on the same floor of the hospital. Also on the b. MRI, in the absence of grossly ulcerative cortical
same floor is the pathology laboratory, where fine- lesion, can be of help to the surgeon regarding a
needle aspirations can be analyzed and reported within decision of mandibular resection-segmental or
30 minutes to 1 hour. One floor above is the operating marginal with preservation of the mandible.
rooms and intensive care unit. One floor below is diag-
nostic and nuclear medicine. It appears that this An MRI can indicate a pathologic process if there is
approach to head and neck neoplasia, including thyroid a change in the marrow. Normal marrow has a whitish
and parathyroid tumors, truly improves patient care color comparable to adipose tissue on Tl-weighted image
without the stigma of "treatment by committee" and due to marrow fat content. Abnormal marrow has a grayish
avoiding the wasted time involved in "turf" conflicts. discoloration. This could be caused by edema, neoplasia,
The Head and Neck Oncology Service is a complex inflammation, or other diseases. Thus, when there is a
system in which the sum of all the components is much neoplasm juxtaposed to the mandible and there is abnor-
greater for patient care than is any independent part. mal marrow on MRI, mandibular resection is indicated.
Fixation of the neoplasm lends further support to the
decision to resect. Fixation alone is a judgment call: it is
Bone Imaging and Pathology better to err on resection of a portion or margin of the
Scott Cholewinski, John Asinvatham, mandible than assume the attitude of wait and see or use
Daniel Broderick, and John M. Lore, Jr. postoperative radiation therapy. Intraoperative smears
of the marrow at the ends of a marginal resected area
Methods of Bone Involvement: Mandible may be worthwhile to histologically evaluate the presence
or absence of abnormal marrow cells.
1. Direct gross extension of a juxtaposed malignant Figure 3-19 is a schematic sketch of an MRI cross
neoplasm through intact periosteum and cortex into section of mandible, demonstrating (I) juxtaposed neo-
the marrow cavity is not very common. plasm involving muscle; (2) periosteum (black line);
2. More often, the extension is through the site of a (3) cortex (black line); (4) marrow; (5) cortex (black
tooth socket, or the periodontal region, or retromolar line); (6) periosteum (black line); and (7) juxtaposed
trigone or related to an alveolar ridge with absent neoplastic process.
dentition. It is very important to have the patient This drawing illustrates a muscle with evidence of
remove all dentures and to scrutinize areas hidden invasion by neoplasm that is adherent to the periosteum
by a denture. (the narrow black line). The cortex appears intact, yet
3. Another route of bone invasion can be metastatic, the marrow is grayish rather than its typical white appear-
usually the bloodstream. The concept of lymphatic ance. This is a suggestion of infection or neoplasia or
spread has not been substantiated, although lym- some other disease within the marrow when using a
phatics may be demonstrated in periosteum accom- Tl-weighted image. This finding, plus the muscle with
panying the small arteries. neoplasia adherent to the periosteum, is an indication
4. When periosteum is involved by tumor, the tumor to resect bone. In addition, an abnormality of the perios-
cells can enter the cortical bone through Volkmann's teum is suggested with a high signal on the T2-weighted
canals and into the haversian system and then into image. The heavy black lines in the schematic repre-
the marrow (medulla). sent the cortex along with the periosteum seen on the
BASIC CONSIDERATIONS
~
Periosteum ~ '\ }
@ Cortex ----
® Cortex } _
Periosteum ~
FIGURE 3-19
MRI. The smaller axial image with the two heavy black Voice, Speech, and Swallowing
lines equates once again the cortex and the surrounding Rehabilitation of the Head and
periosteum. Note that the marrow is not white but Neck Patient
grayish. (Drawing courtesy of Daniel Broderick, MD.) Allen M. Richmond
Involvement of periosteum is an indication to remove
the underlying cortex, because if adjacent cortex remains, The speech pathologist's role in working with the head
the margin would then be a to 1.0 mm and hardly ade- and neck patient appears to grow out of real day-to-day
quate. This would be the error if involved periosteum clinical concerns. The head and neck surgeon may meet
were stripped from the cortex with a periosteal elevator. situations that demand time-consuming and compre-
One answer to this dilemma is treatment with ionizing hensive solutions. The problems that develop may need
radiation postoperatively. Some surgeons (e.g., JML) do a model based on crisis intervention for solution, as
not agree: it is better to remove the adjacent bone and proposed by Salazar-Sanchez and Stark (1972) for the
the margin if possible or perform segmental resection laryngectomy patient. Other types of problems, even
of the mandible with reconstruction. This appears to be those involving extensive head and neck surgery, may
more valid in the younger patient, because the long- involve less complicated, but appropriately timed inter-
term effect of radiotherapy is questionable. Imaging vention to maximize rehabilitation potential.
evaluation with MRI is very valuable, because involve-
ment of periosteum can at times be readily ascertained. Total Laryngectomy
Actual erosion of the cortex can occur but is not very
common. The periosteum, which is juxtaposed to the Evaluation, treatment, and rehabilitation of the laryn-
tumor, may well be involved with the neoplasia. CT gectomized patient involve a comprehensive approach
(using bone windows) is the basic imaging for cortical that takes into account the psychosocial concerns as well
involvement, whereas MRI is ideal for evaluating marrow as the physical limitations of the patient. Significant
and periosteum. depressive reactions can occur as a result of surgery for
Dr. Broderick writes, "On routine Tl-weighted mag- cancer. Sutherland and Orbach (1953) relate postopera-
netic resonance (MR) images, the cortex and the marrow tive depression to a sense of injury and often to impor-
of the bone are easily distinguished with the decreased tant changes in the patient's functioning in the life
Tl signal intensity of the dense cortical bone and the situation. Conley (1985), in discussing the changes that
increased Tl signal intensity of the fatty marrow. The occur as a result of surgical intervention in head and neck
periosteum is rarely evident as separate from the adja- cancer, states that "It automatically generates fear, depres-
cent cortex. The increased Tl signal intensity of normal sion, and possible annihilation mixed with hope for cure,
fat adjacent to the cortex/periosteum is readily visual- palliation programs, experiments, philosophies, calcu-
ized. When tumor extends to the cortex and obliterates lations, emotions, and fantasies which the doctor and
the adjacent fat, invasion of the periosteum and bony the patient can have regarding this confrontation." He
cortex cannot be excluded. Altered signal intensity of further states that "regardless of the amount and quality
the marrow (namely, decreased Tl and increased T2 of external support, [the patient] is singular and alone."
signal intensity) may reflect marrow edema and/or Preoperative visitation by the speech pathologist
neoplastic invasion." with a focus on the method and timing of the visit may
BASIC CONSIDERATIONS
be helpful (Richmond, 1982). In addition, a visit by a 1979). In a similar context Damste (1979) reports pos-
laryngectomized patient can be arranged by the speech sible factors limiting the learning of esophageal speech,
pathologist, who should find a suitable visitor that may which include wound healing, diverticula, fistula, and
share some common connection with the patient. amount of tissue in the pharyngeal wall.
Information on a wide variety of areas facilitates the
informed consent of the patient. Discussion and descrip- Tracheoesophageal Puncture
tion of types of alaryngeal communication, such as the
artificial larynx and other augmentative communication The TEP is a primary consideration for voice restora-
devices, esophageal speech and the tracheoesophageal tion with the post-laryngectomy patient. Considerable
puncture (TEP), may be helpful. The AIdes and Lowry- improvement and development of TEP methods have
Romero protocol (1982) includes a review of physical been effected, dating back to the early innovation of
and lifestyle changes such as taste, smell, bathing, the externally placed valve, which can produce finger-
showering, coughing, throat clearing, lifting, dry nasal free fluent speech. Blom and colleagues (1982), 810m
passages, hygiene, sex, smoking, drinking, first aid, and Hamaker (1996), and Hilgers and associates (1995)
humidity, cold air, and care of the stoma. have improved the technology, with the first handmade
device introduced by Blom and Singer in 1978 to the
Methods of Communication most recent designs and equipment innovations.
A preliminary insufflation test is effective to determine
Artificial Larynx and Other Augmentative potential for cricopharyngeal spasm before surgery.
Communication Devices This difficulty may preclude successful surgery unless
myotomy or neurectomy is carried out to facilitate air
Initial communication efforts can be facilitated through flow through the neoglottis (see Chapter 20). Botox
the use of an artificial larynx, either intraoral or trans- injection is now a method of choice for reducing spasm
cervical, communication charts, and writing materials, (BJom and Hamaker, 1996).
such as a dry erase board and marker. Excellent low-
cost word processing units are of help to some patients.
Patients who are unable to acquire skills necessary to use Conservation Surgery: Cancer of
the telephone can use e-mail, fax, prerecorded messages, the Larynx
answering machines, and special automated emergency
call systems to provide some help. Illiterate patients Conservation surgery for cancer of the larynx may require
may experience considerable frustration until they can voice refinement procedures (Doyle, 1997), special
be evaluated and fitted for an artificial larynx. Interpreters vocal treatment strategies focusing on specialized types
can assist patients whose primary language is different of tracheotomy tubes, and augmentative communicative
from that of the speech pathologist or physician. Bilingual procedures (Mason, 1993) and/or special swallowing
family members can frequently be an asset in bridging diagnostic and therapy procedures (Richmond, 1997).
the linguistic gap. They may be helpful throughout the On occasion, patients may be placed on ventilators,
therapy process in explaining therapy techniques, both preoperatively and postoperatively. Doyle (1997)
describing options, and defining therapy goals. refers to improved diagnostic procedures for malignant
lesions and more accurate identification of histologic
Esophageal Speech character, loci, and spread of disease that result in an
altered conceptual framework for treatment. Important
Esophageal speech continues to form a part of the com- goals of treatment can involve sphincteric and phonatory
munication rehabilitation process for some patients, functions that include safe swallowing, adequate nutrition,
although it is no longer the method of choice in the and postoperative voice conservation (Bailey, 1985).
United States. Webster and Duguay (1990) reported on
1003 laryngectomy operations performed across the Swallowing
nation: the most prevalent type of post-laryngectomy
speech used was "tracheoesophageal shunt speech," now Swallowing Problems
commonly referred to as tracheoesophageal puncture
(TEP), at 38.1%. Weinberg (1981) estimated that 25% Swallowing difficulties often accompany conservation
to 50% of patients do not learn serviceable esophageal surgery procedures. These swallowing difficulties may
speech. Patients are not able to learn serviceable be amenable to special techniques of management.
esophageal speech because of such factors as cranial Logemann (1993) stresses the importance of relating
nerve involvement, strictures, flaccid pharyngoesophageal the swallowing dysfunction to the exact extent of the
segment, hiatal hernia, achalasia, poor diaphragmatic patient's surgical resection to account for variations in
movement, stomach ulcers, and emphysema (Duguay, surgical procedure. Richmond (1992) reviewed the swallow
BASIC CONSIDERATIONS
status of patients who had oropharyngeal dysphagia. the oropharyngeal area act in a coordinated way for
He found that patients with posterior tongue and pha- swallow function. Medications that affect these func-
ryngeal surgery had the poorest swallow rehabilitation tions can impede the swallow mechanism. Each patient's
results. medications should be reviewed because they may
Problems that mayor may not result in aspiration involve mental status changes, confusion, and/or seda-
include delayed pharyngeal swallow reflex, delayed ele- tion. Drugs may increase or decrease esophageal pres-
vation of the larynx, inability to protect the larynx by sure, such as antacids (produce pH-dependent increase
vocal fold closure, cricopharyngeal dysfunction, incom- in lower esophageal pressure), alcohol (decreases lower
plete or delayed velopharyngeal closure, limitations in esophageal pressure), drugs that increase or decrease
pharyngeal motility, pharyngeal and esophageal pressure skeletal muscle function (long-term use of corticosteroids
deviations, and general timing dysfunction. Pharyngeal can cause skeletal muscle wasting), and drugs that
and esophageal pressure deviations are often minimized decrease food intake (antivirals or certain antibiotics
in evaluation and treatment, but they are important facets that cause stomatitis). Some diseases and problems
of swallow function. In a study of pressure function, are treated with medications that cause or exacerbate
McConnel and co-workers (1988) report on manofluo- oropharyngeal dysphagia (e.g., Parkinson's disease,
rographic analysis of swallowing. They studied the hyper/hypothyroidism, steroid myopathy, alcoholic myo-
pharyngeal swallow with strain gauge pressure sensors pathy, diabetic neuropathy, inflammatory myopathies,
that recorded pressure, anatomic events, and bolus and myasthenia gravis).
transit on videotape, in coordination with lateral view Gastroesophageal reflux disease (GERD) may relate
fluoroscopic swallow study recorded on the left side of to excessive or prolonged or intermittent relaxation of
the video screen. They determined that an important the lower esophageal sphincter (LES). The LESprovides
factor for the pharyngeal swallow is the establishment a barrier to the reflux of gastric contents. The elimina-
of a pressure gradient for bolus passage. The oropharynx tion of irritating foods or drugs that lower LES pressure
generates a propulsive pressure and the hypopharynx may be helpful. Additionally, inability to clear refluxed
generates a negative pressure. The analysis of this two- acid from the esophagus due to decreased esophageal
pump system facilitates a means for more precise quan- motility and diminution of saliva may be contributory
tification of swallow function. to GERD. Alcohol taken before lying down may also
Multi-faceted swallowing difficulties are diagnosed contribute to reflux disease.
through instrumental assessment. Instrumental assess- Odynophagia may be the result of esophageal injury,
ments of swallow function include videofluoroscopy, but it can also be caused by a tablet or capsule lodging
flexible fiberoptic endoscopy, ultrasound, electromy- in the mucosal wall of the esophagus. Xerostomia may
ography, electroglottography, and the measurement of cause food to stick in the throat or difficulty chewing.
temporal association between respiration and swallowing Videofluoroscopic swallow study (VFSS) is widely
(Perlman, 1997). Additional instrumental imaging tech- used and considered the gold standard to define pharyn-
nologies may include scintigraphy, X-ray microbeam, geal physiology (Logemann, 1983, 1986, 1993; Perlman,
MRI, real-time assessment of lateral pharyngeal wall 1997). The study begins with presentation of 1 mL of
movement, computer-assisted assessment of hyoid bone liquid barium and progresses to 3, S, and 10 mL. This
movement, three-dimensional ultrasound, image seg- study has been shown to be a safe and effective way
mentation and volume determination, and quantifica- of assessing oral and pharyngeal swallow function
tion of echogenicity of the tongue (Watkin and Miller (Logemann, 1993). It is important to reestablish swallow
1997). Fiberoptic endoscopic video examination, com- function in as natural and timely a manner as possible
bined with a delivered air pulse, can aid in determining with proper diet and without unduly stressing the
laryngopharyngeal sensory discrimination thresholds patient. Dietary control is an important dimension of
and provide a means for examining the sensory and swallowing treatment.
motor aspects of swallow function (Aviv et aI., 1998). The rationale for dietary control appears to relate to
Some of the procedures are not used commonly for the body being able to make natural accommodations
clinic examinations and are applicable to research at this or compensations for food intake, providing the food
time. Clinicians need to be aware of the scope of assess- intake is properly controlled. Involuntary and voluntary
ments to assist in development of therapeutic protocols. compensatory movements are likely. The structures
"affected less by the disease process work harder to
Medication Effects avoid aspiration, excessive retention of bolus in the
pharyngeal cavity or nasal regurgitation" (Donner, 1988
Feinberg (1997) reviews medications that can have detri- [po 2]). Decompensation may occur if the disease pro-
mental effects on swallowing function. The brain stem gresses or, possibly, if the system is not used for long
for swallow reflexive function, cortex for voluntary oral periods of time and the musculature atrophies (Donner,
phase function, and sensory feedback mechanisms in 1988).
BASIC CONSIDERATIONS
According to Logemann and colleagues (1992), head exceed pressures of 25 mm Hg against the tracheal wall,
and neck cancer patients accommodate small amounts and in some cases minimum pressures can be lower
of aspiration with pureed foods. [n studying outcome depending on the patient's trachea size (Mason, 1993).
measures of swallowing rehabilitation in head and neck
cancer patients, these researchers state: "This tolerance
may result from good ciliary action or strong cough which Glossectomy
clears the aspirated material from the tracheobronchial
tree sometime later or may relate to the patient's Increased survival rates for glossectomy patients
mobility and general good health" (p. 185). (Lauciello et a\., 1980) have led to increased need for
The use of a staged diet, the Abbott Northwestern speech-language intervention. Annually, 15,000 people
Staged Diet (Felt and Anderson, 1989), was reviewed are diagnosed with oral cancer and carcinoma of the
for 36 head and neck surgical patients (Richmond, tongue. This type of cancer is second only to lip cancer
1992). The diet controls for elasticity of, particulates in, as the most frequent type of oral cancer.
and viscosity of foods. The treatment of dysphagia Recent advances in chemotherapy and irradiation
appeared most effective when specific dietary planning may have made preoperative speech consultation and
was incorporated. informed consent for total glossectomy more important
Temporary nonoral feeding may be particularly than previously. The patient may want and needs to
important in the management of head and neck surgery know the communicative implications involved after glos-
patients. Kirsch and Sanders (1988) report studies in sectomy. Discussion of implications of speech therapy
patients undergoing abdominal surgery that indicate a and potential communication difficulties can facilitate
IS % incidence of pneumonia as compared with a 1.5 % patient understanding.
incidence in patients without a nasogastric tube. They Paulowski and colleagues (1993) emphasize the
further discuss a possible resultant incompetence of importance of effectively counseling patients with oral
the upper and lower gastroesophageal sphincters, with and oropharyngeal cancer before surgery as well as plan-
regurgitation and aspiration of gastric and pharyngeal ning and assessing appropriate rehabilitation strategies.
contents. An associated 32 % incidence of edema is Further data on functional outcomes for specific surgical
reported with the nasogastric tube. The potential for resections and reconstructions are needed. Sixteen
postcricoid inflammation and resultant chondritis and patients with anterior oral cavity lesions, resection of
laryngeal dysfunction is mentioned. The timely use of the anterior tongue and mouth, distal flap reconstruc-
PEG can measurably improve the speech pathologist's tion, and maintenance of the mandibular arch showed
ability to work with the dysphagia patient. Combined no improvement by 3 months post healing. The lack of
oral and nonoral feeding may be an initial step, because improvement in speech and swallowing function in
patients can have delayed pharyngeal onset owing to these severely impaired patients suggests that speech-
postoperative pharyngeal edema. They may have more language pathologists should be aggressive in the estab-
difficulty in the controlled moving of very thin liquids lishment and maintenance of a treatment program in the
through the pharynx into the esophagus, owing to immediate postoperative period. The aggressive program
delayed pharyngeal swallow onset. Thickening of liquids is important or critical if the patient is receiving post-
is advised for some patients, whereas others may react operative radiation therapy.
against "drinking" thickened liquids, which are changed Differences in prognosis for speech communication
into a puree. The potential for dehydration must be con- recovery can relate to the portion and amount of the
sidered. Quality of life can be improved with improved tongue removed. Skelly (1972) described numerous com-
swallow function, a byproduct of the combined oral pensatory procedures for improving speech intelligi-
and PEG feeding approach. bility after glossectomy. When tongue tip, or a portion
A problem relative to swallowing management with of the tongue tip, can be retained, speech intelligibility
the nasogastric feeding tube may result from the use of may be better. lmprovements in technology have facili-
a tracheal cuff. Complications and hazards in use of a tated communication through the use of fax machines,
tracheal cuff include total occlusion of the airway, her- speech synthesizers, and TOO devices. Implications for
niation of the tracheal mucosa, tracheal stenosis, granu- swallowing post glossectomy also need to be discussed
loma formation, tracheal erosion, tracheal malacia, with the patient. Special dietary adaptations such as
necrosis, erosion of the innominate artery, and tracheo- processing food in a blender or permanent nonoral
esophageal fistula (Mason, 1993). Current tracheotomy feeding may be indicated. Preoperative visitation by a
tubes are manufactured with low-pressure high-volume rehabilitated glossectomy patient may be helpful in pro-
devices that distribute the cuff seal over a larger area viding a basis for improved or increased understanding
with lower pressure. Tracheostomy tube cuffs should not of the pending surgery and its implications.
BASIC CONSIDERATIONS
altered speaking at fundamental frequency after thyroid in a total communication environment that encouraged
surgery (Hirano, 1988). Voice evaluations were per- speech and signs to be used simultaneously had
formed on patients who underwent thyroidectomy. more accurate production of vowels and consonants
Measures were derived from laryngeal stroboscopy, than children who did not receive implants.
which included fundamental frequency, the lowest and 2. With single-electrode and multielectrode cochlear
highest frequency, vocal range, and a number of phona- implants, tactile aids, or hearing aids, better speech
tion time measurements. Deterioration in vocal perfor- intelligibility was associated with earlier implant fitting
mance was noted in patients with complete lesions of (before adolescence) and better ability to perceive
the external branch of the superior laryngeal nerve, speech.
subsequent to thyroid surgery. 3. Adult clients and patients who received various
According to Morrison and Rammage (1994 [po 10]), types of multi electrode cochlear implants achieved
"The comprehensive acoustic evaluation includes high levels of speech perception skill for sound and
assessment of pitch, loudness, rate/duration and quality word recognition.
parameters of phonation and speech." Popular exami- 4. Use of auditory information and feedback from a
nation includes history taking and analysis, videostro- multi electrode cochlear implant alone did not suffi-
boscopy, electroglottography, flow glottography, and, ciently reduce deviant speech behaviors. Combined
when vocal cord movement is of diagnostic importance, behavioral treatment program with a sensory aid
electromyography. was necessary to effect speech improvement.
5. A cochlear implant promoted language development
Vocal Therapy and Vocal Management to a greater extent than would be predicted by
maturation alone.
Treatment efficacy in voice disorders is focused on data- 6. Children using hearing aids who had severe to
based research articles through group designs, single- profound hearing loss, in the range of 90 to 100 dB,
subject experimental designs, retrospective analyses, demonstrated speech perception and production skills
case studies, and program evaluation data (Ramig and superior to the best performers with cochlear implants.
Verdolini, 1998). Experimental and clinical data exist to However, more recent research indicates the gap is
support the effectiveness of voice treatment for voice closing faster, because this group of children with
disorders related to vocal misuse, hyperfunction, and cochlear implants gain listening experience with
muscular imbalance. Voice disorders include those with their devices.
organic changes, special medical or physical conditions,
and psychological causes. Pannbacker (1998) reviewed Middle Ear Surgery: Medical, Audio/ogic, and
voice treatment techniques and outcomes and states that Speech Follow-up
voice treatment depends on diagnostic category, client
characteristics, and the preference of the clinician. Larson Sullivan and Sullivan (1998) discussed surgical artifacts
and Mueller (1992) surveyed speech pathologists for and iatrogenic anomalies in the context of demonstrating
preferences in treatment approaches and ranked them the utility of video otoscopy. They refer to postauricular
in the following order: counseling, vocal abuse elimina- mastoid bowl defects and scar after mastoidectomy, seb-
tion, hard glottal attack, relaxation, changing loudness, orrheic residue, collapsing canal, extended and extruding
pushing, yawn-sigh, ear training, establishment of new pharyngoesophageal tubes, extruding wire stapedectomy
pitch, and digital manipulation of the larynx. prosthesis, fenestration cavity, and other problems.
An important part of management of postoperative ear
problems is a follow-up reassessment. The American
Hearing, Cochlear Implants, and Speech-Language-Hearing Association Guidelines for
Middle Ear Surgery Identification Audiometry with children from 4 years of
age to grade 3 indicate that children who have had a
Cochlear Implants and Rehabilitation myringotomy and other surgical procedures involving
the ear should be followed with periodic hearing
Less than 1 % of 15 million people in the United States examinations and communicative assessments.
with significant hearing impairment are candidates for "Once people have been identified by the program,
cochlear implant (National Institutes of Health, 1988). they should be followed regularly to ensure that their
Outcomes in children following cochlear implants are communication and medical needs are met. It is point-
varied (Carney and Moeller, 1998): less to identify people who have hearing impairments
unless there is a concurrent follow-up program to
1. Children receiving implants before 5 years of age using handle their habilitative educational and medical needs"
nucleus multielectrode cochlear aids and educated (American Speech-Language-Hearing Association,
BASIC CONSIDERATIONS
through the lymphatics to the regional nodal basin to a mapping using the blue dye alone, identification of the
single (and infrequently to two) node(s), which may be sentinel node through the intradermal injection near
called sentinel nodes. In this method of lymphatic map- the melanoma site of a radiocolloid has been reported
ping or sentinel node biopsy, one identifies and dissects with a high rate of success in identifying the sentinel node
the first lymph node that receives lymphatic drainage either by using this method alone or in combination
from the particular skin site involved by the melanoma with blue dye. The radiocolloid, usually 99mTc-labeled
(Morton et aI., 1992). This node should contain a focus sulfur colloid, is injected intradermally on four sites
of melanoma cells, if melanoma cells traveled through around the biopsy site of the melanoma and then the
the lymphatics to the sentinel node. The sentinel node scanning that is obtained serves to point out the nodal
is identified by injection of a blue dye, isosulfan blue, basin(s) to which the melanoma may be draining, being
which is injected near the site of the previous biopsy of particularly useful for melanomas close to the midline
the melanoma. Morton and colleagues initially suggested of the trunk or head and neck; it also helps significantly
injection of 0.5 to 1 mL intradermally on either side of in the localization of the sentinel node (exhibiting a
the biopsy incision. The site of injection is massaged radioactivity two to four times higher than the rest of
gently for approximately 5 minutes, and then an incision the basin) through the use of an intraoperative probe.
is made over the nodal basin in the same direction that If one uses the combination of the two methods at the
would be done for an elective node dissection. Of course time of surgery, usually scheduled 3 hours after injection
the incision for sentinel node biopsy is shorter than of the radiocolloid, one scans with the probe over the
that for the elective procedure. Morton and colleagues skin of the nodal basin, which has been shown to pick
recommended the development of a flap at the nodal up radioactivity with the scan and identifies percuta-
basin toward the primary site and identification of a neously the hottest spot over the nodal basin, which
blue-stained lymphatic channel within the subcutaneous should be overlying the sentinel node. One can then
tissue, which then should be traced to the sentinel make an incision centered over the hottest skin spot in
node. If one cannot identify the blue-stained lymphatic the same direction as one would make for a cervical
channel or the sentinel node, repeat injections of the node dissection. The incision is then deepened through
blue dye are performed at 20-minute intervals. the subcutaneous tissue and platysma, and the probe is
In the author's experience, one actually may inject a used again to further direct the course of the dissection.
larger amount of the dye, 2 to 3 mL, intradermally, Scalpel or light cautery may be used in this process.
because if an inadequate amount of dye is injected ini- If a blue-stained lymphatic channel is found, one may
tially and the dissection in the nodal basin fails to reveal trace this channel with clamp and/or Metzenbaum
a blue-stained lymphatic channel and/or a sentinel scissors dissection toward the actual sentinel node. The
node, further intradermal injections at the primary site sentinel node usually is stained blue in one pole at the
may not help because the afferent lymphatics to the point of entry of the blue-stained lymphatic channel.
nodal basin from the primary melanoma site may have Occasionally, there are more than one lymphatic channels
already been interrupted by the initial dissection. It leading to the sentinel node. Infrequently, there are two
therefore may be best to inject a larger bolus of the dye sentinel nodes and, rarely, three sentinel nodes receiving
initially, hoping that there would be enough dye traveling direct lymphatic drainage from the primary site. The
along the lymphatics so that the lymphatic channels may radioactivity of the sentinel node in vivo is recorded in
be identified, as well as the sentinel node. The ability counts per minute (CPM) by using the probe covered
to detect the sentinel node varies with the experience of with a sterile sheath; and after the sentinel node is
the surgeon in this procedure, and it tends to continually removed, this is recorded ex vivo and the radioactivity
improve as the surgeon acquires more experience with in the remaining nodal basin is also recorded. The last
this technique (Morton et aI., 1992). The success in should be less than half of the ex vivo radioactivity of
identifying the sentinel node varies also according to the sentinel node. If it is higher than that, this may
the anatomic nodal basin, being highest in the groin indicate that there may be additional sentinel node(s)
and somewhat lower in the axilla. In the head and neck to be searched with the use of the probe because they
area, however, the identification of the sentinel node has may not be stained with the blue dye. With the combi-
been problematic. In our initial experience with sentinel nation of the blue dye technique, as well as the use of a
node biopsy for melanomas draining to the cervical node radiocolloid with an intraoperative probe, the detection
basin, the success rate in identifying the sentinel node of the sentinel node in the cervical area should be close
was only 56% (Karakousis and Grigoropoulos, 1999). to 100% (Karakousis and Grigoropoulos, 1999). The
These difficulties have led some authors to suggest that radioactivity counts recorded over the site of injection
sentinel node biopsy is not applicable in the case of the around the primary lesion are about 30,000 CPM. In
head and neck melanomas because of the high rate of the case of a melanoma arising in the skin of the neck,
failure in identifying the sentinel node. Since the report the injection of the blue dye as well as radiocolloid near
by Morton of his technique of intraoperative lymphatic the primary skin site may seriously interfere with the
BASIC CONSIDERATIONS
identification of the sentinel node because of the close warrant attention regarding their prognostic factors and
proximity of the primary skin site to the underlying lymph management. The two most common histologic types
nodes. Therefore, for melanomas arising in the skin of are liposarcomas and malignant fibrous histiocytomas
the neck, although one may try to apply the technique (Morton et a!., 1997). Sarcomas metastasize primarily
just described, there may be serious interference from through the bloodstream but, infrequently, at an overall
the primary site in identifying the sentinel node. In such rate of approximately 5% (2.6% to 10.8%) (Brennan et
cases, the decision can be made for elective node dis- a!., 1997) for all histologic subtypes, they may metas-
section on the basis of the prognostic parameters of the tasize through the regional lymph nodes. Some of the
primary lesion and the likelihood of there being micro-
scopic disease in the regional nodal basin (Balch et a!.,
1996). Generally, if one is unable to identify the sentinel
node, elective node dissection should be performed.
Distant Disease
histologic subtypes, however, such as malignant fibrous extent of the primary tumor. This is true for the head
histiocytoma and synovial sarcoma, have a higher and neck area, as for other regions. In performing the
frequency of metastasis through the lymphatic system resection, an elliptical incision is made around any pre-
to the regional lymph nodes. vious biopsy incision. A decision has to be made pre-
operatively as to whether any substantial amount of skin
Presentation and Diagnosis should be removed, owing to close proximity to the
tumor. If one can avoid a large resection of skin, then
Sarcomas usually present as a mass associated with little one may obviate the additional requirement of flap
or no pain, and, thus, they are often diagnosed when reconstruction. The dissection is carried around the
they are quite sizeable. The diagnosis is established via tumor, trying to stay as far away from the tumor site as
biopsy. Aspiration cytology does not usually provide a local anatomy permits. In situations in which underlying
sufficient diagnosis. A core needle biopsy, such as with bone is in close proximity, one may have to remove a
a Tru-Cut needle, often provides enough tissue to make partial or the full thickness of the underlying bone. In soft
a histologic diagnosis of soft tissue sarcoma and the tissue sarcomas of the supraclavicular area, because
histologic subtype involved. To obtain a core needle some tend to extend underneath the clavicle, it may be
biopsy, the most prominent part of the skin around the necessary to remove the clavicle to permit complete
tumor area is infiltrated with local anesthesia down to resection of the tumor, with simultaneous provision of
the surface of the tumor. A small nick with a No. 11 adequate exposure of the brachial plexus and subclavian
blade is made in the skin to allow passage of the rather vessels. Claviculectomy in itself does not produce any
thick needle through the skin and into the subcuta- significant morbidity or functional impairment for the
neous tissue. Through this small opening in the skin, patients, although for 3 to 4 weeks after the operation
three or four pieces from the tumor are obtained and they may have to wear a sling until the healing is com-
sent for pathologic evaluation. The other alternative is pleted (Karakousis et aI., 1992). The objective is to obtain
open biopsy using an incision adequate enough to get as much margin as anatomically possible around the
to the site of the tumor and obtain a piece. The incision palpable tumor mass. An adequate tumor margin of
should be placed over the center of the tumor mass in normal tissue should be 2 em or greater, but that is not
the direction of what might later be the definitive inci- always obtainable. However, in dissecting around the
sion. A number of these tumor masses, of course, may tumor mass, one should be able to obtain an adequate
turn out to be lymphomas and be treated with means tumor margin in most directions around the mass and
other than surgical resection. During open biopsy, as limit the margin only in the vicinity of critical anatomic
the tumor surface is approached and the incision is structures that cannot be easily replaced or sacrificed.
made through what may be the pseudocapsule of the The goal is to eliminate or at least minimize microscopic
tumor, a deeper cut into the tumor is done so as to have residual tumor. It has been shown conclusively that
a representative piece of tumor tissue. adjuvant radiation (i.e., radiation given for potential
Superficial biopsies are frequently not diagnostic microscopic disease) reduces significantly the rate of
when they are derived from the capsule of the tumor local recurrence (Brennan et aI., 1991).
mass. If there is any doubt as to having a representative Radiation treatment may be given preoperatively, par-
piece of tissue, frozen section may be obtained at the ticularly in cases in which the tumor does not appear
time of the incisional biopsy to ascertain that there is to be resectable without first shrinking down its size.
indeed representative tissue. One should not rely on More commonly, radiation is given postoperatively on the
frozen section to perform the definitive surgery unless basis of the clinical-pathologic assessment of surgical
the latter is not expected to cause a significant functional margins and therefore the actual need for adjuvant radia-
or cosmetic deficit. Frozen section is not as accurate as tion when the margins are considered inadequate. In a
permanent section in determining that one is dealing prospective randomized study, it was found that the
with a soft tissue sarcoma or in defining the histologic preoperative (neoadjuvant) radiation is associated with
subtype. Exuberant granulation tissue can be confused a higher rate of wound complications compared with
with malignant fibrous histiocytoma. postoperative radiation (O'Sullivan et aI., 1999).
Node dissections can be fairly formal in terms of their The rate of local recurrence with local excision alone
extent, the incisions being used, and the dissection has been reported in the literature to be 65% to 95%
involved owing to the fairly constant anatomic location (Abbas et aI., 1981; Cadman et aI., 1965). When local
and the distribution of the regional lymph nodes. In excision is supplemented with irradiation postopera-
contrast, surgical resection of the primary sarcoma has tively, the rate of local recurrence is about 25 %, so it is
to be specifically designed for the anatomic location and significantly decreased but still remains appreciable and
BASIC CONSIDERATIONS
higher than the 10% rate observed after wide excision patients with Graves' ophthalmopathy have systemic
alone (Karakousis et a!., 1995). Therefore, even when Graves' disease (hyperthyroidism). The systemic thyroid
one intends to use the adjuvant modality of irradiation, status may be hyperthyroid, hypothyroid, euthyroid, or
it still is important to try to obtain as wide a margin as even involved in a neoplastic process (Morris, 1988).
possible around the tumor in all directions that is clini- Severity and duration of the disease are unpredictable.
cally feasible. The 5-year disease-free survival depends The proptosis is usually accompanied by other orbital
primarily on the grade of the tumor, being for grade 1 signs, including eyelid retraction, orbital congestion, and
tumors about 90%; grade 2, 65%; and grade 3, 45% motility disturbances, in isolation or in various com-
(Karakousis et a!., 1995). The second prognostic binations. Although orbital manifestations typically
parameter significantly affecting survival is the size of improve over several years, irreversible vision loss due
the tumor. Tumors less than 5 em in diameter have a to corneal exposure or optic nerve compression does
better prognosis than those larger than 5 em. The third occasionally occur (Grove, 1975, 1979). Careful obser-
prognostic indicator is the location of the tumor: whether vation and reassurance are helpful and often adequate,
deep or superficial to the fascia or covering a muscular but medical and surgical intervention may be required
compartment. Sarcomas located in the subcutaneous and are beneficial when used judiciously.
tissue have a better prognosis than those located within The disease may cause disfigurement, which may be
muscle groups. Adjuvant chemotherapy of soft tissue psychologically devastating to the patient. Many patients
sarcomas is still investigational, although there is a trend state that they don't look like themselves anymore. They
among medical oncologists to use adjuvant chemotherapy may have eyes that are protruding, with one eye looking
for high-grade soft tissue sarcomas. This is in contrast in the wrong direction, they are uncomfortable, and
to sarcomas of childhood, especially rhabdomyosar- they feel disfigured. Graves originally described a triad
comas and bone sarcomas, in which the use of adju- of hyperthyroidism, dermopathy, and eyelid retraction.
vant chemotherapy is of proven efficacy in improving Most patients with thyroid-related orbitopathy have pre-
survival. existing or simultaneously diagnosed hyperthyroidism,
but not all of them do. In at least 20 %, the diagnosis of
Local Recurrence a thyroid disorder follows (often by years) the initial
orbital manifestations. Furthermore, 3% never develop
Local recurrence should be resectable in the majority of a clinically apparent thyroid imbalance. Also, rather
instances (95 %). The overall 5-year survival rate is than being characteristically hyperactive, the thyroid is
65 % after resection of a local recurrence similar to that sometimes hypoactive.
of primary sarcomas (Karakousis et a!., 1996). Thyroid-related orbitopathy is primarily a clinical
diagnosis. The classic presentation is easily recognized.
Distant Recurrence Atypical presentations such as marked asymmetry or
purely unilateral disease, euthyroid status, acute severe
Soft tissue sarcomas spread hematogenously predomi- inflammation, myositis, pain, or subtle non inflamed
nantly to the lungs. Resection of pulmonary metastases disease, unusual neurologic symptoms, unusual systemic
is associated with a 5-year survival rate of about 20% disease, trauma, or paranasal sinus disease are not
(Lawrence et a!., 1987), varying with the number of infrequent and may be difficult to differentiate, making
metastases, the prior disease-free interval, the com- the diagnosis suspect or raising the question of a second
pleteness of the resection, and control or lack of control coexisting orbital process, especially if one fails to
of the primary site. consider the diagnosis of thyroid-related orbitopathy.
Orbital imaging studies will help in the diagnosis and
management of these patients.
Thyroid-Related Orbitopathy Conversely, not all individuals with systemic Graves'
Daniel P. Schaefer disease demonstrate orbital involvement. Only 60% to
90% possess at least subclinical orbital involvement,
Thyroid-related orbitopathy, also known as Graves' such as enlargement of the extraocular muscles on CT.
ophthalmopathy, is the most common cause of both uni- The prevalence of symptomatic and clinically apparent
lateral and bilateral proptosis in adults. Synonymous orbital involvement varies but is definitely less than
terms include Graves' orbitopathy, dysthyroid ophthal- 20 % of those with systemic thyroid disease.
mopathy, thyroid eye disease, thyroid-associated orbitopa-
thy, infiltrative ophthalmopathy, congestive ophthal- Pathogenesis
mopathy, endocrine exophthalmos, malignant exoph-
thalmos, and von Basedow's disease (Werner, 1977). The immune system is attacking the thyroid and the
Graves' name can create confusion, because not all orbital tissues. It is probably two different antigens that
BASIC CONSIDERATIONS
cause thyroid disease and thyroid-related orbitopathy leukocyte antigen typing varies by race, and no single
but they are related and similar enough so that the marker has been shown to be universally common.
immune system can attack both or may just attack one Environmental factors are also important. Although
and not the other. the role of stress is disputed, cigarette smoking is clearly
The pathogenesis between systemic thyroid disease capable of aggravating and prolonging thyroid-associated
and orbitopathy remains a point of debate. Activation of orbital inflammation. Patients who have thyroid disease
the thyroid gland, as a result of inflammation, trauma, are seven times more likely to develop a more severe
surgery, smoking, and irradiation, appears to prompt a form of thyroid-related orbitopathy if they smoke. Surgical
release of a thyroid antigen that stimulates both the manipulation of the thyroid gland and radioactive iodine
cellular and humoral cascades of the immune system. treatment have been reported to exacerbate preexisting
This combination of cell-mediated and humoral activa- orbital signs and symptoms, but this connection has
tion promotes inflammatory cell migration and produc- not withstood careful scientific investigation.
tion of edema in the orbit. Activated T lymphocytes
invade the orbital connective tissue at the same time a Clinical Course
local humoral immune reaction is initiated. Retrobulbar
fibroblasts proliferate, resulting in increased synthesis Thyroid-related orbitopathy is frequently a self-limited
and release of glycosaminoglycans. Locally produced disease, but each of its associated orbital signs varies in
lymphokines amplify the cascade. The result is thickening prevalence and persistence. Soft tissue inflammation
of the extraocular muscles and increase in orbital fat and congestion are common and nonspecific signs and
volume. The specifics of each step have been the typically resolve within 5 years. Eyelid retraction, either
subject of intense investigation (Volpe, 1974). A shared unilateral or bilateral, is common (90% prevalence) and
orbit-thyroid antigen(s) is then presented and released the sign most likely to persist chronically. Extraocular
into the circulation (Heufelder, 1995). Therefore, the muscle dysfunction occurs in 40% of patients, and inter-
thyroid gland and the orbital content are probably a mittent diplopia will usually resolve over time. One
secondary responder to the immune system disorder third of the patients who develop constant, noncomitant
rather than a primary etiologic factor. diplopia will improve spontaneously. Unilateral or bilat-
The histopathologic changes in thyroid-related eral proptosis occurs in 60% of patients. Improvement
orbitopathy may cause the retrobulbar fat and con- is unusual in such cases, with fewer than 10% of patients
nective tissue stimulation with increased fibroblastic demonstrating significant improvement within 5 years.
activity, glycosaminoglycan deposition, and edema. The Vision loss, the most feared complication, occurs in fewer
extraocular myositis with edema, lymphocytic infiltration, than 5 % of those with orbital involvement. Sequelae
and muscle necrosis may occur. The pathophysiology that may cause irreversible vision loss if not managed
of thyroid-related orbitopathy is not well understood. appropriately include compressive optic neuropathy,
There appears to be stimulation of orbital fibroblasts to corneal scarring, and secondary glaucoma. Corneal
produce hyaluronic acid. Doubling the hyaluronic acid ulceration is rare.
content in orbital tissue increases the osmotic load five- The clinical course of thyroid-related orbitopathy does
fold. This may lead to passive swelling of orbital tissue not follow a linear progression of severity. It can have
(Kroll and Kuwabara, 1966; Sergott and Glaser, 1981). its onset over days to weeks. The acute phase may last
from 3 months to more than 2 years. This phase is charac-
Epidemiology terized clinically by inflammatory signs, including eyelid
erythema, chemosis, injection, and edema and also by
Thyroid-related orbitopathy most commonly occurs fluctuations that can occur daily or weekly. After reso-
between the ages of 25 and 50. Graves' disease is five lution of the acute phase, proptosis, diplopia, and eyelid
times more likely to affect women than men. The peak retraction may persist owing to the cicatricial changes
incidence is often earlier in women (fourth or fifth that occur in the extraocular muscles and orbital soft
decade) than in men (sixth or seventh decade). Men tissue. The acute episodes may occur from one to three
have been reported to develop thyroid-related orbitopa- times during the course of the disease.
thy more severely than women. All races are affected, The course of thyroid-related orbitopathy is unrelated
but whites are distinctly more commonly affected than to treatment of systemic hyperthyroidism. The thyroid
blacks or Asians. Predominant clinical signs may also and orbital manifestations act as two independent
differ among races. Presentation in childhood is unusual clinical processes, the treatment of either of which does
but not rare (Bartley et aI., 1995). Genetic factors appear not always affect the other. Many patients will have
to have a role in the development of thyroid-related spontaneous improvement of their symptoms. The
orbitopathy, with 20% to 60% of those affected reported physician's goal is to prevent complications while we
to have a family history of thyroid disease. Human are waiting for the disease to "burn out."
BASIC CONSIDERATIONS
Ophthalmic signs and symptoms may worsen, chronic phases of the disease. Treatment should be
improve, or remain the same in patients who undergo individualized. Patients with active thyroid-related
treatment of their hyperthyroidism with radioactive orbitopathy in whom optic neuropathy is present, or
iodine-131 (without concomitant systemic corticosteroid whose corneas are threatened by severe exophthalmos
treatment). Tallstadt reported in 1992 that thyroid-related or eyelid retraction, must be examined very frequently.
orbitopathy might worsen in hyperthyroid patients aged Patients who psychologically adapt poorly to the dis-
35 to 55 treated with iodine-13l. Orbital disease in these figurement that the disease may cause will require
patients became worse compared with that in similar much more time and possibly psychiatric counseling.
patients treated with methimazole or subtotal thyroidec- Symptoms and subtle signs of thyroid-related
tomy. Mendlovic and Zafar suggested that this effect orbitopathy are often present for many months to years
was more likely in patients treated with multiple doses before diagnosis. A significant percentage of patients
of iodine-13l. experience at least mild inflammatory changes at some
Another study revealed that 15% of patients who were point during the course of their disease. Common and
treated only with radioiodine developed or had worsening nonspecific symptoms include tearing, irritation, gritti-
of their thyroid-related orbitopathy. In contrast, none of ness, aching, and photophobia. Early signs include
the patients who were treated with both radioiodine conjunctival injection, periorbital puffiness, abnormal
and prednisone had progression and two thirds showed tear break-up time, superficial punctate keratitis, and
an improvement. Only 3% of those treated with methi- elevation of intraocular pressure. Most commonly, the
mazole had any worsening of the condition (Bartalena conjunctiva is injected over the rectus muscle insertions.
et al., 1998). Patients should be maintained on cortico- This may be accompanied by interpalpebral chemosis.
steroids throughout irradiation. Then the doses of the The chemosis may appear hemorrhagic, and the con-
corticosteroids should be slowly tapered. Levels of serum junctiva may prolapse over the lower lids. Corneal expo-
and lymphatic thyroglobulin as well as of antithyroglobulin sure with keratitis, ulceration, or pannus formation may
antibodies increase in the 6 weeks to 6 months after occur secondarily to the combination of proptosis, eyelid
treatment with iodine-131 and also after thyroidectomy, retraction and lagophthalmos, and restrictive myopathy
which may provide a clue to the clinically observable that reduces the Bell's protective phenomenon.
flare-ups that sometimes occur after treatment. Periorbital skin may become puffy, and mild erythema
Advocates of thyroidectomy believe that removal of may be present. In severe cases, the skin becomes lax
the inciting antigens in the thyroid gland with a total and redundant with palpable subcutaneous edema. Eyelid
thyroidectomy reduces the incidences of thyroid-related retraction (upper and/or lower eyelids), inflammation,
orbitopathy. We have insufficient experience with this proptosis (unilateral or bilateral), lid lag, dry eyes, restric-
treatment option to comment. tive myopathy with diplopia, compressive optic neu-
ropathy, and disfigurements are the primary signs.
Differential Diagnosis Increased orbital volume secondary to inflammation is
believed to impede venous outflow, which further aggra-
Severe cases of nonspecific orbital inflammation, orbital vates congestion and the resulting proptosis. Inflamma-
infection, or cavernous sinus disease may cause conges- tion and congestion are two distinct processes, but they
tion and proptosis that resemble the features of thyroid- are intimately related. There may be resistance to
related orbitopathy. In addition to high-flow fistula of retropulsion of the globe, but this is a nonspecific abnor-
the cavernous sinus, infection and thrombosis may also mality that may also result from a retrobulbar tumor or
cause injection, chemosis, ophthalmoplegia, and prop- from diffuse inflammation. The signs may occur simul-
tosis. Arterialization of conjunctival vessels and an orbital taneously or individually (Gorman et aI., 1984).
bruit are characteristics of cavernous sinus fistulas and Allergic conjunctivitis and dry eye symptoms are
do not occur in thyroid-related orbitopathy. Immuno- common misdiagnoses but eventually recognized to be
compromise or signs of sepsis are typically present thyroid-related orbitopathy. Tears are produced in normal
with cavernous sinus infection or thrombosis. quantity in this disease, at least as demonstrated by
Pseudo proptosis may be caused by an enlarged globe, Schirmer testing. These tears, however, have been found
extraocular muscle weakness or paralysis, contralateral to contain abnormal quantities of proteins and immuno-
enophthalmos, asymmetrical orbital size, or asymmet- globulins, which, in conjunction with increased evapora-
rical palpebral fissures (usually caused by ipsilateral lid tion due to abnormal lid position, result in increased
retraction, facial nerve paralysis, or contralateral ptosis). osmolarity. The lacrimal gland is often mildly enlarged
and may be a target of immune interaction. The change
Signs and Symptoms in tear stability may cause symptoms and corneal changes
identical to those seen in keratoconjunctivitis sicca.
There is no one universal answer as to how frequently Ocular hypertension may be the initial manifestation.
these patients should be monitored in the acute and Orbital congestion and impaired venous outflow may
BASIC CONSIDERATIONS
contribute to the increased frequency of ocular hyper- Hertel exophthalmometry continues to be the standard
tension. The examination should include a measurement method of measurement, despite its limited accuracy. If
of the intraocular pressure in primary and upward possible, the same practitioner should repeat the Hertel
gaze, which may further elevate the pressure. Although measurements with a similar width setting on the exoph-
intraocular pressure may fluctuate between 25 and thalmometer at each evaluation. The Hertel exophthal-
30 mm Hg, development of glaucoma damage is occa- mometer is useful to follow patients, but different
sional. Patients with a preexisting diagnosis of glaucoma observers often arrive at different measurements, espe-
or active thyroid-related orbitopathy of more than 5 years' cially if the base dimensions are not kept constant.
duration are at increased risk for glaucomatous optic However, careful measurements taken by a single
nerve damage. Secondary ocular hypertension usually examiner over a period of time may accurately reflect
resolves as the orbitopathy improves, only rarely changes in globe position. More than 2 mm of asym-
progressing to true glaucoma. metrical proptosis raises the possibility of an orbital
Visual acuity and color vision are not affected until mass mimicking thyroid-related orbitopathy.
very late in glaucoma. Glaucomatous field loss (e.g., Orbital ultrasound is an effective method of demon-
arcuate or nasal step defects) differs from the pattern of strating increased muscle size but lacks specificity and
loss seen in compressive neuropathy or thyroid-related does not rule out other disorders.
orbitopathy (e.g., central or centro cecal defects). The Neuroimaging studies are often required when the
optic disc may initially be normal or edematous, but diagnosis is in doubt. CT will aid with the differential
diffuse pallor develops over time. diagnosis in atypical cases, help to evaluate the optic
nerve in cases of compressive optic neuropathy, serve as
Tests Useful for Early Detection a method to document progression in association with
clinical signs and symptoms, or serve as a planning tool
The baseline examination includes assessment and for possible orbital decompression surgery. Imaging
documentation of visual acuity, color vision, pupillary studies permit the surgeon to evaluate the sinus anatomy
function, intraocular pressure in primary and upward and the degree of orbital congestion when orbital decom-
gaze, lid position, globe position (as quantified by Hertel pression is being considered, especially in patients sus-
exophthalmometer), motility (versions and ductions), pected of having chronic sinusitis, because the finding of
and dilated fundus examination. If intraocular pressure sinus opacification allows for preoperative antibiotics or
is elevated or any component of afferent function is sinus drainage. Nonenhanced CT (axial and coronal views
abnormal, visual field examination is also performed. with thin sections) is the best method to define anatomy.
Visual fields and color vision testing help in early Contrast medium enhancement usually is not required
detection. Pseudoisochromatic plates and red desatu- because the orbital fat provides intrinsic contrast for
ration are complementary tests to establish the status many solid or cystic lesions and vascular anomalies
of color vision. Patients need to be alerted about the frequently manifest radiographically as asymmetrical
possibility of a change in vision and need to arrange to enlargement of the superior ophthalmic vein and a dilated
see an ophthalmologist if this happens (Henderson, 1958). cavernous sinus. Another reason to avoid contrast mate-
Examination of eyes with optic neuropathy includes rial is that iodine-containing agents preclude the imme-
careful evaluation and documentation of visual acuity, diate use of radioactive iodine in the treatment of hyper-
color vision, and pupil function at the initial examination thyroidism. CT with contrast enhancement is helpful in
and each subsequent visit to highlight subtle changes that patients who have more than the typical amount of pain
will prompt further evaluation. Humphrey or Goldmann on extraocular movement. Scleral enhancement and
visual field examinations are performed, as well as CT inflammatory infiltrates may differentiate an inflam-
(both axial and coronal views) to clarify optic nerve matory pseudotumor from thyroid-related orbitopathy
position with respect to the enlarged muscles. Contrast in these patients.
medium enhancement is not necessary. CT is helpful in diagnosing and monitoring patients
Examination of the pupils should include the swing- with optic neuropathy. These patients have enlarged
ing flashlight test to evaluate for an afferent pupillary extraocular muscles compressing the optic nerve at the
defect (Marcus Gunn pupil). In addition, anisocoria apex. This finding will differentiate between thyroid-
should be documented and observation should be made related orbitopathy and other causes of neuropathy,
as to whether the difference is greater in the light such as anterior ischemic optic neuropathy.
(parasympathetic defect) or dark (sympathetic defect). Imaging studies will typical show fusiform expan-
Retrodisplace the globe gently in various directions. sion of one or more of the extraocular muscles, gener-
Orbital tumors cause directional resistance to retrodis- ally with thin tendons. Large muscles, greater than 9 mm
placement of the globe according to their location. in width, or a crowded orbital apex indicates patients
Thyroid-related orbitopathy causes a diffuse increase in at risk for compressive optic neuropathy, as does
resistance to ocular retrodisplacement. restrictive myopathy.
BASIC CONSIDERATIONS
MRI is not necessary in evaluating thyroid-related myotomy of the levator muscle, or inserting a spacer
orbitopathy; it offers little additional information and is (fascia, donor sclera, or ear cartilage) between the distal
more expensive than CT. end of the aponeurosis and tarsus via a cutaneous or
conjunctival approach can lower the resting position of
Eyelid Retraction the upper lid.
Lower eyelid retraction can be managed with recession
A common early finding of hyperthyroidism is eyelid of the retractors of the lower eyelids. Severe retraction
retraction. Like other findings in thyroid-related orbitopa- requires grafting of spacer materials (fascia, donor sclera,
thy, this can also be seen in euthyroid or hypothyroid ear cartilage, and also hard palate mucosa) between the
patients. The classic presentation is a bilaterally sym- lower eyelid retractors and the inferior tarsal border.
metrical retraction of the upper and lower eyelids, the A lateral tarsorrhaphy is a useful technique for pro-
stare of thyroid-related orbitopathy. This generally tecting the cornea, decreasing ocular exposure, but, aes-
improves as the thyroid function stabilizes, but it rarely thetically, the appearance of the horizontal shortened
resolves entirely. Involvement of Muller's muscle is palpebral fissure and the interference with the eyelashes
often found in these patients, and hypertrophy of the and peripheral vision is displeasing to many patients.
levator palpebrae is not uncommon. Lagophthalmos Upper and lower eyelid retractor repairs are much more
(retraction of the upper lid with passive eyelid closure satisfactory.
and in downgaze) and lid lag (a slowing of the descent A tarsorrhaphy may be a helpful adjunct to lower lid
of the eyelid with downgaze) are a result of the infil- retractor repair in some cases. In individuals who have
tration of Muller's muscle and the levator palpebrae. mild upper and lower eyelid retraction, particularly with
Forced ductions of the lid are usually positive in these temporal flare of the upper lid, a conservative tarsorrhaphy
cases. The involvement of the lids is usually asym- may be helpful in improving eyelid malposition, when
metrical, especially in chronic cases, but rarely may be performed in combination with Muller muscle recession
unilateral. in the upper lid and with recession of the retractors in
A number of patients develop an unacceptable the lower lid.
amount of retraction, which causes not only cosmetic When Hertel measurements are greater than 23 mm,
problems but also enhances tear evaporation and lower lid retractor recession is difficult, and an orbital
aggravates dry eye symptoms. Topical eyedrops, such decompression should be considered before eyelid
as the a-adrenergic antagonists, have been used to retractor repair in these patients. Lateral tarsorrhaphy is
counteract the sympathetic tone of Muller's muscle, probably best reserved for patients with Hertel measure-
but sustained improvement is rare, and topical toxicity ments greater than 23 mm who are not candidates for
frequently develops. When the lid retraction has been decompression surgery owing to their medical condi-
stable for at least 6 months in a noninflamed eye, then tion, a poor risk for anesthesia, or refusal to undergo
surgical intervention can be entertained. the procedure.
The differential diagnosis of eyelid retraction should
include lesions that involve the midbrain, such as Proptosis
ischemia or tumors, hydrocephalus, or even contralateral
ptosis. Neurogenic lid retraction will have a limitation The orbital apex has no room for expansion. Muscle
of upward gaze, but lagophthalmos is absent; and enlargement posteriorly results in compression of the
results of forced duction testing of the lid and globe are optic nerve just anterior to the optic canal. Proptosis
normal. Other signs of neurogenic causes include serves as a protective function by expanding the total
convergence-retraction nystagmus and light-near orbital volume. Muscle enlargement in the absence of
dissociation of pupillary response. significant proptosis is most likely to promote optic nerve
Contralateral ptosis may result in lid retraction on compression. It is essential to check for signs of afferent
the intact side due to Hering's law of equal innervation. dysfunction, (e.g., decreased visual acuity, abnormal color
To test for this, elevation of the ptotic lid will result in an vision, afferent pupillary defect, and abnormal visual
improvement of the contralateral lid retraction, demon- fields), even in apparently asymptomatic patients.
strating that the excessive innervation, or Hering's law, Proptosis is less prevalent than eyelid retraction. It is
is the cause of the lid retraction. Also forced duction caused by infiltration of the eye muscles with inflam-
testing is normal and lagophthalmos and lid lag are matory cells and/or an increase in fat volume, resulting
absent. in forward displacement of the globe. Proptosis is
The various surgical techniques for the correction of usually axial and associated with increased resistance
lid retraction involve Muller's muscle and the levator to retropulsion of the globe. In general, bilateral and
aponeurosis in the upper lid and the capsulopalpebral asymmetrical proptosis is not uncommon.
fascia in the lower lid. Excising or recessing Muller's Nonspecific orbital inflammatory syndrome, orbital
muscle and/or the levator aponeurosis, performing a tumors (primary or secondary), orbital infections, and
BASIC CONSIDERATIONS
cavernous sinus processes may cause proptosis. Orbital Botulinum toxin has been utilized in the treatment
inflammatory syndrome (orbital pseudotumor, myositis) of strabismus and can actually achieve a permanent
or rare cases of orbital amyloidosis with muscle involve- cure, obviating the need for surgery in approximately
ment are generally unilateral, accompanied by severe 30% of the patients in whom it is used. It is a great
pain. The inflammation of the muscles involves the temporizing measure in about another 30 % of patients.
tendinous insertions and may simulate thyroid-related Acquired diplopia may also be secondary to cranial
orbitopathy. The fat will appear infiltrated, and scleral nerve paralyses, myasthenia gravis, trauma, tumors, and
thickening is not uncommon on CT. Orbital tumors (pri- orbital inflammatory syndromes. Cranial nerve paralysis
mary or secondary), on the other hand, cause unilateral and myasthenia are not restrictive, and therefore the
and often nonaxial proptosis, without significant pain forced duction test is normal. In myasthenia gravis, the
or inflammation. Orbital infections are also usually patient's symptoms will worsen with fatigue and at
unilateral, but they tend to be accompanied by mild to the end of the day, with ptosis rather than an eyelid
moderate pain, inflammation, and sinus involvement. retraction. If a patient with thyroid-related orbitbpathy
The proptosis secondary to cavernous sinus fistulas or has motility disturbances and/or ptosis, he or she should
dural fistulas is usually unilateral, accompanied by be evaluated for myasthenia, because 5 % of patients
conjunctival chemosis, arterialization of the conjunctival with myasthenia gravis have thyroid disease and I % of
vessels, and mild pain. There may be an orbital bruit or individuals with thyroid disease have myasthenia gravis.
a history of trauma, or the proptosis may be idiopathic. Trauma to the floor or medial wall may result in a
restrictive myopathy, with positive forced ductions. CT
Motility Abnormality with coronal sections should be obtained in any patient
with a history of prior trauma. Orbital inflammatory
Transient or intermittent diplopia is common but can syndrome may mimic thyroid-related orbitopathy but is
progress gradually or rapidly to a constant diplopia. usually unilateral and accompanied by pain. CT often
Patients generally have difficulty with fusion in the demonstrates the characteristic diagnostic tendon
morning, owing to fluid accumulation in the muscles involvement and changes in the orbital fat and sclera.
that occurs with a prolonged prone position. Initially, the
extraocular muscles are infiltrated with inflammatory Optic Neuropathy
cells and edema, which then progress to a fibrosis that
may create a permanent motility restriction. Ocular move- Compressive optic neuropathy is a vision-threatening
ments may be limited in a specific direction of gaze by complication of thyroid-related orbitopathy that requires
the inflammation that involves a single or multiple very careful evaluation and management. It can occur
extraocular muscles. The inferior rectus and then the in inflamed orbits early in the course of the disease or
medial rectus are the most commonly involved, which can late, in the postinflammatory stage, and in proptotic or
result in a noncomitant esotropia and/or hypotropia. nonproptotic orbits. CT or MRI of the orbit with coronal
Thyroid-related orbitopathy most commonly involves sections is required to demonstrate the enlargement of
the inferior rectus muscle with fibrosis, which restricts the muscles and their relations to the optic nerve.
elevation of the affected eye and can even cause it to Sometimes the orbits are congested and inflamed, and
be hypotropic in primary gaze. On attempted upward sometimes they are not. The patients that have minimal
gaze, the intraocular pressure may rise in the affected proptosis, but moderate to marked limitation of
eye. Forced duction testing is the simplest and fastest test extraocular motility and tight orbits show a warning
to evaluate restricted motility and is usually positive in that they are at greater risk for the development of
these patients owing to the restrictive myopathy. This thyroid optic neuropathy, owing to mechanical crowd-
is important because approximately one third of the ing phenomenon.
time the ophthalmologist is the first to recognize the The risk of developing thyroid optic neuropathy and
diagnosis of thyroid disease. CT often reveals bilateral loss of vision is relatively low (1 % to 5 %). Therefore,
involvement of all muscles but sparing of the tendons. these patients should be monitored and followed closely,
When orbital findings have remained stable for at with evaluation of visual acuity, color vision, visual
least 6 months, then strabismus surgery may be enter- fields, and optic nerve examinations. The absence of
tained. Recession of the levator aponeurosis or inferior disc edema or pallor does not exclude the diagnosis of
retractor muscles will reduce corneal exposure. The thyroid optic neuropathy.
aim of extraocular motility surgery is to minimize Orbital decompression surgery is an effective treat-
diplopia in the primary position and in downward gaze ment for compressive optic neuropathy. The medial
but rarely will correct diplopia in all gazes. Adjustable orbital wall, especially the posterior ethmoids, along
suture techniques may be helpful to achieve optimum with the orbital floor is removed to allow expansion of
alignment, and optical prisms are a useful adjunct to the orbital contents into the ethmoidal and maxillary
motility surgery. sinuses. Preservation of the bony strut between the
BASIC CONSIDERATIONS
ethmoidal and maxillary sinuses may reduce the adverse agents may limit damage to the extraocular muscles,
effects on ocular motility caused by a medial and inferior decrease orbital edema, and decrease compressive optic
shift in the globe's position. Removal of the lateral wall neuropathy. High doses in the range of 80 to 120 mg of
and orbital roof sometimes is needed as an adjunctive prednisone daily for adults usually are required for
decompressive measure. suppression of orbital inflammation. I generally reserve
irradiation for the few patients who require additional
Treatment Plan treatment after decompression.
One treatment plan is to initiate a 2-month tapering
Graves' disease is a complex, multisymptom disorder course of corticosteroids, and if there is a rebound when
with a chronic, unpredictable course. These patients the corticosteroids are tapered, then radiotherapy, 20 Gy,
must be monitored and treated with a staged and com- given in ten fractions, is offered along with another
passionate approach that includes educational and course of corticosteroids. Care and judgment must be
emotional support. The course of the thyroid-related used because long-term corticosteroid treatment may
orbitopathy is generally independent of thyroid function. be worse than the disease itself. It is better to defer sur-
The disorder in a hyperthyroid patient is not managed gery until the disease stabilizes into the postinflammatory
differently ophthalmologically from that in a patient or chronic phase. There can still be a waxing and
who is hypothyroid or euthyroid. However, treatment waning of the smoldering inflammation in the postin-
of the systemic thyroid condition often has a beneficial flammatory phase, which is generally characterized by
effect on the thyroid-related orbitopathy. stability and lack of active inflammation. Staged recon-
Treatment may be divided into localized ophthalmic structive surgery is often performed at this time. The
protective measures, medical anti-inflammatory treat- postinflammatory phase is often characterized by
ment, surgical treatment, and radiation therapy. Cosmetic considerable orbital congestion related to venous stasis
surgery should be avoided during the active phase of in a compressed orbit and manifested clinically by edema,
thyroid-related orbitopathy. Occasionally, low-dose irra- chemosis, and commonly a painful pressure sensation.
diation (20 to 2S Gy) or surgical decompression is These congestive symptoms and findings must be dif-
required to preserve visual function. Corticosteroids ferentiated from frank inflammation, because congestive
and irradiation are the most effective during the active disease in the postinflammatory stage responds poorly
inflammation, whereas surgical decompression relieves to medications and irradiation but often responds well
true congestion. to orbital apical decompression surgery, which restores
After identification of early symptoms and signs of venous outflow.
thyroid-related orbitopathy, observation and patient edu- Inflammation that is severe or associated with visual
cation are indicated. It can be reassuring to the patient loss is treated immediately with high-dose oral pred-
to be given a description of the natural course of the nisone; the doses are tapered slowly and tailored to the
disease and suggestions on conservative measures that patient's clinical response. Pulsed corticosteroid therapy
help to control symptoms. When orbital inflammation is can be used in the more severe cases. High-dose cor-
mild to moderate, as in most cases, conservative treat- ticosteroids are usually only temporarily effective in
ment, such as artificial tears and reassurance, is all that treating optic neuropathy, and their significant side
is necessary. Artificial tears and the use of sunglasses effects preclude long-term use. Most of these patients
are helpful during the day, whereas elevating the head will require irradiation or surgery.
of the bed and taping the lids for sleeping are useful at The role of radiation remains in dispute, and some
night. In cases of mild to moderate proptosis and/or orbital surgeons proceed directly to surgical decom-
eyelid retraction, topical lubrication with solutions or pression. Orbital radiotherapy (20 to 25 Gy) is believed
ointment may suffice to provide adequate corneal pro- to reduce the acute inflammatory signs and symptoms
tection. Moisture chambers or patching the eyes closed of thyroid-related orbitopathy. The chronic sequelae,
at night may also be helpful. External treatment with such as restrictive strabismus and eyelid retraction
tears, humidifier, and topical nonsteroidal anti- from muscle and connective tissue fibrosis, are unlikely
inflammatory drugs may be employed. These patients to be relieved. Irradiation is also an adjunctive therapy
have exposure because of eyelid retraction, and its for patients with compressive optic neuropathy that does
treatment is different than that for standard dry eye not adequately resolve with surgical decompression
syndrome. alone. It takes 1 or more months for maximal effect.
Proptosis due to active inflammation may be improved Surgical decompression is more effective than radiation
by oral corticosteroids, whereas proptosis due to chronic therapy for both correction of globe placement and relief
inflammatory changes and fibrosis will not respond to of compressive neuropathy. Only a few patients require
corticosteroids. During the active orbital inflammation, both treatments. Radiation therapy may be used in place
and particularly during the acute phase of extraocular of decompression in patients who are poor anesthetic
myositis, systemic corticosteroids or immunosuppressive risks or who refuse surgery.
BASIC CONSIDERATIONS
In the presence of corneal compromise or optic nerve surgery. Adequate exposure, especially of the ethmoidal
compression, corticosteroids are used in a temporizing vessels and posterior medial wall of the orbit, and ade-
fashion in conjunction with low-dose radiation therapy quate experience are required to avoid these serious
(20 to 25 Gy). If vision deteriorates despite cortico- complications. The surgical assistants should be reminded
steroid and radiation treatment, surgical decompression about the risk of excessive retraction of the globe and
is warranted. Removal of bone from the posterior medial orbital apex. The ethmoidal arteries must be isolated
orbit is essential to decompress the optic nerve and can before bony wall removal. These patients should be
be accomplished by direct or endoscopic techniques. advised that extraocular muscle and eyelid surgery will
Contraindications to radiation therapy include con- often be required after decompression and is part of the
current chemotherapy or preexisting diabetes, because normal order of the treatment plan.
these patients are at risk for postirradiation necrosis of Any or all of the just discussed treatments may be
the retina and blindness. A relative contraindication to necessary in an individual patient with thyroid-related
radiation therapy are patients younger than the age of orbitopathy. When multiple modalities are indicated,
40, owing to the increased risk of late-developing sar- the most commonly recommended order of therapy
comas or other neoplasms of the orbital bones and soft is topical lubrication, trial of corticosteroids, radiation
tissues. therapy, orbital decompression, extraocular muscle
Orbital decompression is indicated in patients with adjustment, and eyelid recession. This order of therapy
significant exophthalmos, with severe cosmetic dis- allows extraocular muscle surgery to be performed
figurement, or visual loss or severe exposure of the after rather than before orbital decompression, because
corneas. It is also indicated when corticosteroids are decompression may alter the ocular motility alignment.
ineffective or contraindicated or the patient is intolerant Eyelid recession is performed after extraocular muscle
or if irradiation fails or vision deteriorates rapidly. surgery, which allows repositioning of the lower eyelid
Removal or restructuring of the orbital fat may be per- retractors, which may be further retracted as a normal
formed in conjunction with the decompression. The sequela of the inferior rectus muscle recession (Wall
number of orbital walls removed should be proportionate and How, 1990).
to the severity of the proptosis. In mild cases, the floor Endocrine co-management is essential in the treat-
and medial wall may be removed through an external ment of thyroid-related orbitopathy. Once this has been
or endoscopic approach. When the operation is per- established then orbital decompression, Botox (botulinum
formed because of optic neuropathy, it is necessary to toxin type A, Allergan) and prisms, strabismus surgery,
remove the bone in the region of the posterior medial and finally lid repairs are administered and performed
wall, the posterior ethmoids, to relieve tissue crowding in this order as needed. Overall, patients are psycho-
at the orbital apex. Lateral wall removal requires an logically devastated by thyroid-related orbitopathy, and
orbital approach, whereas the roof is best approached counseling and support should be requested when
intracranially. indicated.
Until we are able to identify the orbital target tissues
Indications for Orbital Decompression and their interactions with the thyroid, immunoregulator,
and so on, therapeutic intervention will remain reactive
• Progressive proptosis and limited to palliation. In the future the treatment for
• Optic neuropathy thyroid-related orbitopathy will involve selective immune
• Optic nerve compression suppression that it is hoped will prevent many of the
• Orbital inflammation or pain refractory to medical ocular problems that we encounter.
management
• Exposure keratopathy
• Cosmetic deformity
Dental and Prosthetic
Optic neuropathy at any time can change the order Considerations in Head and Neck
of this plan, forcing orbital decompression earlier than Surgery (Fig. 3-21)
planned (Fatourechi, 1994). David M. Casey
The potential complications of orbital decompression
include diplopia, ocular dystopia, cerebrospinal fluid In the surgical management of cancer of the head and
leakage, meningitis, infraorbital nerve paresthesia, blind- neck, the patient's teeth cannot be disregarded. If ignored
ness, nasal lacrimal duct obstruction, infections, and or improperly managed, they may become sources of
death (Garrity et aI., 1993). In patients with muscle acute or chronic complications for the patient, the head
enlargement and preexisting muscle restriction, post- and neck surgeon, and, ultimately, the dental oncologist
operative diplopia is common after decompression but or maxillofacial prosthodontist who treats the patient's
is rare in those who had normal motility before the dental and prosthetic needs.
BASIC CONSIDERATIONS
A
FIGURE 3-21
BASIC CONSIDERATIONS
Dental and Prosthetic soft palate is in overall length, the more difficult this
Considerations in Head and Neck decision becomes. To err on the conservative side may
make prosthetic reconstruction with a speech-aid
Surgery (Continued) (Fig. 3-21)
prosthesis very difficult.
When a partial maxillectomy violates the integrity of
the soft palate, starting at the latter's anterior edge,
confusion often exists regarding whether to save the Dl, D2 When oncologically possible, the saving of
remaining soft palatal segment. It is hoped that the fol- a tuberosity (D1, arrow) or premaxilla will greatly
lowing brief guideline will give direction when the improve stability of a maxillary prosthesis. D2 shows
surgeon is faced with this conundrum. the tissue surface of the resulting stable prosthesis,
Whether to remove the remainder of the soft palate with obturator part and tuberosity-supported section
is based on the fact that the sling of the levator veli (arrow).
palatini muscles occupy the bulk of the middle third of
the soft palate, moving the soft palate posterosuperiorly E Small posterior strands of nonfunctional tissue after
during speech and swallowing to contribute to palatopha- partial soft palatectomy (arrows) are best removed at
ryngeal closure. Thus, when only the anterior one third the time of primary surgery. They prevent direct access
of the soft palate is removed, the remaining two thirds to the palatopharyngeal defect by the speech-aid
will be functional and should be retained. Conversely, prosthesis and make insertion and removal difficult.
when the anterior two thirds is removed, the remaining Removal of the uvula is also advised in these situations,
posterior third will be a useless, adynamic strand that because a long uvula on an adynamic strand of soft
should be routinely removed. palate will give a foreign object sensation on the
The decision-making problem arises when the anterior posterior tongue.
third is removed, along with part of the middle third.
How much of the middle third must be removed before F Rounding over of bone cuts may prevent delays in
the remaining part becomes nonfunctional and is best healing, especially if radiation therapy is anticipated.
totally removed? The answer is probably somewhere in This bone remains exposed 2 years after orbital exen-
the mid-middle third, keeping in mind that individual teration and removal of inferior orbital rim, followed
variation is great, and this decision is totally in the by radiation therapy.
hands of the surgeon intraoperatively. The shorter the
BASIC CONSIDERATIONS
E F
FIGURE 3-21 Continued
BASIC CONSIDERATIONS
FIGURE 3-22
BASIC CONSIDERATIONS
c
FIGURE 3-22 Continued
BASIC CONSIDERATIONS
Osseointegrated Implants in Head Alexander JW: The contributions of infection control to a century of
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4 DIAGNOSTIC
ENDOSCOPY
Probably the most important overall diagnostic measure, 1. Indirect mirror laryngoscopy (see Fig. 20-2) facili-
indirect mirror laryngoscopy utilizes inexpensive tates a view of the larynx, hypopharynx, base of the
equipment, and, when able to be performed, it facili- tongue, and inferior tonsillar poles.
tates a wide view of most of the structures that need 2. Indirect mirror nasopharyngoscopy (see Fig. 4-8A to
examination. Its biggest drawback is a tendency to cause C) facilitates a view of the nasopharynx and nasal
gagging in some patients, despite topical anesthesia. It surface of the palate.
179
DIAGNOSTIC ENDOSCOPY
A Nonflexible (rigid) Berci-Ward instrument B The Lore telescopic biopsy forceps (Karl Storz) is
(manufactured by Karl Storz) utilizes the Hopkins rod another nonflexible optical instrument that can be
principle of optics and affords a complete magnified used to visualize and to biopsy lesions of the
view with a good depth of field of the structures nasopharynx and hypopharynx.
examined. In these respects, it is superior to the
indirect mirror technique and can be adapted to C, D The Lore rigid optical instrument (Karl Storz)
photography, can be used as an observation tube, and can be used for visualization, biopsy, and stripping of
can be connected to closed circuit television, with a vocal cord. It is also excellent for mediastinoscopy
videotape recordings made, and used for stroboscopy. biopsy (see Fig. 19-8). D is a close-up view of the
It facilitates visualization of the larynx, hypopharynx, forceps.
D
FIGURE 4-1
DIAGNOSTIC ENDOSCOPY
The flexible scope (see Fig. 4-9E) can be connected Evaluation of the medial wall of the pyriform sinus is
to an observer's attachment (see Fig. 4-9G) for most important in all moderate and advanced carcinomas
photography as well as to closed circuit television. It of the larynx. Complete examination of the postcricoid
facilitates visualization of the entire nasal cavity, area and esophagus is likewise important.
nasopharynx (see Fig. 4-9F) , nasal surface of soft All peroral direct rigid endoscopic procedures, that
palate, posterior and lateral walls of the oropharynx, is, laryngoscopy, hypopharyngoscopy, bronchoscopy,
base of the tongue, hypopharynx, and larynx. Its main and esophagoscopy, involve the same initial technique.
drawback is the smaller, less magnified view of the In each case the "scope" is introduced into the mouth
hypopharynx and larynx. Small lesions could be and hypopharynx using the same positioning of the
missed. It is excellent for evaluating the motion of the head and neck. Hence, the details of laryngoscopy,
vocal cords in the recovery room, especially after which will be seen in detail (see Figs. 4-2 to 4-5), apply
thyroidectomy. It is inserted through a naris, seldom to each phase of peroral endoscopy.
through the oral cavity. When passed through the oral The supine position is routine; however, the sitting
cavity, the nasal cavity cannot be visualized. The scope and semi sitting positions (Rose) have merit, especially
can be passed through a tracheostoma or tracheostomy in tense, unrelaxed patients and in those patients who
tube for visualization of the trachea and bronchi cannot tolerate a reclined position.
inferiorly and the larynx superiorly. Some of the various types of rigid laryngoscopes
available are:
Cervical Esophagoscopy
Abramson-Dedo: for Venturi type ventilation
The flexible scope with suction tract can be used to Dedo: anterior commissure scope
examine the cervical esophagus and the reconstructed Ossoff: posterior commissure scope
pharyngoesophagus after total laryngectomy and total Jackson: anterior commissure scope
hypopharyngectomy. Air can be fed through the injection Holinger: "hour glass" anterior commissure scope
port with a hand-operated rubber bulb, which can dilate Dedo: double-action anterior commissure scope
the lumen of the esophagus and the reconstructed area. Feder: single-action laser scope, bivalve scopes,
micro laryngoscopy scopes
Jako: laser scope
Direct Rigid Laryngoscopy and Zeitels: wide-angle scope
Nasopharyngoscopy Kleinsasser: scope
The Holinger hourglass anterior commissure speculum While the patient is under general anesthesia it is a
is an excellent scope. Another instrument, interestingly good time to palpate the base of tongue, entire tongue,
enough, is the Jesberg short adult esophagoscope. Both floor of mouth, lateral oropharyngeal walls, and, if
of these can be inserted well into the intrinsic feasible at times, the lower portion of the nasopharynx,
structures of the larynx for careful visualization of the midline, and lateral walls plus perform a bimanual
walls of the ventricle as well as the pyriform sinus of examination with a finger inside the mouth and the
the hypopharynx and the petiolus of the epiglottis. opposite hand on the neck.
DIAGNOSTIC ENDOSCOPY
Direct Rigid Laryngoscopy and amounts (on cotton) in adults to correspondingly less
Hypopharyngoscopy (Fig. 4-2) in children and infants. The application of the topical
anesthetic is started with the patient in the reclining
Highpoints (for All Direct Rigid Peroral Endoscopy) position. After the lips, oral cavity, and supraglottic
regions are anesthetized, the patient is seated upright.
1. Proper positioning of patient is mandatory-flexion The application of the agent to the vocal cords is first
of the neck with head in the neutral position in the performed with cotton on a laryngeal applicating cross
first stages and then extension. Shoulders are at the action forceps (Jackson) with teeth to secure the cotton
free end of the operating table. under vision using a laryngeal mirror. The agent is then
2. Head and neck must be in the midline and not applied with a laryngeal syringe in drop fashion between
rotated to one side or other at the onset. the vocal cords, also under mirror vision. The dosage
3. Do not insert the instrument in midline of mouth depends on the agent utilized as well as on the strength
over incisor teeth. A lateral approach in the region of the agent. During this maneuver the vital signs-
of the premolars is ideal. blood pressure, pulse, and respiration-of the patient are
4. A contralateral approach is used when applicable monitored and an electrocardiogram (ECG) is obtained.
to known disease. Reaction to the topical anesthetic must always be
5. Never use the teeth as a fulcrum when exposing recognized early. Agitation and central nervous system
the larynx; protect the teeth with a plastic guard. (CNS) excitement are the early signs, which proceed to
6. Carefully examine teeth, both upper and lower, convulsions, after which follows marked CNS depres-
beforehand for any "caps," defects, or loose teeth. sion, apnea, hypotension, and cardiovascular collapse.
7. Expose and identify basic landmarks: (a) base of Treatment with oxygen, diazepam, or an intravenous
tongue, (b) epiglottis, and (c) arytenoids. barbiturate is then urgent, with monitoring of the pulse
8. The assistant holding the patient's head should be and blood pressure.
on the left side, leaving the right side clear for There are various opinions regarding the type of
reception of instruments and suctioning. topical anesthetic agent and dosage of each agent rela-
9. When an instrument or suction tip is passed to tive to safety and adequacy and purpose of anesthesia.
the operator for insertion into endoscope, the pass- Topical anesthesia refers to the application of the anes-
ing nurse places the tip of the instrument or suc- thetic agent on the mucous membrane, whereas local
tion tip into the lumen of the endoscope while the anesthesia refers to the injection of the anesthetic agent.
operator grasps the handle or proximal end (see Nevertheless, several points should be emphasized in
Fig.4-3C). the use of topical anesthetic agents:
10. The patient is assisted in relaxing all muscles and
reassured that no obstruction to the airway will 1. Cotton is the preferred material in the method of
occur when using only topical anesthesia. application. Cotton is just moistened; hence the
11. Instruments in immediate use are placed on the dose is minimal. A possible criticism of this method
"overhead" table (see Fig. 4-2A). is the fact that the exact amount of agent absorbed
12. For teaching purposes-observation, a split field T by the patient is relatively unknown, because a
adaptor is used. significant amount of the agent is still retained in the
13. Instruments are reviewed with the nurse before the cotton. Yet, it is emphasized that the dosage absorbed
procedure. is minimal, because, as mentioned, a significant
14. Any instrument that touches or passes by the vocal amount of the agent remains on the cotton. In some
cords can cause laryngospasm and cardiac 48 years of experience (JML), this has proved very
arrhythmias! satisfactory. For example, a total dose of 10% cocaine
would be only 1 mL if all were absorbed. Yet, by
The exception to the lateral approach is microlaryn- using cotton in an unhurried manner, 3 mL has
goscopy, during which the laryngoscope is usually but proved safe. Anaphylactic reaction and idiosyncrasy
not always inserted in the midline. An assistant to hold can occur; hence, time must be taken in applying
the head is not utilized. the agent along with monitoring vital signs.
2. Cocaine, rarely used today, is restricted to those
Anesthesia patients in whom vasoconstriction is desirable (e.g.,
in biopsy or endolaryngeal surgery). Cocaine crystals
Topical anesthesia is the anesthesia of choice for exami- are not utilized.
nation, evaluation, and simple biopsy for most adults, 3. Cocaine colored red and tetracaine colored blue-
children, and some infants. The agents of choice are green are never injected. Hence the coloring is an
4 % lidocaine, 10% cocaine, or 2 % tetracaine, in varying adequate warning sign.
DIAGNOSTIC ENDOSCOPY
4. Epinephrine is seldom utilized either with a topical used, thus allowing for an unhurried procedure. This is
anesthetic agent or with a local (injected) anesthetic routine with all microlaryngeal procedures. Topical anes-
agent. Epinephrine is not used, because it is believed thesia is always used as a supplement to the superior
that many of the so-called reactions to these anes- surface of the vocal cords. This is also routine with all
thetic agents are in fact caused by the epinephrine micro laryngeal procedures. This allows repeat, indirect
itself. If vasoconstriction is required with topical anes- mirror laryngoscopy and reduces laryngospasm and the
thesia, oxymetazoline (Afrin) or phenylephrine hydro- amount of general anesthesia used. Muscle relaxants
chloride (Neo-Synephrine 0.1 %) is utilized. The con- should either not be used or used only in very small
comitant use of a vasoconstrictor allegedly decreases doses when stripping a vocal cord; otherwise, a bowed
the amount of the anesthetic agent absorbed. No vocal cord will result. If a muscle relaxant is used, its
vasoconstrictor is used with local anesthesia. effect must be terminated before the stripping.
S. As a standby precaution the patient is always moni-
tored by an anesthesiologist. Discussion
6. The application of the agent should not be hurried,
with several minutes given for each application to If an examination of the larynx has not been performed
take effect. This also allows time to evaluate the before the direct rigid laryngoscopy, an indirect mirror
patient's tolerance to the agent. laryngoscopy immediately preceding the direct exami-
nation in the operating room is performed. The patient
The total safe dosages of the agents vary. The rule of is now under preoperative medication and is more
thumb to calculate the amount administered is that a relaxed than when he or she was examined in the
1 % solution contains 1 g in 100 mL or 10 mg in 1.0 mL. office. Indirect laryngoscopy affords a "bird's eye" view
The estimated safe topical dosages absorbed vary from as well as the evaluation of function, which is hardly
agent to agent. For an average adult, the estimated possible under general anesthesia. This same view is
dosages (Snow, 1972) are as follows: better achieved with the optical instruments under
topical anesthesia.
1. Lidocaine (Xylocaine) 2 % to 4 % -200 mg Areas in which "hidden" primary tumors may occur
2. Cocaine 4% to 10%-200 mg should be very carefully evaluated: base of tongue, wall
3. Tetracaine (Pontocaine) 0.5 % to 2 %-80 mg of vallecula, pyriform sinuses, base of epiglottis, and
ventricular and subglottic space.
Other references indicate a wide dosage range, for While the patient is under general anesthesia, it is a
example, cocaine 10% (1 mL equals 100 mg). Fatal over- good time to palpate the base of the tongue, entire
dose is 1.2 g, yet severe toxic effects have been report- tongue, floor of the mouth, and the lateral oropharyngeal
ed with as little as 20 mg. Cocaine must be used with walls, and, if feasible, at times, the lower portion of the
caution in patients with severely traumatized mucosa nasopharynx, midline, and lateral walls. Bimanual
and sepsis. examination with the finger inside and the opposite
General anesthesia plus topical anesthesia is used hand on the area on the neck should also be done.
for stripping of a vocal cord or other detailed endola- Refer to Figures 20-2 and 20-3 for details of indirect
ryngeal procedures. A small endotracheal tube can be laryngoscopy.
DIAGNOSTIC ENDOSCOPY
MAYO
OPERATING TABLE
TABLE
FOR TOPICAL
ANESTHESIA
I I
I OVERHEAD I
I TABLE I
I
I I
I I
ANESTHESIOLOGIS~
o
I I
I BASIC I
I INSTRUMENTS:
I
I I
EXTRA
INSTRUMENT
TABLE
U FOOT
STOOL
0 ~NURSE
ENDOSCOPISTD
B
FIGURE4-2
DIAGNOSTIC ENDOSCOPY
Aryepiglottic fold
Cricoid cartilage
Arytenoid
Pyriform fossa
Esophageal lumen
H
' >.. \
.'"
FIGURE 4-2 Continued
DIAGNOSTIC ENDOSCOPY 187
Ventricular
band
FIGURE4-2 Continued
or cushion of the epiglottis. Using the handle of the the endotracheal tube can be displaced anteriorly and
laryngoscope as a lever, but not the teeth as a fulcrum, held in position as follows:
the base of the epiglottis is raised and a full view of the
1. The end of the plastic tooth guard is cut off the
larynx is obtained. The base of the epiglottis is now
guard.
carefully scrutinized as well as the ventricle and
2. This end is sutured with heavy silk to the anterior
subglottic space.
portion of the laryngoscope.
3. The endotracheal tube fits into the concavity of the
Device to Hold Endotracheal Tube at Anterior tooth guard and is thus held at the anterior
Commissure commissure.
J When operating on lesions at the posterior Ossoff has designed a special scope for visualization
commissure or posterior one third of the vocal cords, of the anterior commissure (Weed et aI., 1994).
DIAGNOSTIC ENDOSCOPY
Rigid Bronchoscopy (Fig. 4-3) Sanders (1967) has designed a ventilating attachment
for bronchoscopes utilizing the Venturi effect (Duvall et
Highpoints a!., 1969).
1. The right hand is used to introduce the bronchoscope; A, B There are two methods of introduction of the
this differs from introduction of the laryngoscope. Care bronchoscope. One method relies on a laryngoscope
must be taken not to injure upper or lower teeth. with a removable slide; the other method is direct
2. The total time of instrumentation usually should be insertion of the bronchoscope. The direct insertion is
no longer than 20 minutes. the usual procedure and follows the steps of
3. Avoid indiscriminate and blind punch biopsies, espe- laryngoscopy exactly except that the bronchoscope is
cially of any carina or a bulge with intact mucosa held with the right hand. The method of using a
and, of course, over pulsating areas. laryngoscope is depicted in A. After the vocal cords are
4. Do not force the bronchoscope through the larynx. exposed, the' bronchoscope is passed through the
The vocal cords must be abducted; otherwise, laryngoscope. Vision is then transferred from the
damage may result. Gentle rotation of the tip may laryngoscope to the bronchoscope, which is passed
aid insertion. through the larynx into the lumen of the trachea. In
5. When a foreign body is suggested and granulation either method, the bronchoscope must not be forced
tissue encountered, gently advance the broncho- between the vocal cords. The vocal cords must be
scope beyond the granulation tissue. Granulation abducted; otherwise, injury to the cords will ensue.
tissue may hide the foreign body. The slide of the laryngoscope is removed and the
6. Only the Holinger or similar type ventilation laryngoscope is backed off and gently pulled out,
bronchoscope should be used. leaving the bronchoscope in place.
7. Indirect laryngoscopy (see Fig. 20-2) with topical
anesthesia is usually a routine done before broncho-
scopy. Direct laryngoscopy and hypopharyngoscopy Bronchoscopy using the laryngoscope for introduction
should also be performed. Lesions of the larynx and should be familiar to all endoscopists. It is specifically
hypopharynx have been missed by surgeons who useful in infants and children because identification of
pass the bronchoscope (rigid or flexible or for that the laryngeal landmarks may be obscured through the
matter an esophagoscope) immediately into the smaller-lumen bronchoscopes. In adults with short necks
trachea. and bulky tongues, the laryngoscopic introduction is
also advantageous. It affords a view of the larynx and
Anesthesia hypopharynx and protects the bronchoscope from oral
contamination, although granted this point may have
Either general or topical anesthesia may be used in more theoretical than real value.
adults and cooperative older children. General anesthesia
supplemented with topical anesthesia to the vocal
cords is used for foreign body removal in infants and C The instrument nurse is shown placing the tip of
uncooperative children. After the bronchoscope is the suction cannula in the lumen of the bronchoscope
inserted in the lumen of the trachea, the anesthetic gas while the operator grasps the proximal end. The same
and oxygen are introduced through the anesthesia technique is employed in the introduction of any bron-
adaptor on the Holinger ventilation bronchoscope. The choscopic or esophagoscopic forceps or telescope.
bronchoscopic lumen is then closed with a glass-capped In the background is a pegboard on which all the
adaptor or glass cover on a pivot, thus providing a endoscopic instruments are kept for easy selection by
semiclosed system. If tracheal toilet is the purpose, the operator. These instruments should be kept sterile
topical anesthesia may be preferred. in plastic transparent wrappers for immediate use.
Continued
DIAGNOSTIC ENDOSCOPY
B c
FIGURE 4-3
DIAGNOSTIC ENDOSCOPY
E
Left lower lobe
superior
ant. medial basal Lower lobe
lateral basal superior
post. basal medial basal
ant. basal
lateral basal
post. basal
Middle lobe
carina
lateral
medial
Upper Division
apical post.
anterior Upper lobe
Lower Division (Lingular) apical
superior posterior
inferior anterior
Upper lobe
carina
FIGURE 4-3 Continued
DIAGNOSTIC ENDOSCOPY
6 Adult i2 cm (maie)
10 cm (female)
Child 6cm
4
infant 4cm
2
o 3 6 12 18
AGE IN MONTHS
FIGURE 4--4
From Fearon B, Ellis 0: The management of the long-term airway problem in infants and children. Ann Otol Rhinal Laryngol 669:80, 1971.
DIAGNOSTIC ENDOSCOPY
FIGURE 4-5
carefully examined before the introduction of the is never advanced unless the lumen through this
scope into the lumen of the esophagus. By staying in sphincter is seen. In difficult exposure problems,
the midline there is less danger of perforating either switching to a smaller-lumen esophagoscope will help.
the hypopharynx or the esophagus. The pyriform sinus Another technique that provides aid is to pass a red
approach is through the pyriform sinus. With this rubber catheter before instrumentation and follow the
approach the instrument is introduced into the sinus tube through the cricopharyngeus sphincter. The red
and when near the apex of the sinus it is carefully rubber catheter is inserted through the nose and
displaced medially to the midline above the enters the esophagus through the pyriform sinus. This
cricopharyngeus muscle. The next structure encoun- method has been found more suitable than using a
tered is the cricopharyngeus sphincter, which is the filiform bougie passed through the esophagoscope to
most dangerous area in esophagoscopy. With waiting identify the lumen, and it is much safer. A bougie may
and applying gentle pressure and sometimes with perforate the esophagus when there is significant
gentle elevation of the tip of the esophagoscope, the obstruction due to neoplasm.
lumen is almost always perceptible. The esophagoscope Continued
DIAGNOSTIC ENDOSCOPY
(Fig. 4-5)
If the perforation is in the cervical area, the management
As the esophagoscope is advanced through the is intravenous administration of a broad-spectrum
sphincter, the operator must not be so engrossed in the antibiotic with maximum dosage. If symptoms persist
instrumentation that he or she neglects to examine this or worsen, then external drainage is indicated. Extreme
region carefully for any lesions, if the signs and care must be taken not to injure any major vessel, for
symptoms of the patient so indicate examination. This example, the internal jugular vein or the common
area-especially the postcricoid region-can also be carotid artery, nor the recurrent laryngeal nerve. Closure
evaluated during slow removal of the esophagoscope at of the perforation is not recommended nor is a proximal
the close of the procedure. diversion recommended. One patient was reconstructed
with an oblique end-to-side anastomosis after another
Biopsy surgeon transected the esophagus at the thoracic inlet
with a proximal diversion of the esophagus and closure
Biopsy of neoplastic or suspicious neoplastic lesions of of the distal segment of the esophagus. This was a very
the esophagus must be very carefully performed because difficult reconstruction performed through the cervical
of the danger of perforation. If the lesion is small and area. Exposure was enhanced by resection of the medial
relatively nonprotruding, a cytologic smear is obtained third of the clavicle to expose the posterior superior
using Gelfoam, as described under Bronchoscopy (see mediastinum (see pp. 1041 to 1045). There was a tem-
Fig. 4-3E). Avoid any deep biopsy of any lesion. Frozen porary left vocal cord paralysis, and reconstruction was
sections are often utilized to avoid repeat biopsies. If successful without leak.
the biopsy of the lesion is reported as benign on several If the perforation is in the thoracic esophagus, open
judicious attempts, consideration should be given to thoracotomy with closure is usually immediately indi-
open transcervical or transthoracic biopsy rather than cated. However, small perforations may be observed
risk perforation. from 8 to 12 hours while on antibiotics.
The early signs and symptoms of perforation are Note: These perforations may be the result of the
heart rate and temperature elevation and either cervical, esophagoscope itself or the result of a deep biopsy of a
back, or epigastric pain. Hence, after all esophagoscopies, neoplastic lesion. Remember also there are diverticula
the patient is kept NPO for several hours and is care- in the thoracic esophagus as well as in the pharyn-
fully observed. goesophageal area.
c
FIGURE4-5 Continued
DIAGNOSTIC ENDOSCOPY
Rigid Esophagoscopy (Continued) Beyond the esophageal hiatus of the diaphragm, the
(Fig. 4-5) esophagus continues for about 2 cm as the abdominal
portion before it joins the stomach at the cardio-
esophageal junction. The stomach is easily entered and
D, E After passage of the esophagoscope through is recognized (E) by the change of the whitish esophageal
the cricopharyngeus sphincter, the lumen of the mucous membrane to the reddish larger folds of gastric
cervical esophagus is exposed. Advancement is now mucosa. There may be a regurgitation of gastric juices
quite easy, but again the strict axiom applies that this into the lumen.
be done only when a clear lumen is seen. When the The esophagoscopic distances from the upper incisors
thoracic esophagus is reached, the lumen will be seen are depicted along with the three constricted areas in
to open and close with respirations. As the instrument which foreign bodies are most likely to become lodged:
is advanced past the landmarks of the arch of the aorta
and the point of crossing of the left bronchus, raising 1. The cricoid cartilage, which marks the cricopharyn-
and lowering the head, neck, and shoulders will be geus muscle and the beginning of the esophagus
necessary to keep the esophageal lumen exactly in the 2. The bifurcation of the trachea, which is at the level
center of the esophagoscope. As the cardioesophageal of the descending portion of the arch of the aorta or
junction is approached, the lumen will tend to become the crossing of the left bronchus
obscure. This is the second danger site and indicates 3. The level of the diaphragm, which is slightly above
the level of the diaphragm, and extreme care must the cardioesophageal junction
again be exercised to proceed only when the lumen is
fully exposed. The two leaves of the right crus of the Just above the level of the diaphragm there may be
diaphragm form the hiatus, which may be quite a slight dilatation, which is more noticeable on a
evident as a distinct site of sphincter-like action during radiograph; that is the phrenic ampulla.
the phases of respiration. The esophagus usually bends Another word of caution is needed about the danger
slightly to the left in this region, and this will of esophageal perforation through the sac of an
necessitate pointing the distal end of the esophagus esophageal diverticulum. A full-length esophagogram
toward the left. is always performed except in the presence of a foreign
body. In the latter circumstance an esophagogram is
the choice of the surgeon, because the barium may
If the lumen does not become evident, gentle forward make subsequent esophagoscopy somewhat difficult
pressure usually demonstrates it. The technique of unless it is irrigated and removed by suction. Always
using the red rubber catheter is occasionally necessary. use blunt closed-tip suction in esophagoscopy.
DIAGNOSTIC ENDOSCOPY
12 to 16 em.
Cricoid cartilage
22 to 29 em.
Bifurcation of trachea
32 to 50 em.
Cardioesophageal junction
FIGURE4-5 Continued
200 DIAGNOSTIC ENDOSCOPY
most suspicious area. With vocal cord lesions, for exam- easier to make than still photographs. Television, for
ple, in which virtually the entire cord is involved with teaching purposes, is also possible and yields an excellent
a whitish area, it is usually best to strip the entire vocal picture of the larynx and the surgical procedure.
cord and have the pathologist do serial sections. First,
gently cleanse mucous membranes with acetic acid 1 %, Surgery
apply the toluidine blue 1 % or 2 %, and then gently
wipe with acetic acid 1 % and water. Respiratory epithe- 1. Removal of webs
lium and any benign ulcer yields a false-positive result. 2. Stripping of vocal cords (using adult- or child-sized
The ventricles are lined with respiratory epithelium. Lore, Sf. forceps) (see Figs. 4-7 and 20-5)
Multiple exacting biopsies with small forceps are 3. Selective biopsy
possible. Using the staining technique with the micro- 4. Intralaryngeal incision and/or excision of lesions
scope, biopsies are possible of areas that otherwise 5. Cryosurgery
might be missed. Hence, the unrecognized lesion on 6. Transoral arytenoidectomy (Thornell)
mirror laryngoscopy and ordinary direct laryngoscopy 7. Injection of vocal cords with Teflon or Gelfoam
can be seen, and a biopsy sample can be taken, thus (temporary) for adductor cord paralysis or bowing.
often avoiding repeat examinations. Carcinoma in situ (General anesthesia is not used; rather Innovar is
is a specific example of a lesion that may go unrecog- given intravenously to evaluate amount of material
nized by the ordinary methods. A large diagram of the injected.)
larynx can be used to locate the sources of the biopsies. 8. Carbon dioxide laser
Flexibility of the structures as well as subglottic space
and ventricles is evaluated. Transillumination of the Complications
vocal cords and ventricular bands is possible but of
questionable value. • Injury to teeth. A percentage of patients cannot be
A telescope, Hopkins rod (Karl Storz), foreoblique or examined by the laryngoscopes and holders now
retrograde, can be used through the laryngoscope to available for micro laryngoscopy. A substitute for the
yield additional information of the subglottic space. use of the microscope is the telescopic endola-
When borderline lesions are present the technique is ryngeal instruments designed by Lore and Karl Storz.
especially helpful to evaluate the feasibility of partial • Cardiac arrhythmia
laryngectomy. In addition, hypo pharyngeal lesions can • Although both vocal cords can be operated on, there
be evaluated. is danger that web formation can occur if the
A photograph is taken through the standard beam mucous membrane on both vocal cords is denuded
splitter and sidearm attachments. Videotapes are much at the anterior commissure.
DIAGNOSTIC ENDOSCOPY
Microscopic Endolaryngoscopy
because there can be undue pressure on the upper
(Continued) (Fig. 4-6) (After Kleinsasser,
incisors. At times a contralateral approach can be used
1961; jako and Kleinsasser, 1966) with a smaller-diameter laryngoscope.
A The basic setup is depicted. A Mayo stand is used B The location of the laryngoscope holder with the
to support the elbows of the operating surgeon, thus cuffed endotracheal tube placed at the posterior
steadying his or her hands. The laryngoscope is in the commissure of the larynx is depicted.
midline. This is the main drawback of the technique,
DIAGNOSTIC ENDOSCOPY
FIGURE 4-6
DIAGNOSTIC ENDOSCOPY
Nasopharyngoscopy (Continued)
more difficult. This technique is best reserved for
(Figs. 4-8 and 4-9) occasions when the mirror method fails or when a
specific area noted on mirror examination requires
A, B The tongue is depressed, and the patient is more scrutiny. A biopsy forceps is combined with the
asked to breathe through the nose. This usually throws rigid endoscope (see Fig. 4-9A and B) and affords
the soft palate forward. A suitable-sized warmed good visualization of the suspected area with the jaws
mirror is then inserted, using a head mirror or of the biopsy forceps (Karl Storz) in full view.
headlight for illumination. The angle of the mirror may
require adjustment, depending on the configuration An oral nasopharyngoscope, preferred by some
of the vault of the nasopharynx. Occasionally, physicians, affords a larger field of vision similar to that
grasping the tongue as is done in mirror laryngoscopy seen with a mirror. This instrument consists for the
(see Fig. 20-2) is of aid. most part of a rigid endoscope. The earlier models were
designed by and known as the Beck, Proud-Beck, and
C The area so visualized is depicted. To obtain Wolf. The more modern ones utilize the Hopkins rod
complete visualization, the mirror is simply rotated a principle and include the Berci-Ward instrument manu-
few degrees. The posterior wall of the vault is first factured by Karl Storz (see Fig. 4-90). This instrument
examined for any tumefaction, benign or malignant. is also used to visualize the hypopharynx and larynx.
The ostia of the sphenoidal sinus may be seen. The Digital examination is also performed to evaluate the
roof of the vault is likewise scrutinized and then the consistency of any abnormality visualized. The index
posterior end of the nasal septum. The posterior tips of finger is inserted through the mouth and behind the
all six turbinates should be visualized lying in the soft palate. The operator may find that standing to the
posterior nares. Laterally, the eustachian tube orifices side of the patient facilitates this examination.
in Waldeyer's ring are evaluated. The posterosuperior
aspect of the soft palate is checked. Retraction of Soft Palate
D Another technique of nasopharyngoscopy is the When the soft palate obstructs visualization of the
use of a rigid optical endoscope-O, 30, and 70 degrees vault either during examination or biopsy or in minor
(e.g., scopes used for rhinoscopy via the nasal route).
operations, it may be retracted in several ways.
Another instrument, preferred by many physicians, is
the flexible nasopharyngoscope (see Fig. 4-9E). After
topical anesthesia to the nasal cavity, the instrument is E A specific soft palate retractor is available that has
inserted through the anterior naris. Rotation of the its fixed point on the upper lip and alveolar ridge. The
scope at various depths is necessary to cover the drawbacks of the instrument are its size and the fact
nasopharynx. Because only smaller visual fields are that it tends to slip and is awkward.
available at each degree point, a composite picture is Continued
DIAGNOSTIC ENDOSCOPY
FIGURE 4-8
DIAGNOSTIC ENDOSCOPY
F G
A
o B oIf()
c
FIGURE4-9
DIAGNOSTIC ENDOSCOPY
Cervical Esophagoscopy Hendren WH, Henderson BM: Immediate esophagectomy for instrumen-
(See Fig. 4-5B and C) tal perforation of the thoracic esophagus. Ann Surg 168:997-1003,
1968.
Hoeksema PE, Huizinga E: On foreign bodies and perforations of the
A bulb insufflator can be attached to a flexible optical esophagus. Ann OtoI80:36-41, 1971.
scope that has a channel for instillation of medication Holinger PH: Complications of esophageal perforations. Ann Otol
and suctioning in the nasopharynx, hypopharynx, or 50:681, 1941.
larynx. A bulb insufflator can be attached to the medicinal Holinger PH: Management of esophageal lesions caused by chemical
burns. Ann Otol 77:819-829, 1968.
channel for instillation of air. This will distend the
Holinger PH: Photography in otorhinolaryngology and broncho-
esophagus for insertion of the optical scope. The cervical esophagology. In Coates, Schenk, and Miller (eds): Otolaryngology.
esophagus can thus be visualized and inspected as well Hagerstown, MD, WF Prior, 1957.
as suctioned. Holinger PH, Holinger LD: Endoscopy of the head and neck. In
Goldsmith HS (ed): Practice of Surgery. New York, Harper & Row,
1976, chap 7.
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DIAGNOSTIC ENDOSCOPY
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Surg 122:696-698, 1971. patients of oral and pharyngeal components of deglutition. Arch
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techniques. Chest 57:426-427, 1970. Slater G, Sicular A: Esophageal perforations after forceful dilatation
Newell RC, Watson RL, Po BT, et al: Intravenous anesthetic techniques in achalasia. Ann Surg 195:186-188, 1982.
for peroral endoscopy. Trans Am Acad Ophthalmol Otolaryngol Snow JC: Anesthesia in Otolaryngology and Ophthalmology. Spring-
73:71-77, 1969. field, IL, Charles C Thomas, 1972, p 32.
Norris CM, Tucker GF Jr, Woloshin HJ: Bronchoesophagologic appli- Stetson JB: Retropharyngeal abscess and endotracheal intubation.
cation of recent advances in lluoroscopy. Ann Otol 80:528-534, Communications to the Editor. Chest 74:4, 1978.
1971. Strong MS, Vaughan CW, Incze JS: Toluidine blue in the management
Olsen AM: The esophagogastric sphincter. Chest 60:421-422, 1971. of carcinoma of the oral cavity. Arch Otol 87:527,1968.
Ono J, Saito S: Endoscopic microsurgery of the larynx. Ann Otol Tucker JA: Application of mediastinoscopy to carcinoma of the larynx:
80:479, 1971. A preliminary report. Laryngoscope 79:118-124, 1969.
Pearson FG: An evaluation of mediastinoscopy in the management of Valaitis J: Bronchial brushing cytology in localization and sputum
presumably operable bronchial carcinoma. J Thorac Cardiovasc cytology in detection of bronchogenic carcinoma in-situ of high
Surg 55:617-625, 1968. risk smoker population. Med Ecol Clin Res I (Summer), 1968.
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mediastinum. Can J Surg 6:423-429,1963. tered during mediastinoscopy. Ann Otol 80:487-491, 1971.
Pereira W Jr, Kovnat D, Snider G: A prospective cooperative study of Waterman DH, Domm SE, Rogers WK, Borrell JL: The effective use
complications following flexible fiberoptic bronchoscopy. Chest of bronchoscopy in chronic bronchitis: A review of 15,719 cases.
73:813-816, 1978. Ann Otol 78:449, 1969.
Puryear GH, Osborn JJ, Beaumont 10, Gerbode F: The influence of Webb WA, McDaniel L: Endoscopic evaluation of dysphagia in 293
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900-909, 1969. Weed DT, Courey MS, Ossoff RH: Microlaryngoscopy in the difficult
Putney FJ: Bronchoesophagology. Arch Otolaryngol 92:293-298, 1970. surgical exposure: A new micro laryngoscope. Otolaryngol Head
Ramsey MA, Salyer JE: The management of a child with a major Neck Surg 110:247-252, 1994.
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5 THE SINUSES AND
MAXILLA
214
THE SINUSES AND MAXILLA
c c'
FIGURE 5-1
rotated 180 degrees after the antral wall is punctured. C, C1 A curved rasp (Wiener) is inserted, and with to
The undercut edge of the instrument then engages and fro motion the opening is enlarged. Care must be
the rim of the opening. As the instrument is with- taken that the tip of the rasp is pointed downward.
drawn, the opening is thus enlarged. This avoids injury to the floor of the orbit and removes
the bone at the base of the medial wall, allowing
adequate drainage. No ledge of bone should remain
To enlarge the antrostomy farther, several techniques at the base.
are available. Continued
116 THE SINUm ANDMAXIll~
Caldwell-luc Antrotomy (Fig. 5-2) This procedure should be avoided when a malignant
lesion is suspected. Needle aspiration through the
Indications inferior meatus or the use of an intranasal antrostomy
with curettage using Coakley curets is preferred (see
• Benign tumors Fig. 5-1). If these methods fail, do not hesitate to explore
• Chronic empyema resistant to conservative treatment the antrum through this Caldwell-Luc antrotomy.
• Complicated fractures of maxilla Refer to Figure 6-10 for the trans maxillary approach
• Exploration to the nasopharynx and base of the skull.
FIGURE 5-2
THE SINUSES AND MAXILLA
Intranasal antrostomy
FIGURE 5-3
THE SINUSES AND MAXILLA
Intranasal Ethmoidal Surgery for for bacterial growth. Depending on the duration and
Benign Disease (Continued) (Fig. 5-3) intensity of an infection in such a place, mucosal hyper-
plasia occurs and thus results in a focus of permanent
Endoscopic Diagnosis and Surgery for infection. From areas like these, which can be free of
Sinusitis symptoms for quite a long time, infections can spread
time and again to the immediate vicinity and especially
Another approach to inflammatory ethmoidal sinus into the dependent larger sinuses.
disease as well as antral and frontal sinus involvement Nasal endoscopy combined with CT enables us to
has been detailed by a number of authors. Messerklinger, localize exactly the diseased areas. Transnasal, endo-
in Austria, and Kennedy, in the United States, as well scopic surgery is then carried out. The patient is sedated
as others have described telescopic endoscopic diag- and the medial wall of the ethmoidal infundibulum is
nosis. These techniques are described in detail later in resected under local and surface anesthesia. This pro-
this chapter. Instruments are shown in Figure 4-9A and cedure opens the middle nasal meatus, and the view is
B, for anatomy see page 267, and the technique as out- free into the ethmoidal bulla, the frontal recess, and the
lined by Messerklinger (1985) is as follows (with per- sinus of the middle turbinate. Depending on the local-
mission from Elsevier Science Publishers): Numerous ization and the extent of the disease, the ethmoidal
endoscopic investigations and examinations have indi- bulla is resected and the frontal recess, the conchal
cated the following relating to the pathophysiology of sinus, and/or the ethmoidal infundibulum are cleared
chronic and recurring sinusitis: Most infections of the of diseased mucosa. If the maxillary ostium is stenotic,
paranasal sinuses are rhinogenic, spreading from the it is enlarged into the anterior nasal fontanel. This area
nose into the sinuses. is the osteomeatal complex-a critical region.
If a sinusitis does not heal or is constantly recur- If the posterior ethmoidal or the sphenoidal sinus is
ring, a focus of infection usually has remained in a diseased, it is cleared endoscopically after resection of
stenotic area, which keeps the infection ongoing, or the ground lamella of the middle turbinate.
wherefrom the dependent larger sinuses are reinfected In the first 2 days after operation, wound secretion
time and again. This is true as well for primarily is removed with an aspirator. For 8 to 10 days, an oral
dentogenic, traumatic, or blood-borne sinusitis that antibiotic effective in the nasal mucosa is prescribed.
is recurring after the primary source of infection has After this procedure even chronically recurring
been cured. infections of the dependent larger sinuses usually heal
The narrow or stenotic areas involved are the within 5 to 6 weeks, even if their mucosal pathology
ethmoidal infundibulum at the entrance to the maxil- seemed almost irreversible. (See Figures 1-1 to 1-15 for
lary sinus and the frontal recess at the entrance to the radiographic anatomy and imaging studies.)
frontal sinus. They build up a system of fissures and
folds in the middle nasal meatus, all of them being Complications
parts of the anterior ethmoidal sinus.
Thus, the physiologic status and pathologic status of • Perforation of cribriform plate and lamina papyracea
the maxillary sinus and frontal sinus are dependent on • Blindness (see Chapter 2): order stat ophthalmologic
any disease process of the anterior ethmoidal sinus and consult; perform lateral canthotomy and external
the osteomeatal complex. ethmoidectomy.
Narrow space-like fissures and ostia under normal • Injury to the lacrimal duct or sac
conditions are very resistant to infections; as, for • Bleeding from the anterior or posterior ethmoidal
instance, in a fissure the ciliary beat can transport a arteries
pathologic mucus from two sides, in an ostium even • Injury to internal carotid artery just lateral to posterior
circularly. If, however, corresponding mucosal areas ethmoidal and sphenoidal sinuses
are firmly pressed together, only the superficial secre-
tion around the contacting area can be transported Admonition
away. The mucus in between contacting or inflamed
mucosal areas is retained and provides ideal conditions "Stop if you cannot see" (Kennedy).
THE SINUSES AND MAXILLA
External Ethmoidectomy (Fig. 5-4) 3. Elevate the periosteum carefully from the lacrimal
(Chiari, 1912) (After Kirchner et aI., bone, lacrimal sac, and lamina papyracea. Do not
1967; Montgomery, 1971) injure the lacrimal sac, its proximal canaliculi, or its
distal outflow, the nasolacrimal duct (see Fig. H-12B).
Indications 4. Extreme care should be taken not to injure the globe
and orbital contents (tarsorrhaphy and gentle pressure
• Extensive ethmoiditis refractory to conservative man- when retracting the periosteum and orbital contents).
agement as well as intranasal ethmoidectomy (see 5. Remove major portion of the lacrimal bone, portion
Fig. 5-3). This indication is believed to be rare because of the lamina papyracea, frontal process of the maxil-
intranasal ethmoidectomy usually accomplishes the lary bone, and, at times, varying portions of the nasal
desired results. bone, depending on the exposure necessary.
• Epistaxis high in the nasal cavity refractory to eth- 6. Remove at least the anterior portion of the middle
moidal artery and internal maxillary artery ligations turbinate. If the purpose of the operation is to reach
• Mucocele and benign tumors of the ethmoidal sinus; the sella, the medial wall of the ethmoidal labyrinth
malignant tumors of the ethmoidal sinus almost and thus the middle turbinate are not removed.
always require a combined craniofacial resection of 7. Take care to achieve good hemostasis to prevent
the cribriform plate. increased intraocular pressure as well as any pres-
• Approach to the frontal sinus (Lynch, 1921; see sure on the optic nerve. Danger: blindness!
Fig. 5-70 and E) 8. If there is any question regarding the patency of the
• Approach to sphenoidal sinus and pituitary nasofrontal duct, insert a fine polyethylene tube.
• Repair of cerebrospinal fluid leak through the cribri-
form plate Anesthesia
• Approach to the anterior cavernous portion of the
internal carotid artery-possible application in carotid Although the operation can be performed under local
cavernous fistula and topical anesthesia, this author (JML) prefers general
• Approach to the optic foramen for decompression anesthesia for patient comfort as well as control of the
and biopsy airway. However, topical anesthesia consisting of 10%
cocaine and oxymetazoline (Afrin) is used in the nasal
The trans septal approach to the sphenoidal sinus cavity to control mucosal bleeding. A tarsorrhaphy is
and pituitary (see Fig. 23-11) is preferred rather than an performed using 3-0 silk sutures, and the eyes are
external ethmoidectomy approach. protected with soft moist eye pads.
Refer to the alternate approach of Denker, page 294. A curved incision is made similar to that depicted in
Figure 5-7A, except that the incision does not extend as
Highpoints far medially as is shown for the external frontoeth-
moidectomy. Bovie cutting current is used to transect
1. Important landmark: the foramina of the anterior the soft tissue down to the periosteum. Stay sutures are
and posterior ethmoidal vessels as they perforate the utilized to retract the skin edges, with care taken not to
medial orbital wall mark the level of the cribriform contact the globe. The angular vessels are clamped and
plate. This is the suture line between the frontal bone ligated.
above and the ethmoidal labyrinth below. Hence, do
not go above this line to avoid injury to the cribri- Complications
form plate. The foramen of the posterior ethmoidal
artery indicates the plane of the most posterior • Hemorrhage-must have careful hemostasis
ethmoidal cells. • Blindness (see Ophthalmic Complications III
2. If necessary to transect the medial canthal ligament Chapter 2)
for additional exposure, be certain to preserve a • Diplopia
medial stump of the ligament for approximation of • Meningitis
the ligament at the close of the operation.
THE SINUSES AND MAXILLA
FRONTOMAXILLOLACRIMAL
"SUTURE
, FRONTAL PROCESS
FRONTOETHMOID MAXILLARY BONE
SUTURE
(PLANE OF CRIBRI
PLATE) LACRIMAL FOSSA
ANGULAR A.
B
FIGURE 5-4
THE SINUSES AND MAXilLA
B
FIGURE 5-5
THE SINUSES AND MAXilLA
Point of entry
Mid. turbinate'
FIGURE5-5 Continued
THE SINUSES AND MAXilLA
Highpoints
C Two small plastic tubes are inserted and held in
place with sutures. One tube can be used for daily
1. Keep incision well above the medial canthal ligament.
irrigations with a suitable antibiotic solution (e.g.,
2. Continue conservative management.
neomycin, 1%) for 24 to 48 hours. The other tube acts
3. Careful radiographic evaluation preoperatively and
as the release for the irrigation fluid.
postoperatively, especially for any evidence of dehis-
cence of the inner wall, thus exposing dura. Remem-
ber plain Caldwell radiographic films of the frontal After the frontal sinusotomy, the cause of the sinusi-
sinus can be deceptive. This radiographic view is tis must be ascertained, and treatment must be initiated
obtained by placing the nose and the forehead on as soon as possible to prevent chronic frontal sinusitis.
the table top so that the orbital meatal line (join- The object is to reinstate intranasal drainage. Probing
ing the outer canthus of the eye to the superior and any attempt to recanalize or simply enlarge the
margin of the external auditory canal) is perpen- nasofrontal duct will only worsen the condition, because
dicular to the film. The angulation of the x-ray beam such procedures will lead to complete stenosis of the
is 15 degrees craniocaudad. CT scans and/or tomo- nasofrontal duct.
grams are necessary for complete evaluation of the The steps to take are the following:
status of the inner and inferior wall of the frontal
sinus. 1. Meticulous and complete submucous resection of
4. Avoid injury to the globe. the nasal septum
S. A trephine is used in or near the floor, not the ante- 2. Removal of any nasal polyps
rior wall, thus avoiding cancellous bone containing 3. Resection of anterior portion of the middle turbinate,
marrow, which could be an excellent avenue for if necessary
osteomyelitis. 4. Anterior ethmoidectomy, as indicated
6. Do not irrigate if roof of orbit has a dehiscence; this
may cause blindness! (Thompson et aI., 1980.) (See For details on fractures of the frontal sinus and
the discussion of blindness in Chapter 2.) ethmoidal sinus, refer to the discussion on page 638.
THE SINUSES AND MAXilLA 231
FIGURE 5-6
THE SINUSES AND MAXilLA
LACRIMAL SAC
MEDIAL CANTHAL
A B
FIGURE 5-7
frontal sinus operation may then be necessary at a later anteriorly the sphenopalatine vessels may be encoun-
stage (see Fig. S-8A to E). tered, which then will require occlusion with silver
As much of the middle turbinate is removed (by clips or electrocoagulation.
punch, not tearing) as is necessary to provide a suitable If the purpose of the operation is to perform a
communication into the nasal cavity. This is accom- hypophysectomy, the frontal sinus portion of the opera-
plished both through the operation wound and through tion is deleted. From here on the reader is referred to
the naris. the section dealing with hypophysectomy in Chapter 23.
FIGURE 5-8
Complications
autogenous adipose tissue graft into the sinus cavity
and duct remnant to aid in the obliteration; otherwise, • Fracture of the inner wall or table leading to a
perform a transfrontal ethmoidectomy. When the sinus possible cerebrospinal fluid leak
cavity is obliterated with adipose tissue (obtained from • Fracture of the roof of the orbit
the anterior abdominal wall), it is best to remove as • Injury to the inner wall or table during the initial
much cortical bone as possible from all areas, includ- saw cut through the outer table
ing the bone flap. This aids in supplying blood to the • Air leak into operative area during postoperative
adipose graft. period
Continued • Recurrent disease
THE SINUSES AND MAXILLA
Osteoplastic Approach to the one septum between the right and left sides of the
Frontal Sinus (Continued) (Fig. 5-8) frontal sinus. Be sure all septa are removed as thoroughly
(After Alford, 1964; Beck, 1908; as possible with a large communicating fenestra. The
nasofrontal duct on the uninvolved side must be patent.
Goodale and Montgomery, 1964)
This can be verified with the instillation of methyl blue
dye. This maneuver is controversial, however, and yet
F The flap of bone and the periosteum are returned, it has proved efficacious.
and the periosteum is approximated with 4-0 catgut
sutures. The skin flap is closed in two layers. Debride
the edges of skin if there is thickened scar tissue from Partial and Radical Maxillectomy
chronic sinusitis. This will reduce the unsightly bulge
over the diseased frontal sinus. A cutaneous drain is Operations involving resection of the maxilla and con-
used only in those patients with active infection. tiguous structures for carcinoma can be divided into
three main types: partial maxillary resection with pres-
G An outline is shown of the extension of the brow ervation of the roof and superior portion of the pos-
incision in bilateral frontal sinus disease. Occasionally, terior wall of the antrum, total maxillary resection and
the opposite sinus may be approached through the ethmoidal exenteration with preservation of the globe,
original exposure by removing the sinus septum. This and total maxillary resection with ethmoidal exentera-
depends on the extent of disease and the size of the tion and orbital enucleation.
sinus. It is usually more beneficial to use a bilateral One of the perplexing problems in the surgical treat-
approach. ment of carcinoma of the maxilla is the evaluation of
the extent of the neoplasm. This problem is aggravated
H A coronal hairline incision may be preferred in the at times by late diagnosis as well as by concomitant
female patient to avoid the brow incision. In the male infection. Another problem is the extent of the malig-
patient this may be disastrous if he is bald. Regardless nant changes in an inverted papilloma. Inverted papillo-
of the skin incision, in the bilateral approach the bone mata without malignant change can cause bone changes.
across the nasal process of the frontal bone usually Hence, the question arises as to the extent of the sur-
requires transection with saw or chisel. gical resection and the frequency of combined therapy
with radiation (preferably postoperative). Evaluation of
Occasionally, if the infectious disease is limited to the extent of the neoplasm is done both preoperatively
one side (e.g., mucocele of the frontal sinus), drainage and operatively and follow-up is done for life.
may be achieved by taking down the septum in the The preoperative evaluation includes careful inspec-
frontal sinus, thus facilitating drainage to the uninvolved tion of the nasal cavity, its floor and lateral wall, the nasal
side and its nasofrontal duct. There may be more than septum, and the nasopharynx; the standard paranasal
sinus radiograph, tomograms, CT, and MRI; and radio- overlying the hard palate. Regardless, this mucosa IS
graphic views of the base of the skull. Ophthalmologic always resected with the hard palate.
consultation may be helpful in ascertaining whether In the following discussion the indications for radical
the orbital contents have been invaded. The obvious and partial maxillectomy are reviewed with each descrip-
signs-proptosis and extraocular muscle impairment- tion of the surgical technique. Each patient must be
leave no doubt that orbital exenteration is necessary, individually evaluated and consideration given to pallia-
if indeed the lesion is resectable. Occasionally, the first tive resection-usually partial maxillectomy combined
sign of maxillary sinus carcinoma is an enlarged metasta- with radiotherapy or preoperative induction chemother-
tic sub digastric cervical lymph node. A Caldwell-Luc apy-to remove offensive necrotic tumor.
operation is a last resort for diagnosis and is best It is suggested that preoperative chemotherapy be
avoided if an unequivocal histologic diagnosis can be considered in advanced squamous cell carcinoma of
made through an intranasal antrostomy. Regardless, the paranasal sinuses following the regimen detailed
errors have been made by confusing long-standing in Chapter 3. Although neoplasms of the paranasal
inflammatory disease with neoplasm. sinuses were not included in that review, owing to the
Difficulty can also be encountered in differentiating limited number of patients, nevertheless one would
anaplastic squamous cell carcinoma from large cell expect similar favorable results.
lymphoma (formerly classified as reticulum cell sar- Ohngren, in 1933, divided the maxilla into an ante-
coma). This differentiation can be aided by immuno- rior inferior portion and a posterior superior portion by
staining. For example: drawing an imaginary line from the medial canthus of
the eye to the angle of the mandible. He pointed out
1. Leukocyte common antigen: positive-lymphoma; that lesions arising in the anterior inferior section carried
negative-most likely not lymphoma a better prognosis than those in the posterior superior
2. Cytokeratin: positive-anaplastic carcinoma section because the extension of the disease in the latter
section "very soon encroached upon the meninges and
Historically, the electron microscope was of some vascular stems, thereby eliminating every chance of
help in this differentiation. In all epidermal tumors there successful therapy." This thesis has withstood the test
are desmosomes between the outer cell membranes. of time and forms the basis for the decision whether to
This feature is somewhat more obvious in squamous perform a partial or radical maxillectomy. Yet it must
cell carcinoma and is absent in large cell lymphoma. be emphasized that error in management rests with the
Operative evaluation of the extent of disease is des- lesser resection because of the inherent difficulty in the
cribed during the following discussion of surgical tech- preoperative evaluation of the extent of the disease.
nique. In view of this additional information relative to Three anecdotal examples are reported demonstrating
the extent of disease, permission for removal of the eye the place for chemotherapy in the treatment of esthe-
must be obtained in all patients. sioneuroblastoma, as well as neuroendocrine carcinoma.
Another problem in maxillectomy for carcinoma is
the fact that when the disease has extended beyond the Case 1: Esthesioneuroblastoma
confines of the antrum, many of the contiguous struc-
tures (e.g., the ethmoidal sinus, sphenoidal sinus, crib- A 39-year-old white man presented with a stage III
riform plate, posterior aspect of the maxilla with ptery- tumor primarily involving the right nasal cavity, eth-
goid plates, posterior portion of the orbit, and infratem- moidal sinus, and cribriform plate confined to the
poral fossa) defy uniform en bloc resection. Other exten- extradural space. The tumor was deemed to be resec-
sions that involve the nasal septum and nasal cavity, table. Treatment consisted of two preoperative courses
palate, and skin of the cheek can usually be encom- of chemotherapy with cyclophosphamide, etoposide,
passed with maxillectomy with little difficulty. Exten- vincristine, and cisplatin. Craniofacial resection was
sion to the base of the skull and resection is described performed. Four years later metastasis was discovered
in Chapter 23. When the lesion is not resectable, in the right submandibular area and a right radical
chemotherapy and radiation therapy combined with a neck dissection was done. The pathologic report showed
drainage procedure and removal of grossly involved four positive nodes (three level I, one level IV). One
and necrotic tumor is the best that can be afforded the year later the tumor recurred in the cribriform plate. A
patient for palliation. secondary craniofacial resection was done that included
At other times the extent of the surgical resection maxillectomy and orbital enucleation. Three years later
can be more easily modified. For example, if there is there was spread to the temporal lobe. One year later a
gross evidence of disease involving the bony wall at the craniotomy was performed for recurrence followed with
canine fossa, this area must be widely encompassed, gamma knife therapy. The patient received late radio-
including a portion of the upper lip and possibly the therapy (5040 rads) but died 9 years after the initial
cheek. The same applies to extension into the mucosa treatment.
THE SINUSES AND MAXILLA
Highpoints
B The bony area resected includes the entire antrum
with hard palate and floor of the orbit, lateral orbital
1. Antrum is not entered.
rim, body of the zygoma (malar bone), and portion of
2. Orbital contents should be resected with roof of
zygomatic arch (the double dotted lines on the arch
antrum in any extensive carcinoma of maxilla or
indicate the portion of arch excised to facilitate the appli-
with involvement of roof of antrum.
cation of silver clips to the internal maxillary artery per-
3. Resect as much of the ethmoidal sinuses en bloc as
formed early in the operation). The internal maxillary
possible. Remainder will require curettage.
artery may be superficial or deep to the external ptery-
4. Graft raw surfaces with split-thickness skin.
goid muscle or pass between the two heads of the
5. Leave orbital skin defect open to future inspection
muscle. The ethmoidal labyrinth, anterior wall of sphe-
for early detection of recurrences.
noidal sinus, and complete lateral wall of the nasal
6. Preserve soft palate if levator muscle is intact.
cavity with all three turbinates are included in the
7. Tracheostomy is indicated.
resection. The nasal septum ;s left intact unless the
septum is involved. If it is involved, the line of resection
Refer to Figures 1-1 through 1-6 for radiographic
through the floor of the nose is on the contralateral
anatomy.
side. It is preferred that the incision through the alveolar
ridge be made through the tooth socket to preserve
viability of the juxtaposed tooth.
Continued
Lamina papyr
Co.,
Maxillt.
Zygoma "'
:tub. of maxilla
B
-'Lat.pterygoid plate
FIGURE 5-9
THE SINUSES AND MAXilLA
FIGURE5-9 Continued
H Directing the Gigli saw upward and forward tran- visual field defects in the opposite eye. The ophthalmic
sects the lateral orbital rim. The optic nerve is severed artery, which is medial to the optic nerve, is ligated.
midway between the globe and the optic foramen Within the fat pad are small vesselsthat should likewise
(dotted line) or as far posterior as indicated. Avoid be ligated.
excessive traction on the optic nerve because it may Continued
produce damage to the optic chiasm and subsequent
THE SINUSES AND MAXilLA
Radical Resection of Maxilla With rence of disease would be obscured. The argument for
Orbital and Partial Ethmoidal vascularized flaps is the adequate coverage of the
operative defect.
Exenteration (Continued) (Fig. 5-9)
Pterygomaxillary fissue
Deep Temporal a.
Pterygomaxillary fissure
Internal Maxillary a.
K L
M N
o p
Resection of Maxilla Including • Partial incision dehiscence under one eye. This serves
the Floor of the Orbit With as an excellent port for inspection and insertion of
padding.
Preservation of the Globe
(Fig. 5-10)
A Exploration of the floor of the orbit is performed
This procedure is indicated when there is no erosion of with an incision (dotted line) along the superior aspect
the orbital floor (hence the importance of CT for bone of the infraorbital rim. By careful elevation of the
detail and MRI for soft tissue/tumor detail) but the periosteum at this point, palpation of the orbital
tumor involves somewhat more than half of the contents contents is possible. If there is no gross evidence of
of the antrum. Permission for orbital exenteration should disease in the orbit, if the floor of the orbit is intact,
be obtained, because intraoperative evaluation may dis- and if preoperative (T reveals no bone erosion, the
close extension into the orbit. floor of the orbit (roof of the antrum) is resected,
The technique combines the initial steps of resection preserving the globe.
of the maxilla with orbital exenteration except that the
globe is preserved. The globe is then supported by a B The frontal process and arch of the zygoma are
temporal muscle flap across the inferior aspect of the transected with a Gigli saw. The medial attachment of
globe (Wise and Baker, 1968). The orbicularis oculi the infraorbital rim is transected with a sagittal plane
muscle is preserved. saw just inferior to the medial canthal ligament. The
Steps are shown that modify the basic operation dotted lines depict the extent of the osseous resection.
depicted in Figures 5-8F to Hand 5-9. The globe is The central incisor tooth on the involved side is extract-
protected by a temporary tarsorrhaphy or contact lens. ed. The osseous transection is through the tooth socket.
The skin has been elevated superiorly to the orbicularis
oculi muscle, which is preserved and carefully retracted C With a small malleable or curved retractor, the
upward with a Cushing vein retractor. globe with the orbicularis oculi muscle and periosteum
is gently retracted upward. Posteriorly and inferiorly
En-Bloc Resection for Chondrosarcoma the orbital floor is transected with a curved osteotome.
The bony incision can be carried far posteriorly approxi-
A patient with extensive chondrosarcoma of both maxil- mately 4 cm from the inferior orbital rim with care not
lary antra, both ethmoidal sinuses, and the entire nasal to injure the optic nerve and without entering the
cavity and entire framework had these structures removed antrum. The danger to the optic nerve is greater medially
en bloc with the cribriform plate (Craniofacial Resection, when dissecting the lamina papyracea.
see Chapter 23). The exposure consisted primarily of a
degloving procedure of the skin overlying the maxilla D The remaining steps in the procedure are similar
and the nasal framework, thus preserving the overlying to the more radical operation except that the globe is
skin and also both eyes. A unilateral Weber-Dieffenbach preserved. A temporal muscle flap (X) is then mobi-
(Fergusson) incision (see Fig. 5-11) was made to facili- lized by separating a 1-cm strip of the muscle from its
tate the exposure. All margins were histologically free insertion and attaching this free distal end near the
of disease. Immediate reconstruction consisted of sus- inner canthus of the eye. This attachment can be made
pending the medial canthal ligaments with stainless to the fascia in the area or through a small hole drilled
steel wire to the frontal bone, and a temporary Steinmann in the remaining bone on the medial aspect of the
pin (see Fig. 13-29) (panje) was inserted through both orbit. The temporal muscle flap thus forms a sling to
malar bones to support the immediate postoperative support the globe. The medial canthal ligament requires
prosthesis. Dermal grafts were placed to line the bare resection when the osseous resection is higher. Then
areas of the flaps. The prosthesis was thus made in an the lateral portion of the medial canthal ligament is
upper and lower portion, the upper portion to fill out later secured to drill holes in the nasal bone. These drill
the face and skin of the nose, and the lower portion for holes are the same site where the temporal is muscle
the lower maxilla and upper teeth (follow-up at 14 years sling is attached. (See Fig. 14-3D to F.) Care is taken
showed no evidence of disease). not to disrupt the lacrimal sac deep to the medial
canthal ligament.
Complications
Superior
orbital fissure
,-cr'
FIGURE 5-10
THE SINUSES AND MAXILLA
Limited Resection of the Maxilla The inferior turbinate (a separate bone) is thus includ-
(Fig. 5-") ed in the resected specimen, whereas the superior and
middle turbinates, which are part of the ethmoid, are
The technique of this procedure follows the basic prin- excised as separate fragments after the main specimen
ciples of the radical maxillary resection except that the is removed.
orbit is left intact and the ethmoidal labyrinth is not If the t~mor grossly involves the medial wall of the
removed en bloc but cleared by curettage. Permission antrum, the middle turbinate and the superior turbinate
for orbital exenteration should be obtained, although are removed en bloc with the main specimen. When
the need for this procedure would be unlikely. the tumor involves the septum, the floor of the nose is
transected on the contralateral side. The septum is thus
Highpoints removed with the main specimen. If possible, the
columella is preserved; otherwise, an anterior strut
1. This procedure is indicated mainly in carcinomas graft is inserted for support.
involving only the floor of the antrum.
2. A portion, or all, of the floor of the orbit is preserved C The orbicularis oculi muscle is retracted upward. A
as well as all the orbital contents. Stryker saw transects the upper third of the maxilla,
3. The skin incision is made as close as possible to preserving most of the infraorbital rim and floor of the
lower eyelashes-otherwise troublesome edema of orbit. This cut is' extended laterally across the body of
lower lid will result. the zygoma. The posterolateral attachment of the maxilla
4. Ethmoidal air cells are removed by curettage. is separated from the pterygoid process of the sphe-
5. Preserve the soft palate. noid bone with a chisel as depicted in Figure 5-9K. The
6. All raw areas are covered with split-thickness skin. posterior wall of the maxilla is then usually free enough
for removal of the specimen by rocking the maxilla.
The branches of the internal maxillary artery, especially
A After the eyelids are approximated (temporary those in the pterygomaxillary fissure, will require ligation.
tarsorrhaphy, see Fig. 11-15), a Weber-Dieffenbach The anterior and posterior ethmoidal sinuses are
(Fergusson) skin incision is started across the mid- curetted as in Figure 5-9M, with the same precautions
portion of the upper lip in stepladder fashion to mini- as in an ethmoidectomy (see Fig. 5-3). A split-thickness
mize scar contracture. The incision is carried upward in skin graft is used to line all bare areas (see Fig. 5-9N).
the nasolabial sulcus to the level of the inner canthus
and thence horizontally just beneath the eyelashes of D Povidone-iodine (Betadine)- or iodoform-impreg-
the lower lid and beyond the outer canthus. The nated cotton is used as packing (see Fig. 5-9P).
orbicularis oculi muscle is left intact and preserved at The packing is removed in 7 to 10 days, and a
its orbital location. temporary prosthesis is inserted. In 2 weeks the tem-
An incision is made in the gingivobuccal fold, and porary tarsorrhaphy is released.
the cheek flap, including the buccinator muscle, is
reflected back to the tuberosity of the maxilla.
A more extensive resection of the maxilla can be
B The area resected is schematically represented. This performed in which the entire maxilla is resected as in
includes the lower two thirds of the maxilla including Figures 5-8F to H, 5-9, and 5-10, with preservation of
the juxtaposed hard palate. A Gigli saw is used to the eye. In such procedures, a portion or slip of the
transect the hard palate as in Figure 5-9D and E. The temporalis muscle is detached from the coronoid process
nasal process of the maxilla is sectioned with a chisel of the mandible and swung as a sling under the eye for
for a distance of 1.0 to 1.5 cm to the level of the support. The distal end of the muscle is sutured in the
infraorbital rim. region of the inner canthus of the eye.
THE SINUSES AND MAXILLA 249
c D
FIGURE 5-11
250 THE SINUSES AND MAXILLA
Cysts of Maxilla (Fig. 5-12) juxtaposed portion of nasal or antral mucous mem-
brane, if necessary.
3. Teeth are retained if this is compatible with adequate
A TO E Odontogenic and developmental fissural or cyst wall removal. Devitalized teeth require root
inclusion cysts of the maxilla are shown: radicular- canal treatment.
dental root or dentoperiosteal; follicular-dentigerous 4. Frozen section should be performed if there is any
(contains a tooth); nasoalveolar; nasopalatine; and question regarding a possibility of neoplasm.
globulomaxillary.
Resection of odontogenic cysts follows much of the
Highpoints same technique and approach as with the basic
Caldwell-Luc operation (see Fig. 5-2). When possible,
1. Preoperative radiographs should be taken to eval- the juxtaposed, normally located teeth are preserved by
uate the extent of bone encroachment. dental care. The oroantral communication is closed, and
2. The entire cyst wall must be removed, including a drainage is obtained with an intranasal antrostomy.
THE SINUSES AND MAXILLA
ODONTOGENIC
DEVELOPMENTAL
FIGURE 5-12
THE SINUSES AND MAXILLA
A Cystic swelling is shown at lateral base of right ala D A small, curved, blunt-nosed scissors is used to
nasi and vestibule with partial obstruction of anterior enucleate the cyst, keeping the wall intact. In this
naris. Cavitation of the bone is not present and rarely patient there was a line of cleavage between the cyst
occurs in these cysts. wall and the nasal mucous membrane. The nasal cavity
was not entered. If there were no Iine of cleavage, the
B An incision is made along a portion of the nasolabial adherent nasal mucosa would require excision.
fold forming the lateral base of the ala nasi. If the The wound is closed with 5-0 nylon sutures without
presenting portion of the cyst were lower, an approach drainage. Nasal packing impregnated with an antibiotic
in the alveolar labial gutter could be used. ointment may be placed in the vestibule to coapt the
elevated nasal mucous membrane to the concavity of
C With blunt and sharp dissection, the presenting the defect.
wall of the cyst is exposed. If the cyst is extremely large,
THE SINUSES AND MAXILLA
A B
FIGURE 5-13
THE SINUSES AND MAXILLA
A Depicted is a form of nasopalatine duct cyst pre- D The entire lining of the sinus tract must likewise be
senting as a sinus tract through the hard palate just removed. This requires an elliptical incision around the
behind the right medial incisor tooth. This would sinus tract in the hard palate, with careful curettage
correspond to the right incisive canal. The cyst presents along the walls of the defect in the bone. Considerable
in the right nasal cavity, displacing the inferior turbinate bleeding may occur from terminal branches of the
superiorly, reaching the nasal septum, and causing greater palatine artery or the nasopalatine artery in the
severe nasal destruction. tract. Electrocautery is used to control this bleeding.
Cautery is also utilized to destroy any possible remain-
A 1 An incision is made in the gingivolabial sulcus ing epithelial elements of cysts and duct. A single suture
slightly acrossthe midline transecting the superior labial of 4-0 nylon is placed through the mucous membrane
frenulum. The incision is so placed that sufficient mucous of the hard palate to close the defect, whereas a con-
membrane remains on the gingival side to facilitate tinuous 4-0 nylon suture closes the gingivolabial inci-
placement of sutures for closure. The dotted line around sion. Packing of 0.5-inch strip gauze impregnated with
the sinus tract indicates the incision to remove the antibiotic ointment or nitrofurazone (Furacin) is
lining of the sinus tract. inserted in the defect in the floor of the nose and
brought out through this defect. Additional nasal pack-
B With blunt and sharp dissection, the labial flap ing may be required to control any oozing blood.
is elevated, exposing the anterior wall of the cyst. A
small probe can be passed through the sinus tract to E Shown here is another type of nasopalatine cyst
demonstrate the communication with the cystic that presents in the roof of the mouth rather than in
cavity. the nasal cavity.
C Cross section shows the location of the sinus tract F A palatal flap based posteriorly is elevated with an
and cyst with a small blunt curet attempting to sepa- incision just behind the gingiva, thus preserving the
rate the mucous membrane of the floor of the nose greater palatine vessels.The cyst and wall are resected
from the cyst wall. This is not possible posteriorly, and using much the same technique as for the previous
thus juxtaposed nasal mucous membrane and cyst nasopalatine cyst. Closure is with 4-0 nylon and a
wall are removed together. It is most important that all drain brought out anteriorly, if necessary.
portions of the cyst wall be excised; otherwise, recur-
THE SINUSES AND MAXilLA
FIGURE 5-14
THE SINUSES AND MAXilLA
FIGURE5-15
25& TH£ ~INU~£~
AND MAXILLA
A B
FIGURE 5-16 A, Preoperative CT scan demonstrating maxillary disease. B, CT scan after endoscopic middle meatus
maxillary antrostomy showing resolution of maxillary disease without removal of the maxillary lining.
THE SINUSES AND MAXILLA
Complications (Not Restricted to Endoscopic extensive injection may be necessary and can include
Approaches) transpalatal sphenopalatine block. Recommended
anesthetic is 1% lidocaine with 1:100,000 epinephrine
• Intranasal bleeding to cause vasoconstriction and provide postoperative
• Synechiae formation comfort.
• Stenosis and obstruction of sinus ostium with recur-
rence of disease Holding Endoscopes
• Lateralization of middle turbinate
• Obliteration of frontal recess with persistent or de The endoscope should be held between the thumb and
novo frontal disease forefinger and embraced with the other fingers while
• Mucocele formation, especially in the frontal sinus resting the hand or fingertips on the patient's nose or
• Orbital emphysema cheek. The scope is held as close to tlje lighted end as
• Epiphora possible, and the viewing end is supported by the
• Anosmia or hyposmia surgeon's periorbital structures. All light cords and
• Persistent or recurrent sinus disease camera wiring are directed against the surgeon's chest
• Severe arterial hemorrhage and then back to lie across the patient's chest. The
• Orbital hematoma scope should be placed in the nasal vestibule first to
• Diplopia view the caudal septum. Then the dissecting instru-
• Visual loss or blindness ment held in the other hand is passed into view and the
• Cerebrospinal fluid leak scope and dissecting instrument advanced together
• Intracranial bleeding deeper into the nasal passage. Thus, the scope follows
• Stroke the instrument into place. A gauze pad moistened with
• Death antifogging solution is placed near the patient's nose to
wipe away blood and prevent fogging. The position of
Technique-General the hand on the scope can serve as a depth gauge for
rapid cleaning of the endoscope tip and quick replace-
Preoperative ment of the scope to the same depth each time. A
common mistake is to hold the scope near the viewing
Several preoperative considerations are important to
improve the intraoperative conditions, including treat-
ment with antibiotics, avoidance of topical deconges-
tant sprays, and treatment with topical or systemic corti- TABLE 5-1 Surgically Important Anatomic
Variations
costeroids, especially in the case of allergy, fungal
sinusitis, or the presence of polyps. Anticoagulants,
aspirin, and other nonsteroidal anti-inflammatory agents Frontal Sinus
should be discontinued well in advance of the surgical Supraorbital ethmoidal cells
procedure. High frontal recess ethmoidal cells
Narrow frontal sinus ostium
Atelectaticfrontal sinuses
Surgical Planning
Ethmoidal Sinus
A thorough understanding of the operative technique, Concha bullosa
Paradoxicallybent middle turbinate
identification of landmarks intraoperatively, and the
Infraorbital ethmoidal cells
identification of anatomic variants (Table 5-1) seen on Mediallydownsloping skull base with low medial lamella
endoscopic examination and/or a CT scan are critical. of cribriform plate
Dehiscence of lamina papyracea or skull base
Anesthesia
Maxillary Sinus
Lateralization of the uncinate process
Endoscopic surgery can be performed under local or Maxillaryatelectasis
general anesthesia. In the preoperative holding area, it Infraorbital ethmoidal cells
is helpful to decongest the nose with a topical decon- Accessoryostium
gestant such as oxymetazoline. The face is draped with Sphenoidal Sinus
the eyes exposed to enhance the surgeon's ability to Onodi cells (sphenoethmoidal cells) overriding the
recognize intraoperative orbital hematoma. Local anes- sphenoidal sinus
thetic is injected to the inferior turbinate, at the ante- Projection of carotid artery and optic nerve into the
rior attachment of the middle turbinate, and at the region sphenoidal sinus
of the uncinate process. During awake sedation, more
THE SINUSES AND MAXilLA
Uncinectomy
Accessory
ostium
Ethmoid
bulla
Middle
turbinate
FIGURE5-17 Uncinectomy. FIGURE 5-19 Maxillary antrostomy.
THE SINUSES AND MAXilLA
Ethmoidectomy
A
FIGURE 5-21 Ethmoidectomy.
THE SINUSES AND MAXILLA
the ethmoidal sinus, and extending posteriorly to the widened by removing inferior and medial bone. Only
ground lamella of the middle turbinate. A total eth- overhanging bone should be removed from the supe-
moidectomy includes removal of the ground lamella to rior and lateral aspect, and this is done very carefully.
open into the posterior ethmoid cell. Pitfalls during It is important to avoid sharp instrumentation of the
ethmoidectomy mainly relate to penetration of the sphenoidal contents, because it is possible to injure the
lamina papyracea, in which case a surgeon must recog- carotid artery or the optic nerve. In addition, preopera-
nize the difference between mucosal thickening in the tive CT should be evaluated for the presence of an
sinuses and adipose tissue of the orbit. Bleeding usu- overriding posterior ethmoidal cell, which makes the
ally occurs diffusely but can be profuse in the region of likelihood of an exposed optic nerve greater. It is not
the sphenopalatine arteries inferiorly and laterally near necessary to perform ethmoidectomy to perform a sphe-
the sphenoid natural ostium, as well as the anterior noidotomy. The sphenoidotomy can also be done directly
ethmoidal artery in the posterosuperior aspect of the through the nose by gently fracturing the inferior
frontal recess. The fovea is most likely to be injured in turbinate and the posteroinferior aspect of the middle
the region of the anterior ethmoidal artery, at the junc- turbinate and then identifying the natural ostium by
tion between the posterior ethmoidal and the sphenoidal palpation or direct visualization. The ostium can then
sinus and along the attachment of the middle turbinate. be widened as described.
Anywhere along the fovea is at risk. The medial lamella
of the cribriform plate, which is medial to the middle Frontal Sinusotomy (Figs. 5-23 to 5-25)
turbinate, should never be traumatized or anosmia or
cerebrospinal fluid leak will ensue. Use the 3D-degree endoscope. The curved suction with
a large diameter curve is very useful for palpating the
Sphenoidotomy (Fig. 5-22) frontal recess area. It can be used to gently displace
ethmoidal septa in the frontal recess, which then can
Use the D-degree endoscope. The sphenoidal sinus can be removed with a suction ctebrider, curved curet, giraffe
be approached from the ethmoidal sinus once the total forceps, or up-biting forceps. The 3D-degree sinus endo-
ethmoidectomy is completed, by examining the region scope allows easy visualization of the frontal foramen,
in the inferomedial posterior ethmoidal sinus using the which should be exposed without denuding mucosa
point above the lower edge of the middle turbinate as from bone. Various instruments are available, including
a landmark. The sphenoidal opening can be palpated giraffe forceps, curved curets, and probes. The frontal
by placing a suction tip 7 em from the nasal sill at an sinus and foramen anatomy can be evaluated pre-
angle of 3D degrees. The posterior wall of the sphenoidal operatively with C1. There are situations when a very
sinus is 9 em from the nasal sill. Once the natural small opening could be made, in which case it is best
ostium of the sphenoid is identified by palpation, the
suction tip can proceed from the posterior ethmoidal
sinus into the sphenoid ostium. The ostium should be
Frontal Foramen
Sphenoid
ostium
Septum
Curved
Suction
FIGURE5-22 Sphenoidotomy. FIGURE5-23 Frontal sinusotomy.
THE SINUSES AND MAXilLA
A B
FIGURE 5-24 Frontal sinusotomy.
to avoid direct instrumentation of the area. On other turbinate should be left undisturbed. It should not be
occasions, a very large frontal foramen can be iden- fractured. It is not usually necessary to trim it. There
tified, in which case a large opening can be made that are occasions when the inferior horizontal segment is
will remain patent. The frontal sinusotomy is one of the very large and the anterior portion can be removed. In
more difficult techniques in endoscopic sinus surgery, addition, a concha bullosa, or aerated middle turbinate,
and it is the most likely site for postoperative stenosis should be treated by removal of the lateral wall. This is
and persistent sinus disease after endoscopic surgery. done using scissors, but care should be taken to avoid
Transillumination of the frontal sinus is an excellent fracturing the attachment of the turbinate. If the turbinate
method of determining that one has actually opened is removed because it has become diseased or is par-
the frontal sinus. Bright transillumination will only tially removed for exposure, the attachment should be
occur when the frontal sinus is illuminated directly. If left in place as a future landmark. The medial attach-
there is a persistent high anterior ethmoidal cell, there ment of the middle turbinate is the medial extent of the
will be very minimal, if any, transillumination. This ethmoidectomy. It is easy to injure the cribriform area,
high ethmoidal cell can be recognized on the CT scan and this can more likely occur if this landmark is lost.
and certainly more easily identified using computer Should the turbinate become fractured and flaccid, it
image-guided technology. will undoubtedly lateralize and should be held medially
by a method that will allow at least 1 month of stabi-
Surgical Pitfalls lization against the septum. This can be done with a
transfixion suture through the septum, 3- to 4-week
Battered Middle Turbinate Syndrome (Fig. 5-26) stenting, or scarification of the turbinate to the septum.
Remember, middle turbinectomy does not guarantee
Lateralization of the middle turbinate with associated frontal recess patency.
obstruction of the maxillary, ethmoidal, and frontal
sinuses is a common postoperative problem that can be Cerebrospinal Fluid Leak
prevented by avoiding trauma to the turbinate mucosa
and/or fracture of the turbinate attachment. The middle Cerebrospinal fluid leak is a known complication of
ethmoidectomy and is best recognized and repaired at
the time it occurs.
Orbital Complications Arlen M, Tollefsen HR, Huvos AG, Marcove RC: Chondrosarcoma of
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Kurohara SS, Webster JH, Ellis F, et al: Role of radiation therapy and advanced carcinoma of the orbital-ethmoid and maxillary areas.
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Lewis JS: Sarcoma of the nasal cavity and paranasal sinuses. Ann the maxillary sinus. Presented before the Wisconsin Otolaryngological
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Loeb HW: Operative Surgery of the Nose, Throat and Ear. St. Louis, Schuknecht HF: The surgical management of carcinoma of the
CV Mosby, 1917, vol II. paranasal sinuses. Laryngoscope 61:874-890, 195!.
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Lore JM Jr: Partial and radical maxillectomy. Ololaryngol Clin North Mexico, 1969.
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THE SINUSES AND MAXilLA
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6 THE NOSE AND
THE NASOPHARYNX
267
THE NOSE AND THE NASOPHARYNX
MIDDLE TURBINATE
BULLA ETHMOID
FRONTAL SINUS DUCT HIATUS SEMILUNARIS
EUSTACHIAN TUBE
FIGURE 6-1
THE NOSE AND THE NASOPHARYNX
Anatomy of Epistaxis (Fig. 6-2) will achieve control of the hemorrhage. Lateral rhinot-
(After Koh et aI., 2000; Montgomery, omy may be necessary especially in familial telangiec-
1971 ) tasia to insert a dermal graft for septal dermoplasty
(see Fig. 6-6) (Saunders, 1960).
Epistaxis can be either a very minor or a very major
problem. The most common area in children and young 1. Cauterization
adults is anteriorly on the septum (Kiesselbach or Little 2. Nasal packing-anterior, posterior, or both
area) and is the easiest controlled (see Fig. 6-3E and F). 3. Submucosa resection or septoplasty
The more complicated areas are posterior and superior, 4. Ligation of arteries
both on the lateral wall of the nose and the septum in a. Ethmoid arteries, anterior and posterior
older adults (see Fig. 6-3). b. Internal maxillary and sphenopalatine arteries
The important factors in the control of epistaxis are c. External carotid artery rarely controls epistaxis.
etiology, location, and management. 5. Septal dermoplasty-removal of offending mucosa
and application of a dermal graft rather than split-
Etiology thickness epidermis .
6. Basic care of severe hemorrhage-frequency and
A. Local disease selection depends on degree of severity of blood loss.
1. Crusting and ulceration a. Vital signs-every 1 to 2 hours
2. Nose picking b. Hemoglobin and hematocrit determination, one
3. Infection to three times per day
4. Neoplasms c. Blood transfusion
a. Malignant neoplasms d. Central venous pressure
b. Juvenile nasopharyngeal fibromas e. Blood volume
c. Angiomas f. Venous cutdown or intracatheter in vein
d. Metastatic renal cell carcinoma to the paranasal g. Blood urea nitrogen determination-elevation is
sinuses and/or nasal cavity. Massive epistaxis result of swallowing and absorbing blood.
can occur. If feasible, resection of the meta- 7. Embolization of branches of external carotid
static lesion may be the treatment of choice. artery-hazard of hemiplegia and facial palsy
5. Trauma
6. Foreign body Angiography-Digital Subtraction
B. Generalized disorders and disease This is seldom necessary but is of distinct use in per-
1. Arteriosclerosis-hypertension sistent and refractory epistaxis to determine feeding
2. Rheumatic heart disease vessels as well as recurrent epistaxis after unsuccessful
3. Blood dyscrasia and associated diseases arterial ligation. Obtain true lateral and anteroposterior
a. Anemia views (Koh et aI., 2000).
b. Polycythemia vera Angiography usually requires selective external
c. Thrombocytopenia purpura carotid artery with internal maxillary artery arterio-
d. Hemophilia gram and then an internal carotid artery arteriogram
4. Leukemia with visualization of the ophthalmic artery and its
5. Familialtelangiectasia (Rendu-Osler-Weberdisease) anterior and posterior ethmoidal branches. A bilateral .
6. Hepatic diseases angiogram is ideal but may have to be staged, depend-
7. Chronic nephritis ing on find-ings and patient tolerance. Complications
8. Vicarious menstruation of possible stroke and blindness must be explained to
9. Atmospheric pressure changes (e.g., scuba divers; the patient.
caisson disease)
10. Generalized infectious diseases Complications
11. "Stigmata"?
• Shock
Location • Aspiration of blood with airway obstruction causing
respiratory arrest and then cardiac arrest. Never have
Exact determination of the bleeding site must be made, patient keep the head back. 1f bleeding is to occur,
if at all possible, to facilitate direct attack. Occasionally, let it run out of the nose rather than down the pharynx
a submucous resection (see Fig. 6-12) or septoplasty and into the larynx. Oversedation can be the cause
(see Figs. 6-13 and 6-14) is necessary to visualize the of this complication.
site. Often under such circumstances these procedures • Death
THE NOSE AND THE NASOPHARYNX 271
ANT
SUPERIOR ETHMOID ~ OPHTHALMIC _..•• _ INTCAROTID
POST
FACIAL
A SEPTAL BR. ..- SUP.LABIAL ~(EXT. MAX-) - EXT.CAROTID
ANT
• SUPERIOR ETHMOID _ OPHTHALMIC.~"'_----_ INT.CAROTID
POST
o POSTERIOR
SPHENOPALATINE
(POSTLATNASAL)
.•.• INT MAX. ••• EXT.CAROTID
FIGURE 6-2
Anterior and Posterior Packing by systemic antibiotics. Strip gauze one-half inch,
for Epistaxis (Fig. 6-3) impregnated with an antibiotic ointment, is ideal.
n. Occasionally in persistent epistaxis (e.g., in familial
Highpoints telangiectasia), an arteriogram may be helpful.
Collateral blood supply has been demonstrated via
I. Attempt to locate bleeding site by cleansing nasal the vertebral artery and the occipital artery into the
passages with cotton-tipped applicator dipped in internal maxillary artery in a patient with external
solution of cocaine 10%, or tetracaine 2 %, and a carotid artery ligation.
vasoconstrictor. 12. A nasal mucous membrane dermoplasty (excision
2. Anterior septal vessels (Kiesselbach's plexus) are of diseased mucous membrane and coverage with
the most common site. dermal graft) may be required in familial telangiec-
3. In the absence of hypertension, bleeding at this tasia (see Fig. 6-6).
common site is usually controlled with a pledget of 13. All packing should be impregnated with antibiotic
cotton gauze soaked with cocaine or tetracaine and ointment plus systemic antibiotics for normal flora
a vasoconstrictor. If bleeding persists from this loca- and gram-negative bacilli.
tion, cauterization with either a silver nitrate stick or
electrocautery is performed (see Fig. 6-3E). Ante- Posterior Packing
rior packing (see Fig. 6-3F) may also be necessary.
4. Fatal hemorrhage is very rare, especially in hyper-
tension, if meticulous care is given. A Topical anesthesia may be applied to the nasal
5. Epistaxis in hypertension is looked on as a fortu- mucosa. A small rubber catheter (No. 10 French), to
nate safety valve mechanism, provided the patient's which an l8-inch length of soft-bodied string is tied, is
vital signs are monitored carefully. inserted into one naris. The forward end is grasped
6. Aspiration and swallowing of blood should be with a small sponge stick and pulled out through the
avoided. If oozing persists, allow blood to run from mouth, leaving the string in the nasal cavity and
anterior nares with head flexed forward. Overseda- mouth. This maneuver is repeated through the other
tion is strongly condemned because of the danger naris.
of aspiration, respiratory obstruction, and death.
For the same reason the patient must not be B The oral ends of the string are then secured to a
restrained. prearranged roll of gauze impregnated with antibiotic
7. Ligation of one or both external carotid arteries is ointment to which is tied a third section of string.
occasionally necessary.
8. Occlusion of anterior ethmoidal, posterior ethmoidal C Steady traction is then applied to the nasal ends of
(see Fig. 6-4), or internal maxillary arteries (see the strings and, with the index finger of the opposite
Fig. 6-7) with silver locking clips may be necessary. hand, the roll of gauze is firmly directed into the
9. Ligation of the common carotid or internal carotid nasopharynx. The third string protrudes from the
artery is neither necessary nor justified. corner of the mouth.
10. Nasal packing of any type should be accompanied Continued
THE NOSE AND THE NASOPHARYNX
FIGURE 6-3
THE NOSE AND THE NASOPHARYNX
D The two nasal ends of the string are tied securely Currently, most clinicians prefer endoscopic examina-
over a small cushion of gauze or dental roll across the tion of the nasal cavity, under general anesthesia, direct
columella. The oral string is loosely taped to the cheek. visualization of the bleeding vessel(s), and electrocau-
This latter string facilitates easy removal of the poste- terization. This approach avoids the discomfort and
rior pack. morbidity associated with nasal packing, particularly
When this equipment is not available, a Foleycatheter posterior nasal packing, and considerably shortens
is inserted through one naris. When the tip has passed hospitalization time.
the nasopharynx, the bag is inflated and pulled forward
THE NOSE AND THE NASOPHARYNX
CRISTA GALLI
FRONTAL SINUS
FRONTOMAXILLOLACRIMAL SUTURE
SUP. OBLIQUE M.
MEDIAL RECTUS M.
POST. ETHMOID A.
10-13MM!
OPTIC N.
LACRIMALA.
4-7MM
OPHTHALMIC A.
FRONTOMAXILLOLACRIMAL
SUTURE
OPTIC FORAMEN
FRONTAL PROCESS MAXILLARY
BONE
LACRIMAL FOSSA
ANGULAR A.
WabniQ
B
FIGURE 6-4
THE NOSE AND THE NASOPHARYNX
LACRIMAL SAC
c D
External Ethmoidectomy Approach phy (DSA) (arterial route) is necessary to evaluate the
to Epistaxis (Fig. 6-5) presence of such vessels (Fig. 6-5). In one patient, an
angiomatous type lesion was seen on the DSA, and
In the unusual event that bilateral ligation of the ante- the external ethmoidectomy was used to resect this
rior and posterior ethmoidal vessels as well as internal suspicious area as well as clip the feeding vessel that
maxillary arteries fails to control hemorrhage high in existed through the cribriform plate (Sobie and Loft').
the nasal cavity, an external ethmoidectomy may be The accompanying anteroposterior left carotid angio-
necessary (see Fig. 5-4). The extent of the osseous gram (DSA, arterial route) demonstrates a concen-
resection of the lacrimal bone to the frontal process of tration of dye (circled) just inferior to the cribriform
the maxillary bone and the nasal bone for the approach plate in a patient with recurrent, severe, life-threatening
to the vessels perforating the cribriform plate depends epistaxis. (Angiogram courtesy of Dr. David Rowland,
on whether the location of the bleeding site is anterior Director of Radiology, Sisters Hospital of Buffalo,
or posterior. Preoperative digital subtraction angiogra- New York.)
FIGURE 6-5
THE NOSE AND THE NASOPHARYNX
I. SPLIT THICKNESS
1 OR
I DERMAL
GRAFT
FIGURE 6-6
THE NOSE AND THE NASOPHARYNX
(Medial to mandible) only the maxHiary artery branches but also the bilateral
ethmoidal arteries. In one patient (with familial telan-
I. Deep auricular giectasia) who previously had bilateral external carotid
2. Anterior tympanic artery ligations as well as ethmoidal and sphenopala-
3. Middle meningeal (and accessory meningeal) tine artery ligations, an angiogram performed via the
4. Inferior alveolar superficial temporal artery revealed anastomoses of a
branch of the maxillary artery with the vertebral artery
Part II via the occipital artery. It is in such situations that an
angiogram is of help. A common carotid arteriogram
(Relationship deep or superficial to external pterygoid would also demonstrate any significant variant of the
muscle-all muscular branches) internal carotid, which is extremely rare, as shown by
Quain (1844), in which the branch to the foramen
1. Masseteric rotundum and the accessory meningeal arteries sub-
2. Deep temporal (2) stituted for the internal carotid artery.
3. Buccinator
4. External and internal pterygoid Highpoints
POSTERIOR
PHARYNGEAL
PTERYGOID CANAL
{ FORAMEN
ROTUNDUM
EXT. PTERYGOID M.
SUP. HEAD
INF. HEAD
MEDIAL & SUPERIOR
SPHENOPALATINE
MIDDLE
POSTERIOR NASAL
MENINGEAL AND
ACCESSORY A.
LATERAL
A POST. SUP.
{
ALVEOLAR
FIGURE 6-7
UPPER HEAD
LOWER HEAD
D INT. PTERYGOID M.
FIGURE 6-7 Continued
THE NOSE AND THE NASOPHARYNX
• Hemorrhage
THE NOSE AND THE NASOPHARYNX 287
FIGURE 6-8
THE NOSE AND THE NASOPHARYNX
Transpalatlne Exposure of the invasive test, stroke is possible if the dye reaches
Nasopharynx and the Sphenoidal the intracranial circulation; the complications
Sinus (Fig. 6-9) must be explained to the patient. Do not perform
a selective vertebral arteriogram. It can result in
Indications basilar artery syndrome and adds no useful
information.
• Removal of large benign and locally invasive lesions 2. Tumor can extend into the orbit, any paranasal
(juvenile angiofibroma); nasopharyngeal chordoma sinus, pterygomaxillary space, nasal cavity, or
• Exposure for surgical correction of posterior choanal temporal fossa and involve the foramen of the
atresia skull and extend intracranially.
• Diagnostic exploration when other methods have 3. Bleeding is usually profuse-have up to 12 units
failed of blood available.
• If lesion extends beyond confine of nasopharynx, 4. The use of hormones such as estrogens as
another approach or combination of approaches is definitive treatment has not been proved to be
necessary. of value.
• An alternate approach to the sphenoidal sinus (see 5. A computed tomographic scan with enhancement
p.228). is mandatory in the evaluation of the extent of
tumor.
Alternate Techniques 6. Temporary occlusion of the external carotid
artery. The vessel should not be permanently
1. Most benign pedunculated lesions in the nasopharynx ligated, because subsequent arteriograms to
can be removed with nasal snare (see Fig. 6-8). evaluate recurrence will then be quite difficult to
2. Posterior choanal atresia also can be surgically treated perform. However, such an arteriogram can be
via the nasal cavity with or without the operating performed with permanent ligation through a
mIcroscope. catheter in the superficial temporal artery.
7. A transpalatine approach is usually preferred.
Highpoints The pterygomaxillary space can be reached via
this approach. The combination of trans maxillary
1. Never biopsy a lesion in the office that is suggestive and lateral rhinotomy approaches may be
of being an angiofibroma. necessary, depending on the extent of the tumor
2. A mucoperiosteal hard palate flap is used. behind the antrum (Pressman, 1962). Lateral
3. Remove and discard the major portion of the bone of rhinotomy can be performed via an extended
the hard palate. Caldwell-Luc approach. This can be performed
4. Preserve the greater palatine arteries bilaterally. Elevate without an external facial incision (see Fig. 6-10).
the vessels and nerves with a mucoperiosteal hard 8. Cryosurgery has been utilized in conjunction with
palate flap. this surgical procedure to reduce the size of the
5. Safeguard as much mucous membrane as possible tumor and to reduce the hemorrhage, but late
(e.g., along floor of nose, septum, vomer, and palatal hemorrhage has occurred.
crest). If the lesion is malignant, the mucous mem- 9. Radiation therapy is not advised unless absolutely
brane is removed with the lesion. necessary because of the subsequent danger of
6. Additional exposure can be achieved by mobilization malignant change. Hypotensive anesthesia,
of the greater palatine vessels by removing surround- although used by some surgeons, carries too
ing bone. great a risk.
7. Flexible and rigid telescopes are a great aid in evalu- 10. Some of these tumors are very friable, others
ation of lesions in the nasopharynx. are very firm. If at all possible, they should be
removed intact rather than piecemeal. This
Additional Criteria and Characteristics of requires careful blunt dissection.
Juvenile Angiofibroma 11. If the tumor is large and bleeds profusely, external
carotid artery ligation can be attempted, but by
1. External carotid arteriogram (digital subtraction) and large this has not proved useful. The better
is helpful in delineating feeder vessels that are approach would be to ligate the internal maxillary
usually the internal maxillary and ascending artery via a transantral approach. In addition this
pharyngeal arteries. Although uncommon in this trans antral approach will give additional exposure
THE NOSE AND THE NASOPHARYNX
to the larger tumors that extend into the antrum, 14. Magnetic resonance imaging may prove to be
behind the antrum into the lining of the antrum, of help in the evaluation of the extent of the
or further into the pharyngomaxillary space as tumor.
well as the sphenoidal sinus. The author's
technique is to perform a transantralligation of Complications
the internal maxillary artery as the initial step,
depending on the findings of digital subtraction • Naso-oral fistula, especially at the anterior portion
angiography (arterial). • Related specifically to angiofibroma: profuse hemor-
12. Infratemporal or infrazygomatic swelling indicates rhage during and following surgery
further spread of the tumor. Intracranial spread • Incomplete removal or recurrence; neurologic seque-
must also be evaluated before any surgical lae from vertebral arteriogram-possibly due to blood
approach. Chemotherapy has been reported for flow stasis from catheter in vertebral artery or bolus
nonresectable intracranial extension. of the radiopaque material
13. Consider the use of fresh-frozen plasma after 4 • Rhinism
to 6 units of blood transfusion.
THE NOSE AND THE NASOPHARYNX
LESSER PALATINE
ASCENDING PALATINE
,.j
D
FIGURE 6-9
THE NOSE AND THE NASOPHARYNX
MIDDLE TURBINATE
NASAL SEPTUM
FIGURE 6-10
THE NOSE AND THE NASOPHARYNX 29S
4.4cm
/
FIGURE 6-11
THE NOSE AND THE NASOPHARYNX
E G
FIGURE 6-11 Continued
THE NOSE AND THE NASOPHARYNX
FIGURE 6-12
THE NOSE AND THE NASOPHARYNX
F In preparation for the Ballenger swivel knife, a J Occasionally, an osteotome is necessary to remove
small cut is made with scissors at the superior edge of a thick bony ridge along the base of the septum. A free
the incised cartilage. septal cartilage graft is then reinserted to support the
anterior portion of the septum so further support is
G, G 1 The swivel knife is placed at this cut straddling given the dorsum of the nose. Anterior to the dotted
the cartilage. Before the knife is pushed backward and line is the critical area for support; posterior to the dotted
upward, make certain that no portion of mucoperi- line no support is necessary (Tardy et aI., 1985). A sep-
chondrium or mucoperiosteum is caught on the edge tal cartilage graft can be added to the anterior area.
of the knife. The knife is then advanced to the bony The septal flaps are coapted and the incision approxi-
septum and follows this junction downward to the mated with 4-0 nylon. Two techniques are available:
vomer bone and then anteriorly. The freed cartilage is
removed with forceps. K A specially designed (Lore, Sr.) septal hollow needle
with suture material already threaded is inserted as
H Cartilage-cutting forceps (McCoy) or duckbill depicted. The free posterior end is grasped with forceps,
forceps (Watson-Williams) allow for the removal of any and the needle is withdrawn.
remaining cartilage as well as portions of the per-
pendicular plate of the ethmoid and vomer. A portion L The knot is tied anteriorly.
of septum 12 to 16 mm wide must be left dorsally to
support the bridge of the nose. When removing the M If such a needle is not available, the incision and
deviated portion of the perpendicular plate of the anterior portion of the septum are approximated with
ethmoid, the cribriform plate of the ethmoid must not one or two through-and-through sutures. In each case,
be injured. Proper use of the bone forceps is necessary. a portion of the anterior cartilage strut is included in
Fragments are not avulsed; small complete bits are the suture. These sutures are removed in 3 to 7 days.
taken carefully. When rotation of the forceps is utilized,
it is done gently around a single axis. It is often best
to remove such mobilized fragments with bayonet Teflon splints are now used routinely (see Fig. 6-131
. forceps, because the mucoperiosteum may be adher- and L) to coapt the flaps and to control bleeding. One-
ent in several areas and require sharp separation. A half inch gauze impregnated with antibiotic ointment is
Jansen-Middleton spoon-shaped biting double-action inserted in both nares to add support to approximate
forceps is also excellent for this stage. the flaps. This packing is removed the following day.
If the flaps appear to separate-this will not occur if
I Inferiorly, portions of a broadened vomer or ridge the Teflon splints (see Fig. 6-13) or the septal needle has
are difficult to remove with forceps. Decussation of the been used-the packing may be reinserted. Johnson
periosteum and perichondrium at this point is best (1971) reports the use of small suction catheters insert-
separated by sharp dissection (see Fig. 6-13Al). An open, ed under the septal flaps. These are connected to suc-
sharp, ring curet placed posteriorly and drawn forward tion, thus removing serum and approximating the flaps.
THE NOSE AND THE NASOPHARYNX
wab~
A CI
3, I !
D F
G H
FIGURE 6-13
immobilization. They are secured in position with degree of caudal external deformity; otherwise, the
through-and-through 4-0 nylon sutures. Details of the septal cartilage will most likely assume its original
use of these splints are shown in Figure 6-131 to L. deviated position days or weeks postoperatively.
G Incision is made between the lateral nasal cartilage H Suture supporting repositioned cartilages.
and the septum. This step is most important with any Continued
THE NOSE AND THE NASOPHARYNX
Septoplasty Type I (Continued) be relatively loose, and their purpose is mainly just to
(Fig. 6-13) (Gorney, 1962) hold the splints in position as far as dislodging them
posteriorly is concerned.
One surgeon has reported slough of the mucoperi-
Teflon Splint
chondrium following the use of splints. This may have
been the result of excess pressure due to tight sutures.
I Outline of a typical Teflon splint cut to size of
patient's nasal cavity after the technique of Johnson. Correction of Septal Cartilage and Anterior
The Teflon is from 0.022 (less than 1 mm) to 0.034 Nasal Spine Deformity
inch (about 1 mm) in thickness; the holes are made
with an ordinary leather or paper punch. The holes are
M When the inferior portion of the caudal end of the
optional and are usually omitted. A smooth lateral
septum is overriding the anterior nasal spine or maxil-
bend at the caudal inferior end of the splint is made
lary crest, fixation of the realigned septal cartilage is
with a clamp. This prevents the base of the caudal end
necessary. This is achieved by drilling a hole using a
from cutting into the soft tissue (see also Fig. 6-13L).
sturdy Keith needle through the spine or crest.
Pink dental wax as well as Silastic may also be used.
Exposure is either through an existing incision with a
tunnel at the base of the spine and the floor of the
J To prevent overriding of the sections of cartilage,
node or through a sublabial incision.
especially when no splint is used, a 4-0 nylon suture
can be placed as depicted following the technique of
N Fixation of the cartilage to the spine or crest is
Wright.
then secured with a buried 4-0 or 5-0 nylon suture.
K, L Details of placement of the Teflon splint. Also
shown is another variety of cartilaginous sutures that
o When the septum is arched in its superior-inferior
axis at the caudal end, the mucoperichondrium being
help prevent overriding of sections of cartilage.
elevated, a section of cartilage is removed. The septal
nasal spine relationship is corrected. If the normal
A ring curet can be used to set the knot when the V-shaped approximation is absent and this becomes
suture is placed deep in the nasal cavity (Johnson, necessary to maintain the position of the cartilage, the
1971). Or, the tip of the needle can be inserted into the spine is reconstructed in V fashion.
turbinate after it passes through the septum to localize
the needle. The needle tip is then removed from the P A 4-0 or 5-0 nylon suture is buried beneath the
turbinate. mucosa for fixation. A Teflon splint is usually necessary
Because there is usually no bleeding with the use of to maintain the superior and inferior sections of the
splints, intranasal packing is not necessary. The splints nasal septum.
may be left in place for up to 2 weeks. Care must be
exercised to avoid any pressure points along the edges Pl Numerous types of deformities can occur at the
of the splint. A suitable surgical ointment is applied to region of the anterior nasal spine. Depicted is a devi-
the splints at the time of insertion and postoperatively ated caudal end of the cartilage resting on a ridge of
along the free presenting edges, especially at the infe- the spine. This ridge (hatched area) can be removed
rior (base) aspect of the columella. and the base of the caudal end of the septum then
These splints should protrude several millimeters sutured to the main portion of the nasal spine as
distally beyond the columella. This will prevent undue depicted in steps M and N. A wedge of cartilage is
pressure on the mucoperichondrium of the nasal excised from the nasal septum to facilitate its
septum. The sutures should not be tight. They should realignment to the spine.
Continued
THE NOSE AND THE NASOPHARYNX 307
TEFLON
SPLINT
J K
pili
!!
M N o p pi
FIGURE6-13 Continued
THE NOSE AND THE NASOPHARYNX
CARTILAGE
GRAFT
Q R
I
FIGURE 6-13 Continued
THE NOSE AND THE NASOPHARYNX
1. Complete mobilization of the deviated septum is D A small right-angle knife is inserted under the
obtained. elevated mucoperichondrium to the point of angula-
2. Preservation of as much cartilage as possible is done. tion of the septum. The cartilage is then transected
3. If possible, mucoperichondrium is left at least par- along the dotted line leaving a narrow bridge of carti-
tially attached to one side of the mobilized septal lage intact along the upper border (X). Partial incision
cartilage. of the narrow ridge of cartilage may be required at a
later stage to permit the anterior portion of the septal
Complications cartilage to be swung and maintained in the midline.
The base of the cartilage must likewise be transected
• Saddleback deformity (may occur many years later) along the dotted line. If the nasal spine and/or base of
• Septal hematoma the vomer bone is significantly off center, this may
• Collapse of nasal tip and columella require correction with a chisel (see Fig. 6-14]). Fixation
• Nasal obstruction-incomplete resection of the anterior spine is then necessary.
• Mucosal tear-if feasible repair with fine chromic
catgut. Teflon splints will likewise aid in coapting E Through the incision in the cartilage, the muco-
mucosa. perichondrium is elevated posteriorly on the opposite
• Toxic shock syndrome-following any nasal packing side if there is a posterior deviation that is causing
(see p. 274) obstruction.
• Septal perforation-if troublesome, a Silas tic button Continued
may be used. Mucosal flaps are seldom successful.
The alternative is to widen the perforation posteriorly
if a "whistling" noise occurs.
• Cartilage and bone may have "memory" to return to
original deformed position.
THE NOSE AND THE NASOPHARYNX
Bony septum
Mucoperichondrium
Medial crura of
alar cartilages
c D
FIGURE 6-14
THE NOSE AND THE NASOPHARYNX
Excised hump
A ALAR CARTILAGE
MEDIAL CRUS ALAR CARTILAGE
LATERAL CRUS
SEPTUM
FIGURE 6-15
THE NOSE AND THE NASOPHARYNX
Rhinoplasty (Continued)
H The bony hump is then sawed through from one
(Figs. 6-15 and 6-16)
side to another. This requires a saw cut from the oppo-
site side. Both nasal bones and the dorsum of the
E After the preceding steps are repeated on the septum are cut in this manner. The hump usually still
opposite side, a button end knife initiates the so-called has lower attachments of the lateral and septal carti-
transfixion incision, which runs along the dorsal and lages that are not cut with the saw. A small curve
distal borders of the septum. To commence this inci- button end knife is used to sever these attachments in
sion, a curved button end knife may be more adapt- a manner similar to its use in F.An osteotome may also
able. In either case, the knife is inserted in the original be used to separate higher attachments. The hump is
intercartilaginous incision on one side reaching and then removed with a clamp. An alternate method of
lying in the subperiosteal plane over the bony hump. removing the hump is with a chisel. Remember to be
The knife is then brought downward over the dorsum conservative in the amount of hump removed. It is very
of the septum, thus transecting the attachment of the difficult to correct an overaggressive hump removal.
septum along its dorsal margin. When the knife reaches
the level of the opposite intercartilaginous incision, I A sharp rasp is used to smooth any rough areas
the instrument is advanced through this incision and along the bony edges as well as to round the outer
extended to the septal tip or angle. At this point the (dotted) edges of the cut surfaces of the nasal bones
direction changes almost at a right angle, hugging the (11). The rasp must be used in single downward strokes
lower or distal margin of the septum. The apices of and after each stroke the rasp should be cleaned of all
both nares are not retracted upward as in F so that the bony fragments. Additional bone is removed at the
membranous distal end of the septum is placed on the nasal dorsal angle (glabella). This step is very impor-
stretch. In this manner the knife can follow the plane tant to avoid a "straight line" effect. At times this may
between the membranous and cartilaginous portions be overlooked because of soft tissue edema.
of the septum, leaving the membranous septum caudad
with the columella. J The small curved button end knife is used to correct
any irregularities of the lower portion of the incision
F The lower portion of this transfixion incision is that involves the septal and lateral cartilages. This may
completed with a No. 11 blade knife or scissors down require the use of scissors. It is important that follow-
to the anterior nasal spine. ing the use of the rasp and the button end knife all
fragments of bone and cartilage are removed; other-
G A long narrow retractor (Aufricht) exposes the wise, they may serve as a nidus for regeneration of
subperiosteal plane for the bayonet saw, which will be bone and cartilage.
inserted through the intercartilaginous incision. Care Continued
must be taken not to injure or dull the teeth on the
saw, at the same time avoiding entanglement with soft
tissue.
THE NOSE AND THE NASOPHARYNX 319
J
H
Rhinoplasty (Continued)
Ml A schematic drawing shows the portion of the
(Figs. 6-15 and 6-1 6)
lateral cartilage excised in the previous step. Again do
not shorten this cartilage any more than is necessary.
K Any remaining attachments of the lateral cartilages It is usually necessary to excise two triangular wedges
to the septum are transected with scissors close to the of bone, one on either side of the septum at its junc-
septum. ture with the nasal bones. This step may be done at
this stage of the operation or concomitantly with the
L The distal or lower margin of the septum is now "outfracturing" of the lateral bony nasal wall (see
delivered into one naris and a triangular section of Fig. 6-15U).
cartilage with overlying mucoperichondrium is excised
with scissors. The shape of this excised section depends N Using a narrow osteotome, a cut is made close to
on the relationship of the nasolabial angle (90 degrees). the septum. A saw can likewise be used to prepare for
It is important to evaluate carefully the amount of the fracture.
shortening necessary to correct the existing deformity.
This may be done by raising the tip along a fixed ruler o With the same osteotome, another cut is made
and measuring the distance between the two points. close to the edge of the nasal bone. In such fashion, a
Remember that excising an extra amount of the distal wedge of bone is, one hopes, outlined and freed. (This
margin of the septum is nO assurance of a properly wedge of bone is removed with a hemostat. The same
raised tip; it is catastrophic if too much is excised. procedure is performed on the opposite side.)
L1 The septal angle or tip of the septum is then P The two wedges of bone are removed.
rounded with a No. 15 blade knife. A small section of
mucoperichondrium is also trimmed back from this Q To expose the nasal (anterior) process of the
angle to prevent any untoward bulkiness at the tip. maxilla for the lateral osteotomy, an incision is made in
the pyriform recess that lies at the inferior margin of
M As the tip is raised and the nOse shortened, there the nasal process. This incision is so directed that it
is usually a protrusion of the lower end of the lateral leads to the periosteum on the external surface of this
cartilage through the intercartilaginous incision. This is inferior bony margin.
excised, Continued
THE NOSE AND THE NASOPHARYNX
Q
FIGURE6-15 Continued
THE NOSE AND THE NASOPHARYNX
Rhinoplasty (Continued)
needle holder is used to grasp this lateral nasal frame
(Figs. 6-15 and 6-16)
and "outfracture" it again. The "infracturing" is repeat-
ed. The bridge of the nose is again evaluated for any
R First a Joseph knife and then a periosteal elevator rough or sharp edges, which now may be rounded to
is inserted through the incision in the pyriform recess, a pleasing contour.
and the periosteum is elevated along the base of the
nasal (frontal) process of the maxilla up to its suture W Before the transfixion sutures are placed, evalua-
line with the frontal bone at the region of the inner tion of the hanging septum is made. This consists of an
canthus of the eye. This tunnel is as close to the base excessively deep columella made up of folds of skin
or origin of the nasal process as possible except that and broad medial crura of the alar cartilages. An ellip-
superiorly it is anterior enough so that the medial tical section of both skin and cartilage is excised as
palpebral ligament is not detached. This ligament is depicted by the dotted lines. The two transfixion sutures
attached to the nasal (frontal) process of the maxilla in of 3-0 nylon are then inserted, being certain that there
front of the lacrimal groove. is good coaptation of the septal angle with the carti-
lages of the tip. These are through-and-through sutures
S Using a narrow retractor or curved saw protector, joining the septum with mucoperichondrium and
the bayonet saw is inserted through the subperiosteal columella with skin. They are usually staggered so that
tunnel. This is done with the same care as depicted in when they are tied they will tend to raise the columella
G when the saw was inserted for excision of the hump. and thence the tip. A problem may arise with an even-
tually dropped tip after these sutures are removed. To
T Keeping as close to the base or origin of the nasal minimize this complication, buried sutures of 6-0 nylon
(frontal) process of the maxilla as possible, this bone can be placed. These sutures are not removed.
is sawed through at right angles to the body of the
maxilla. An attempt is made to remove the "sawdust"
Rhinoplasty Dressing
with small scoops. The entire procedure is now
repeated on the opposite side. An alternate method is
the use of an osteotome or small circular saw (see Fig. X Nasal packing of one-half inch strip gauze impreg-
6-16B to D). nated with an antibiotic ointment or liquid nitrofura-
zone is then gently and rather loosely inserted into the
U The next step consists of the "outfracturing" of nose. A small plastic tube can then be inserted along
these two lateral bony frames, each consisting of the the floor of the nose on each side for breathing pur-
nasal bone and nasal process of the maxilla. This poses. Some surgeons eliminate any intranasal packing.
maneuver aids in the ultimate narrowing of the nasal The skin is cleansed with hydrogen peroxide and
bridge, because it usually establishes a clean fracture water, dried, and then coated with tincture of benzoin
line along the region of the suture line between this or povidone-iodine (Betadine). Narrow strips of adhe-
lateral frame and the frontal bone. The outfracturing is sive are then applied with one or two strips placed
accomplished by the insertion of an osteotome between around the tip and the superior portion of the columella
the septum and the nasal bone. Several slight taps on and then pinched at the tip (see Fig. 6-17D).
the osteotome are made and then, using the septum
as a fulcrum, the osteotome is moved laterally, thus Y A thin layer of lint, cottonoid material, or Telfa is
pushing the nasal bones outward. Beware of a green- placed over this adhesive dressing. Then a splint com-
stick fracture. Some surgeons do not outfracture. posed of a dental mold compound or soft malleable
metal is used as an additional external protection. This
V The lateral nasal frame on each side, which is now external splint is held in place with adhesive strips as
quite mobile, is fractured inward by pressure with the shown. Five to 7 days later, the splint is removed.
operator's thumbs. If mobility is incomplete on one
side or the other, a Walsham nasal forceps or heavy
THE NOSE AND THE NASOPHARYNX . 323
1/
/ 1
x y
FIGURE 6-15 Continued
THE NOSE AND THE NASOPHARYNX
A Removal of the dorsal hump, especially if small, C Another technique for lateral osteotomy is the use
can be performed entirely with an osteotome along the of a small power -d riven Seltzer saw.
dotted line. A Hilger guarded osteotome is ideal for
this purpose. Deepening of the nasofrontal angle at the D Close-up of Seltzer saw.
glabella can also be achieved by use of an osteotome
along the solid line. E Cross section of correct (1) and incorrect (2) planes
for the lateral osteotomy. The horizontal osteotomy
B The lateral osteotomy can be accomplished with facilitates support for the transected bone. The arrow
a guarded osteotome inserted in the pyriform recess. shows the lack of support for the transected bone when
Tardy uses a micro-osteotome (2 to 3 mm wide) to the osteotomy is oblique.
FIGURE 6-16
THE NOSE AND THE NASOPHARYNX
D
FIGURE 6-17
THE NOSE AND THE NASOPHARYNX
EXCISED CARTILAGE
WabritU
F G
FIGURE 6-18
THE NOSE AND THE NASOPHARYNX
A Through an incision made anterior to the medial I The lateral margins of the upper lip defect are first
crura of the alar cartilages, a tunnel is developed down approximated with deep sutures of 4-0 or 5-0 chromic
to and anterior to the anterior nasal spine. The tunnel catgut. The skin is closed with 5-0 nylon. The usual
is extended upward into the bulk of the nasal tip but rhinoplasty splint and nasal packing with nitrofurazone
not so far that the end of the cartilage graft will be (Furacin) strip gauze are used. The upper lip is best
noticed subcutaneously. immobilized with adhesive, and the patient should be
kept on liquids until healing occurs.
B A thin strut of cartilage with attached perichon-
drium is then inserted in this tunnel. An anchor mattress
suture of 4-0 nylon is placed through the base of the After any graft, primary healing may be delayed. The
graft and brought out through the skin of the columella. patient should be kept on antibiotics and liquids with
This suture is tied over a small rubber or plastic bootie. the upper lip immobilized. Secondary healing occurs
The lateral incision is approximated with fine sutures. usually within 7 to 10 days.
THE NOSE AND THE NASOPHARYNX
,
I
J
FIGURE 6-19
THE NOSE AND THE NASOPHARYNX
Narrowing a Flared Naris For enlargement of nares with Z-plasty see Figure
6-31G to I.
F A flared naris often accompanies a complete cleft
lip and is corrected by the excision of a triangular piece
of skin along the floor of the nose. Only skin is excised,
because there is usually a deficiency of subcutaneous
tissue.
THE NOSE AND THE NASOPHARYNX 331
G H
FIGURE 6-20
THE NOSE AND THE NASOPHARYNX
FIGURE 6-21
THE NOSE AND THE NASOPHARYNX
PERPENDICULAR PLATE OF
THE ETHMOID
FIGURE 6-22
THE NOSE AND THE NASOPHARYNX
o E
FIGURE 6-23
THE NOSE AND THE NASOPHARYNX
C The separation of the lateral cartilage from its peri- I If skin closure is under too much tension, a superior
chondrium is continued using a Joseph knife up to the nasal flap is elevated with the excision of a triangle
nasal bone. The lateral extent of the resected area is (Burow's triangle) of skin bilaterally.
shown by the dotted line.
J The completed closure is shown with the superior-
D After the previous steps are completed, on the based nasal flap pulled downward.
opposite side the so-called transfixion incision of a
rhinoplasty is performed. It is modified in that only the
distal portion of the transfixion incision is necessary.
A B
FIGURE 6-24
THE NOSE AND THE NASOPHARYNX 339
\IIi
\uf
>
c D
When the lesion is higher on the midportion of the B The lesion is then excised. If it is thought to be
dorsum, the reconstruction can be accomplished by malignant, biopsy may be bypassed, with wide exci-
using the rhombic geometric principles as depicted in sion done as a primary procedure. In such cases deep
Chapter 3 under Rhombic Flap, page 140. excision and frozen section are mandatory. A stay suture
When the defect is large, an inferior-based midline rather than a forceps is used for traction. Absolute
forehead flap can be utilized (see Fig. 8-12). hemostasis is necessary.
c D
FIGURE 6-25
THE NOSE AND THE NASOPHARYNX
C With a 6-0 silk suture through an edge of the graft, Type of Flap
a No. 11 blade knife is used to cut the helix. No
forceps is placed on the graft; the cut is clean and The surgeon should recognize the fundamental differ-
deliberate. ence relative to the etiology of a defect, for example,
trauma or secondary to ablative surgery for a malig-
D The recipient site is clean and the edges are sharp. nant neoplasm. Briefly, avoid the use of flaps for the
defects relative to ablative surgery where a prosthetic
E With 6-0 silk sutures, the anterior edges of the skin device will serve the same purpose. Whether the flap
are first approximated with very delicate care. be a local transposition of tissue or a microvascular
free flap depends on a number of factors: availability
F The graft is then gently everted using a cotton- of microvascular technique; adequate artery and vein
tipped applicator. The posterior skin edges are approx- for blood supply; donor site; whether previous radia-
imated. tion therapy has exposed the recipient site or the donor
site, which might interfere with the viability of the
G The completed graft is supported internally with free flap; and cosmetic, functional, quality of life, and
cotton soaked with povidone-iodine or antibiotic oint- other factors.
THE NOSE AND THE NASOPHARYNX 343
G
\
\
J
\ K
FIGURE 6-26
THE NOSE AND THE NASOPHARYNX
FIGURE 6-27
THE NOSE AND THE NASOPHARYNX
future nosel on1r skin is incised, This permits a better furnish adequate arterial supply and venous return for
blood supply for the pedicle, and at the distal end there the flap. This step is very important.
is only full-thickness skin, thus avoiding a bulky future
nose. At the end of 2 weeks, the skin of the distal end F After 3 to 4 weeks, the flap is divided in V fashion
is shaped and incised with flares to form the nares and (see Fig, 6·31A to C). If desired, this division may be
a projection to form the columella. It is not necessary staged over a period of 1 week. The remaining portion
to undermine the flap completely because there is no of the flap is then returned to the forehead, removing
significant blood supply from the periosteum. the unwanted skin graft. The top wing of the V on the
returned flap may be rotated downward to meet the
B Two weeks later the entire flap is elevated, swung lower wing.
into position, and evaluated regarding length. If addi-
THE NOSE AND THE NASOPHARYNX 347
FIGURE 6-28
THE NOSE AND THE NASOPHARYNX
Nasal Reconstruction With tumor, especially when the nasal mucosa is involved,
Combined Scalp and Forehead is sound even though frozen section may have been
Flaps (Fig. 6-29) used. Delay also allows skin grafting for the lining of
the flap. Turn-in flaps at the site of the defect are not
The Sickle Flap recommended in the surgery for a malignant tumor,
because extension of disease at a later date may be
The technique of elevation, delay, shaping, and skin masked. During this delay, the raw areas at the site of
grafting is similar to that for the forehead flap, illus- the nasal defect are covered with split-thickness skin.
trated in detail in Figure 6-28.
Stages
C, C1 The flap is outlined and incised as depicted.
The details of size and shape are as shown in Figure
A, B Stages of the technique. 6-28A. The distal end does not include the frontalis
muscle, which is left in place, as is done in the other
1. Elevate flap between the two ends. forehead and scalp flaps (see Fig. 6-28B). This minimizes
2. Two weeks later the distal or forehead end is the occurrence of a bulbous nose. The remainder of
transected. the flap includes all layers down to the periosteum.
3. Three weeks later the entire flap is elevated and Hence, the frontalis muscle is split at the medial border
returned to its bed. At this stage a split-thickness of the free distal end so that it can be included in the
graft may be inserted as the lining of the future base of the flap.
nose.
4. Six to 9 weeks later-after the edema has sub- D The entire flap is elevated and folded on itself,
sided-the flap is rotated into position over the thus covering the major portion of the raw area of the
nasal defect. flap. If any raw area remains, especially in the region
5. Three to 4 weeks later the pedicle is transected in V where the flap crosses the brow and that portion of
fashion. This may be staged over a I-week period. nose which is intact, split-thickness skin is used for cover.
6. Two to 4 weeks later refinement of the grafted nose This is most important, because any raw area is sus-
is begun (see Fig. 6-31). ceptible to infection and troublesome drainage. The
7. Blood supply is from the superficial temporal and donor site is likewise skin grafted.
posterior auricular arteries.
E The flap in position. The distal end forming the
nose is shaped as in Figure 6-28C to E. Take care to
The "Scalping" Flap (Converse, 1959) avoid crossing and touching the eyes.
The main difference in technique with this type of flap F The pedicle is transected in V fashion in 3 to 4 weeks,
is that it can be swung either at the initial stage or with in stages, if necessary. The final shaping follows the
only one delay. If used for reconstruction after subtotal technique shown in Figure 6-31. When the flap is
or total nasal resection for carcinoma, the flap is out- returned to the scalp, an attempt is made to adjust it
lined and edges incised at the time of the resection. so that a minimal forehead defect results.
Although immediate reconstruction with transfer of the
flap is more common, a delay of 1 or more weeks may
be preferred. This delay serves several purposes. Time Complications
is allowed for permanent histologic sections to be eval-
uated regarding adequacy of the resection for the carci- • Problems in shaping the ala nasi
noma. This basic principle in the surgery of a malignant • Nasal obstruction
THE NOSE AND THE NASOPHARYNX
FIGURE 6-29
THE NOSE AND THE NASOPHARYNX
FIGURE 6-30
THE NOSE AND THE NASOPHARYNX
D E F
FIGURE 6-31
THE NOSE AND THE NASOPHARYNX
FIGURE 6-32
TW~Nm~ AND TH~NASOPHARYNX
Total Resection of Nose for
Carcinoma (Fig. 6-33) D After both lateral walls of the nose have been
sectioned, excision of the columella and nasal septum
Highpoints is begun. Liberal margins are resected. Stay sutures are
used on the specimen to avoid use of clamps or forceps,
1. Unusually wide resection of external framework is which might fragment the tumor and cause implants.
required.
2. Careful evaluation of internal extent of disease is E Whereas the cartilage is easily transected with a
mandatory. knife, the bony septum, nasal bones, and nasal processes
3. A wide resection is done of the nasal septum and of the maxillae, if encompassed in the resection, may
columella. require bone-cutting forceps.
Transected base
of columella
F G
FIGURE 6-33
THE NOSE AND THE NASOPHARYNX
1. A nasal glioma is a space-occupying expansile lesion, B The external appearance of a glioma is depicted in
histologically usually benign, arising from congenital this 4-month-old child that was present since birth. It
central neural elements. It is an encephalocele and resembles a dermoid cyst. Nasal gliomas may be either
not a neoplasm. external or internal or both.
2. There may be a connection with the intracranial The dotted and solid lines represent the skin inci-
cavity, and hence removal may cause a dural defect sion. The excess skin is left attached to the glioma. The
with leakage of cerebrospinal fluid and danger of incision is that of an external ethmoid approach.
meningitis unless recognized.
3. In view of the possibility of dural defect, any nasal C Medial and lateral flaps are developed. A O.5-cm
polypoid mass in the newborn must be considered a diameter (external) pedicle of gliomatous tissue is seen
glioma until proved otherwise. extending through a smooth, well-rounded defect in
4. Intracranial extent of glioma is evaluated by air the nasal bone and nasal (frontal) process of the
studies according to signs and symptoms. Computed maxilla.
tomographic scan with enhancement may help in
the evaluation of the extent of the lesion. D The inferior margin of the nasal bone and nasal
5. If the intracranial portion is large and especially if a process of the maxilla are exposed, and an incision is
large dural defect is anticipated, the initial surgical made along this margin to elevate the periosteum.
approach is transcranial using a craniofacial tech-
nique. See Chapter 23 for details. However, dural E The external portion of the glioma has been removed
defects are usually handled easily through an ade- for simplicity of exposure and working space. Because
quate transnasal approach. An important point is to it is not a neoplasm, this technique is permissible. In a
recognize them and treat them accordingly. staged procedure, this may conclude the first stage for
6. TWo-stage procedures may be necessary when the diagnostic purposes and further evaluation. With a
initial diagnosis is obscure. nasal freer, the periosteum is elevated over and under
the nasal process of the maxilla.
In addition to gliomas, meningiomas can extend into
the nasal cavity. These require a combined cranio-facial F A lateral osteotomy is performed with a small curved
approach. See Chapter 23. Death can occur when an chisel up to the bony defect. From this point, the
intracranial approach alone is utilized. Entry into the chisel is directed horizontally across the superior suture
anterior cranial fossa is the serious complication. line of the lateral nasal bone to the midline. This forms
a periosteal bone flap that is attached to the midline
along the dorsum of the nasal septum.
Continued
THE NOSE AND THE NASOPHARYNX
FIGURE 6-34
THE NOSE AND THE NASOPHARYNX
H As the glioma is dissected, another (internal) pedicle L The skin is approximated with interrupted 5-0 nylon.
becomes exposed, extending through the roof of the Massive doses of penicillin and a broad-spectrum anti-
ethmoid labyrinth into the anterior cranial fossa. The biotic are used until all evidence of cerebrospinal fluid
middle and inferior turbinates are not involved. leak has ceased. Bacitracin is used locally on the packing.
THE NOSE AND THE NASOPHARYNX
K L
FIGURE 6-34 Continued
THE NOSE AND THE NASOPHARYNX
B
FIGURE 6-35
THE NOSE AND THE NASOPHARYNX
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Allen GW: Ligation of the internal maxillary artery for epistaxis. passages and the accessory nasal sinuses. Ann 010158:1055,1949.
Laryngoscope 80:915-923, 1970. Brown JB, McDowell F: Skin Grafting, 3rd ed. Philadelphia, JB
Anderson JR: New approach to rhinoplasty. Arch Otolaryngol 93: Lippincott, 1958, chap 13.
284-291,197!. Brunk A: A new case of unilateral osseous choanal occlusion: An
Anderson JR: A reasoned approach to nasal base surgery. Arch operation through the palate. Z Ohrenheilkd 59:221, 1909.
Otolaryngol110:349-358, 1984. Bryce DP, Crysdale WS: Nonhealing granuloma: A diagnostic problem.
Apostal JV, Frazell EL: Juvenile nasopharyngeal angiofibroma: A Laryngoscope 79:794-805, 1969.
clinical study. Cancer 18:869-878, 1965. Butler RM, Nahum AM, Hanafee W: New surgical approach to
Ardran GM, Kemp FH: The nasal and cervical airway in sleep in nasopharyngeal angiofibromas. Trans Am Acad Ophthalmol
neonatal period. AJR Am J Roentgenol 108:537-542, 1970. Otolaryngol 71:92-104, 1967.
Aretsky PJ, Freund HR, Kantu K, Polisar IA: Chondrosarcoma of the Callaghan DJ, Conner BR, Strauss M: Epstein-Barr virus antibody titers
nasal septum. Ann 0101 79:382, 1970. in cancer of the head and neck. Arch Otolaryngol 109:781-784,
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7 THE FACE
FRONTALIS M.
SUPRAORBITAL A.
FRONTAL A.
DEPRESSOR GLABELLAE M.
ANGULAR A.
ORBICULARIS OCULI M.
SUPERFICIAL ZYGOMATICUS MINOR M.
TEMPORAL
A.
LEVATOR LABII SUPERIORIS M.
ZYGOMATICO-
ZYGOMATICUS MAJOR M.
ORBITALIS
ORBICULARIS ORIS M.
A.
DEPRESSOR LABIlINFERIORIS M.
TRANSVERSE FACIAL
A. DEPRESSOR ANGULI ORIS M.
STERNOCLEIDOMASTOID M. MODIOLUS
RISORIUS M.
A
367
368 THE FACE
SUPERFICIAL FASCIA
APONEUROSIS
SUBAPONEUROTIC
FIBROUS SEPTA TISSUE
OUTER COMPACT BONE i·~ PERICRANIUM
DIPLOE - BONE
INNER COMPACT BONE DURA MATER
B
FIGURE 7-2
THE FACE
FIGURE 7-3
3'2 THE FACE
Dermabrasion (Continued) (Fig. 7-3) • Erythema. This reddish hue always occurs immediately
after dermabrasion and usually gradually disappears.
Again, overexposure to sunlight is to be avoided.
B Close-up view of Iverson dermabrader shows small • Hypertrophic scars. These result with too deep der-
cylinder covered with emery paper sleeve. mabrasion or with dermabrasion in which there is a
paucity of cutaneous adnexa, as in the lower ante-
Postoperative dressing consists of antibiotic ointment rior neck.
covered with Telfa or Adaptex and an outer fluffed gauze • Hypopigmentation. This is usually due to deep abra-
pad held in place with a Kling bandage. This outer sion into the dermis.
pressure dressing may be removed in 24 to 48 hours, • Pain. This is rare.
whereas the inner dressing is left in place for 7 to • Infection. Although rare, it is usually due to Staphy-
10 days. It is important that this inner dressing not be lococcus aureus and should be treated vigorously to
forcibly removed earlier because this would injure the prevent scarring. Use bacitracin ointment plus sys-
regenerating epithelium. temic antibiotics, depending on results of culture
Approximate regeneration periods include: and sensitivity studies.
2
FIGURE 7-3 Continued
THE FACE 373
,
FIGURE 7-4
THE FACE
FIGURE 7-5
THE FACE
Temporalis m.
Auricularis m.
Temporal fascia
Zygomatic arch
Highpoints
Incorrect Method
I. Adequate deep and wide resection of lesion is neces-
sary if it is malignant -show no regard to facial nerve B This poorly devised flap is short and almost
if it is clearly involved by tumor, except to identify vertical.
and tag proximal and distal ends, if feasible, for a
sural nerve graft (see pp. Il2 and Il3). C The result is an objectionable upward distortion of
2. However, do not injure the zygomatic branch with a the eyebrow and noticeable drop in hairline on a
flap incision. conspicuous area of the forehead.
3. Avoid traction superiorly on the eyebrow-flap must Continued
be well mobilized and long.
;I
...
.'
I
....
,
1I:.z;
....~:.~ ...
-.-
'.
. :0-.,
fl.'
FIGURE 7-6
THE FACE
c D
FIGURE 7-7
THE FACE
1. Immediate end-to-end anastomosis, if feasible Spontaneous facial animation with the most natural-
2. Interposed graft (e.g., greater auricular nerve or appearing motion of the restorative procedures has been
sural nerve) (see Fig. 3-8) championed by several authors (Harii et al., 1982). This
3. Hypoglossal-facial nerve anastomosis (see Fig. 7-10) two-step procedure requires patient cooperation for the
4. Crossover facial nerve graft from the contralateral most complete rehabilitation.
facial nerve with sural nerve grafts (see Fig. 7-8A
and B) Indications
1. Reanimation with cross-face nerve graft (see Fig. 7-8A) • Complicated two-step procedure
followed by free neurovascular muscle transfer (see • Asymmetrical smile
Fig. 7-8B and C) • Additional scars on calf and thigh
2. Nerve crossover
a. To facial muscles Highpoints
b. To masticatory muscles
I. Identify several buccal nerve branches before sacri-
Slings ficing one or two to anastomose to the sural nerve.
2. Mark the end of the sural graft on the zygoma of the
1. Fascial paralyzed side.
2. Superficial musculoaponeurotic system (SMAS) 3. Follow Tinel's sign to follow nerve growth.
4. Frozen section identification of nerve tissue in the
Another important consideration is that reported by nerve graft is helpful at the time of the second
Martin and Helsper in 1960, in which they documented procedure.
spontaneous recovery of verified sectioning of the facial 5. Carefully mark the relaxed gracilis muscle in situ
nerve without any reconstruction. This phenomenon before dividing with silk sutures placed approximately
has been described many times. They suggested the 2 cm apart.
possibility of cross re-innervation via the trigeminal 6. Identify and dissect the facial artery and vein and
nerve. Conley (1974) had reported data relative to the nerve graft.
another route of cross-innervation. Parnes and colleagues 7. Place nonabsorbable sutures in the zygoma and in
(1982) have reported data that further suggest, in addi- the desired locations in the upper lip and commissure
tion to the facial nerve, the facial muscles that have an before muscle transfer. Pull to check proper angle of
additional nerve supply, hence the difficulty in evalua- contraction.
tion of the various surgical procedures used in the
management of facial nerve paralysis.
THE FACE
c
cross-facial
nerve graft
Anastomosis to
facial A, V and N gracilis m.
FIGURE 7-8
Superior tarsus
Gold plate
Gold plate
Inferior tarsus
A B
FIGURE 7-9
THE FACE
Hypoglossal-Facial Nerve
the tongue. It is transected just deep to the mylohyoid
Anastomosis (Fig. 7-10) (After Conley
muscle. The proximal end of the hypoglossal nerve is
and Baker, 1983) tunneled beneath the posterior belly of the digastric
muscle and anastomosed with the distal end of the
Although the author has no specific experience with
main trunk of the facial nerve. Problems may occur in
the anastomosis of the 12th to the 7th nerve for facial
that the distal end of the main trunk of the facial nerve
nerve paralysis, this procedure nevertheless has been
may be lacking and there may be only the cervicofacial
accepted as one of the methods of treatment of facial
and the zygomaticotemporal divisions available for
nerve paralysis when the proximal main trunk of the
anastomosis. Whether the 12th nerve is then split and
facial nerve is not accessible and, thus, interposition
independently anastomosed is a moot question. At any
graft is not feasible. rate, the anastomosis is performed using the operative
microscope or a four-power loupe utilizing several
The 12th cranial nerve is identified just anterior to the epineural sutures of 10-0 nylon. The problems associated
internal carotid and external carotid arteries medial to with this type of anastomosis are basically twofold.
the vagus nerve and the internal jugular vein. It is One is the hemiparalysis of the tongue, and the other
identified as it passes beneath the posterior belly of the is the mass movement of the facial muscles basically
digastric muscle. The nerve is then followed upward related to the act of chewing and swallowing and
beneath the stylohyoid muscle and beneath the tendon speaking. The reader is referred to Conley and Baker's
of the digastric muscle and is traced superiorly toward article (1979).
THE FACE
/
/
FIGURE 7-10
THE FACE
FIGURE 7-11
THE FACE
82
FIGURE 7-12
THE FACE
C By direct exposure a wider (1 to 1.5 em) and This deformity, usually due to injury of the mandibular
longer (15 em) piece of fascia lata is removed and used branch of the facial nerve, as well as transection of the
as the sling. The previous lateral incision 3 in B is platysma muscle, which at times extends over the
opened, and the ends of the previously placed fascia mandible and blends with other muscles (e.g., the riso-
are localized. Another incision is made in the temporal rius muscle), often follows operations in the sub-
region with a preauricular extension if a rhytidectomy mandibular region and in the parotid salivary gland
(face-lift) is also planned. The temporal fascia is exposed. and neck dissection (see Fig. 7-1). Often, it resolves with
A subcutaneous tunnel is then made connecting the time, especially when it is due solely to section of the
two incisions. A long slender clamp or fascia carrier platysma muscle and when this muscle is carefully
can be used for this purpose. approximated at the time of the wound closure. However,
if the deformity persists, several procedures are avail-
D The lower end of the fascia is then passed around able for at least partial correction. These include the
the loop formed by the fascia placed in stage I and following:
sutured with 4-0 nonabsorbable material. Redundant
skin may be excised, and then the dermis on the lateral 1. Z-plasty (see Fig. 9-2G and H).
skin wound (rolled edge) is approximated to the fascia 2. Plication of the orbicularis oris muscle (see Fig. 9-6).
with fine white non absorbable sutures. This wound is 3. Transposition of the tendon of the subdigastric muscle
left open until the operation is completed so as to view into the lower lip. This procedure, of course, would
the resulting effect with tension on the sling. have to be performed at the time of the definitive
surgery, and although the author (JML) has had no
E The fascial sling is then drawn upward through the personal experience with this technique, the fact
temporal incision so that the deformity is slightly that the lip is fixed in a depressed position may be a
overcorrected. The fascial end is then passed through cause of additional deformity.
THE FACE
E F
FIGURE 7-12 Continued
THE FACE
A B
FIGURE 7-13
the lingual nerve or inferior dental nerve is performed. Resection of portions of the lingual and inferior dental
Various techniques to block the maxillary division of the nerves has been performed intraorally. The lingual nerve
trigeminal nerve in the pterygopalatine (sphenomaxil- is exposed at the posterior floor of the mouth, while the
lary] fossa as it leaves the skull through the foramen inferior alveolar nerve is exposed on the lateral aspect
rotunda have been used. The reader is referred to of the oropharynx, overlying the mandibular foramen
Hollinshead (1954] for an anatomic description of the on the inner surface of the mandible and offering some
problem. temporary relief.
THE FACE
E F
FIGURE 7-14
396 THE ~ACE
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THE FACE
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8
Microvascular free flaps are depicted in Chapter 24. flaps are interchangeable, the cause of the defect is impor-
Some of the areas require reconstruction, outlined in tant in the decision regarding the use and selection of
this and other chapters. For example, large defects of flaps. The use of a flap developed from the potential
the buccal wall, face, and lips may be better recon- areas of spread of a malignant tumor is contraindicated
structed with a microvascular free flap. (e.g., the use of a sternocleidomastoid myocutaneous
flap if cervical metastasis is at all possible). The complete
coverage of the location of the primary tumor site
Introduction: Flap Selection and when such a tumor has a high rate of local recurrence
Design (Tables 8-1 and 8-2) is likewise contraindicated (e.g., an orbital defect after
a maxillary resection and orbital enucleation). In this
Highpoints case a split-thickness skin graft with prosthetic device
is preferred. Another example is a defect due to a recur-
1. Etiology of the primary defect: should a flap be rent adenoid cystic carcinoma of the palate or nose. A
utilized or is a prosthetic device preferred? prosthetic device is also preferred in this situation.
2. Donor site consideration is a factor. Regardless of the type of flap utilized, the adage of
3. The simpler the flap, the better. avoiding coverage of areas of highly probable recurrent
4. Is a local or distant flap necessary? Should it be carcinoma still applies. Most of the time this problem
cutaneous or myocutaneous? cannot be avoided except for coverage as mentioned
5. Age and general medical condition of the patient are earlier of an orbital defect or a defect after resection of
factors. the ear. In these two latter areas, a full-thickness flap-
6. There should be a minimal number of stages. either free microvascular or full-thickness local rotated
7. There should be minimal disability. flap-thwarts the use of a prosthetic eye or ear in
8. Inform the patient that the flap may be hair bearing! addition to masking recurrent disease.
As a basic principle, knowledge of the natural history
Three Basic Principles of a malignant neoplasm is paramount when deciding
whether a flap is preferred over a free skin graft and/or
Etiology of the Primary Defect a prosthetic device. Aside from the natural history of
the malignant neoplasm, the surgeon must determine
Should a flap be utilized or is a prosthetic device preferred? whether the defect site is such that a prosthetic device
Is the defect due to (1) surgical ablation for neoplasia, is the simpler method of rehabilitation. Circumstances
(2) trauma, or (3) congenital deformity? Although many that usually are more amenable to devices are (1) total
DefectExample Choices
399
G~N~RALPURPOS~FlAPS
the time of the initial surgery or later on, is so high 3. Previous radiotherapy to the neck may result in scatter
that the flap will obscure the clinical early detection radiation over the anterior chest wall. This could be
of metastatic cervical disease. This results in the so- avoided by shielding during the radiotherapy; other-
called violated neck. A pectoralis myocutaneous or wise, the upper incision of the flap should be moved
free vascularized flap is recommended. inferiorly 2 to 4 em below the level of the clavicle,
S. Forehead flap. This is an excellent flap as far as blood and delay may entail several stages, starting with
supply is concerned. The problem is in the defect in only skin incisions.
the donor site, which can be minimized by placing 4. 1fthe deltopectoral flap is used to cover, for example,
the incision along the hairline. Nevertheless, in a a vascular anastomosis just above or deep to the
younger individual the defect is not warranted if clavicle after a radical neck dissection, a dead space
some other flap can be utilized. A free vascularized can result with carotid artery blowout unless the
flap would be preferred. clavicle is resected.
S. Dependent traction of a deltopectoral flap by its mere
Limitations and Pitfalls with Major weight can cause deformity (e.g., reconstruction of a
Standard Regional Flaps large portion of the skin of the soft tissue of the chin
will pull the lower lip inferiorly). Suturing of the upper
1. Usual lack of function of a flap (e.g., a flap brought and lower lips with a small opening in the middle
into the floor of the mouth and/or tongue will not in may minimize this problem. On the other hand,
itself move with deglutition); dysphagia and pooling bilateral advanced lateral cheek flaps (e.g., Bernard
of food may result. [with Burow triangles] method) would prevent this
2. Compromise of viability of the flap by ablative sur- problem (see p. 482).
gery and/or radiotherapy relative to the donor site
3. Generalized arteriosclerosis Forehead Flap
4. Severe diabetes mellitus
S. Severe malnutrition 1. Donor site defects especially in the younger patient
6. Kinking or compromise of a flap by dressings, drains, are detrimental.
tubes, or tracheostomy tube tape 2. Compromise of blood supply is possible via the
7. Flap must be in contact with the underlying structure superficial temporal artery if a simultaneous radical
that is to be protected. This must be accomplished neck dissection has sacrificed the external carotid
without pressure on an underlying firm object, artery. Although McGregor and Reed (1970) minimize
whether it be a clavicle, a zygomatic arch, Kirschner this possibility, loss of a portion of the forehead flap
wire, Steinmann pin, or a mandibular bar or plate. can occur. 11is most important to include the pos-
terior auricular artery with a portion of the scalp
Limitations and Pitfalls According above and behind the ear. Delay is advised.
to Specific Flaps 3. In the reconstruction of the floor of the mouth and
portion of the tongue, do not drape the flap over a
Deltopectoral Flap bare Kirschner wire that is being utilized to stabilize
the mandibular ends when a section of the mandible
1. A failure rate of 9% to 18% may occur, especially has been resected. Another problem that can occur
with an extended deltopectoral flap. Although this is pinching of the flap if it crosses opposing teeth to
failure is usually not a disaster, if the flap is used to reach the floor of the mouth or tongue.
cover the carotid vessels in the presence of a fistula 4. There is danger of compromise of blood supply if
and/or previous radiotherapy, carotid artery blowout the flap is tunneled deep to the zygomatic arch. 1f
is a possibility and has been reported. this is the approach to reach the oral cavity, it is best
2. When used to reconstruct defects of the hypopharynx, to fracture the arch outward with two osteotomies.
oropharynx, cervical esophagus, or oral cavity, a The other approach is over the zygomatic arch.
planned fistula is usually necessary. This then requires S. Injury to the facial nerve may occur when performing
at least one more operative stage and prolongs the an access to the oral cavity.
"wait to swallow period" up to 11/, to 3 months. At
times, de-epithelialization of a portion of a flap may Nape of the Neck Flap
obviate the fistula. A simpler one-stage reconstruc-
tion utilizing a tongue flap and dermal graft is pos- 1. This flap must be delayed.
sible for hypopharyngeal defects up to 8 em in length. 2. Possible injury may occur to the spinal accessory
A free jejunal or tubed radical forearm free flap is nerve.
ideal for this type of defect. 3. This flap has limitations in regard to its length.
GENERAl PURPOSE FlAPS
Apron Flap 4. Bulk is good and bad-good for buccal wall defect,
bad for cheek defects.
1. Do not extend below the level of the clavicle, other- 5. Details are presented in Chapter 24.
wise the tip may necrose.
2. Unless an epithelial shave is utilized, a planned, yet
temporary, orocutaneous fistula will result when Blood Supply to Skin Flaps (Fig. 8-1)
this flap is utilized to reconstruct the floor of the (After McGregor and Reed, 1970;
mouth. Ariyan, 1979; Baek et aI., 1981)
Converse Scalping Flap for Total or Subtotal The blood supply to skin flaps has been described by
Nasal Reconstrucuon McGregor and Reed (1970) as being axial or random.
Actually, a combination of both types may exist in a
1. Take care to avoid pressure on the eye on the side of number of skin flaps, for example, the pectoralis major
the base of the flap. myocutaneous flap (Ariyan, 1979), which is the most
2. There is a problem in shaping the ala nasi. versatile of all flaps for head and neck reconstruction.
3. Nasal obstruction may occur. The axial pattern has a distinct arteriovenous circula-
tion that follows the long axis of the flap, giving off
Pectoralis Major Myocutaneous Flap branches to the dermal-subdermal plexus of vessels.
The viability of the flap depends on the length of these
1. This flap appears to be one of the best myocuta- axial vessels (artery and veins) and not on the ratio of
neous flaps utilized in head and neck surgery. length to width. The random flap, on the other hand,
2. Muscle bulk can be a problem in this flap. When has no axial vessels and derives its blood supply from
utilized for the reconstruction of the cervical the communication vessels in the dermal-subdermal
esophagus and/or hypopharynx, use a dermal graft plexus (the deltopectoral flap [Bakamjian, 1968]). Hence,
for the posterior wall of reconstructed gullet rather the length of the random flap has a significant relation
than a flap (see Fig. 8-2G and G'). to the width of the flap. It should be stressed that the
3. If muscle bulk is desirable, be certain that the nerve axial-patterned flap can and does have random por-
supply is preserved. tions, depending on the location of the flap, either at its
4. There is some limitation as to the length and mobility distal end or along its sides. For example, the distal end
because of the vascular supply. Resection of medial of a pectoralis major myocutaneous flap can have a
third of clavicle is of help (see p. 1041) but is rarely random portion beyond the pectoral branch of the
used. thoracoacromial artery when the skin and underlying
rectus fascia are included. In addition, a random por-
Trapezius Myocutaneous Flap tion of the pectoralis major myocutaneous flap can
have a medial random portion extending over the ster-
1. There will be a defect at the donor site with a num (Baek et a!., 1982). Any of these random portions,
shoulder droop. however, can be tenuous and not as reliable as the pure
2. At times there are problems with blood supply, axial component.
usually from the transverse cervical artery. When the The myocutaneous axial flap is based on a dominant
blood supply is solely or primarily from the trans- axial arteriovenous circulation from segmental vessels
verse cervical artery, this flap can be mobilized on that lie beneath the transposed muscle. This axial cir-
its long vascular pedicle and utilized as an island flap. culation in turn has branches (perforators) that supply
Reports state that this can be combined with bone the muscle. Either directly from the axial vessel (myocu-
from the spine of the scapula. Bulk may be a problem taneous) or from the perforators (direct cutaneous) are
if it is used to reconstruct cervical esophagus. cutaneous vessels that supply the skin.
Depicted (after Ariyan, 1979; Harii, 1983) are varia-
Free Flaps with Microvascular Anastomosis tions of the myocutaneous flap that involve flat muscles
(e.g., the pectoralis major, trapezius, and latissimus
1. These flaps require additional time. dorsi muscles).
2. They are not for the surgeon who performs the The pectoralis major muscle without skin can be
isolated reconstruction; the operation is relegated to used for reconstruction of the pharynx. The fascia of
larger services with two teams. the flap is sutured to the esophagus and the pharynx.
3. Skin and adipose tissue should be 10% to 15% larger This is ideal for reconstruction after partial resections
than is needed. of the base of the tongue.
GENERAL PURPOSE FLAPS
RANDOM PORTION
PERFORATOR
. CUTANEOUS-DIRECT
SEGMENTAL
A B
c
FIGURE 8-1
A In the intact myocutaneous flap, for example, the B This is the so-called paddle myocutaneous flap in
pectoralis major flap, the axial vessels (the pectoral which the arteriovenous circulation along with the
branch and at times the lateral thoracic) are seen overlying muscle is transposed. The intervening skin
arising from the thoracoacromial artery giving off the between the base of the flap and the paddle is not
perforating muscular branches, and these in turn give utilized. The advantage of this flap is that the axial vessels
off the two types of cutaneous vessels, the myocuta- and the muscle can then be buried under skin. Numerous
neous and direct cutaneous. The axial portion of the examples are shown in the following figures.
flap is with the pectoralis major muscle and axial vessel.
The portion of the skin beyond the extent of the C This modification, in which the muscle is tran-
muscle and the axial vessel is the random portion of sected, is primarily used to achieve additional length
the flap. This random portion without the axial vessel and can be more easily rotated. The danger is in the
depends on its viability from small vessels in the dermal- interruption of the vascular pedicle, especially the veins.
subdermal plexus. Not shown are the accompanying Additional length can be achieved with a pectoralis
veins, which are as important as the arteries. major myocutaneous flap by resection of the clavicle
This type of flap is utilized when the entire portion (see Fig. 8-2H). Another application is the use of these
of the overlying skin is required to cover the defect as flaps as free flaps with microvascular anastomosis. This
well as forming a tube flap pedicle (see Fig. 8-2 0). variation has many drawbacks and is usually not
utilized with the pectoralis major myocutaneous flap.
GENERALPUR~SEFLAPS
PECTORALIS
MAJOR M.
SERRATUS ANTERIOR MJ
RECTUS FASCIA
LATISSIMUS DORSI M.
EXTERNAL OBLIQUE M.
A
FIGURE 8-2
Pectoralis Major Myocutaneous with the deep fascia of the pectoralis major muscle, and
Flap (Continued) (Fig. 8-2) runs inferiorly along the oblique fibers of that muscle
to about the fifth or sixth rib. This axial artery is thus
(After Ariyan, 1979)
medial to the nipple. However, in two overweight female
patients with pendulous breasts, this vessel could not
B Depicted are the dotted lines that indicate graphi- be identified in this location. In one patient in whom
cally the general course of the pectoral branch of the the distal one third to one half of the flap failed, there
thoracoacromial artery, which is the main axial artery was a major vessel more lateral. On venous digital
of the pectoralis major myocutaneous flap. This subtraction angiography performed postoperatively on
pectoral branch may be displaced laterally on females the contralateral side, no pectoral branch as such could
with large pendulous breasts. be identified. The more lateral vessel appeared to be
The initial dotted line runs from the shoulder tip to the lateral thoracic artery. In any event, in overweight
the xiphoid process. The second line runs from the females with pendulous breasts, it appears worthwhile
midportion of the clavicle at a right angle to the first to identify the blood supply to the pectoralis major
line. muscle with preoperative digital subtraction angiog-
Continued raphy. It is possible that the pendulous breasts are a
factor in displacing the entire pectoralis major muscle
laterally. An intraoperative aid may be the first
The thoracoacromial artery is a short trunk arising perforator of the pectoral artery, as described by Kaplan
from either the first or second part of the axillary artery and Harwick (1983).
several centimeters below the clavicle. The thora- The thoracoacromial artery usually has four branches
coacromial artery pierces the coracoclavicular fascia, (pectoral-the largest, acromial, clavicular, and deltoid),
which runs from the subclavius muscle to the pectoralis although there may be a fifth branch, the lateral thoracic.
minor muscle. The axillary artery (Anson and McVay, DeGares, in Gray's Anatomy, states that the lateral tho-
1971), which is a continuation of the subclavian artery, racic artery arises directly from the axillary artery (as
extends from the outer margin of the first rib to the depicted) in 30% of patients, whereas in 60% of patients
lower border of the teres major muscle, where it becomes it arises from the thoracoacromial artery or the sub-
the brachial artery. The subclavian artery is divided scapular artery. In any event, the lateral thoracic artery
into three divisions or sections. The first division lies contributes to the blood supply of the pectoralis major
behind the clavicular pectoral fascia and the clavicular muscle as well as the pectoralis minor muscle, and this
head of the pectoralis major muscle, the second divi- author attempts to preserve this vessel whenever pos-
sion lies behind the pectoralis minor muscle, and the sible. It often lies behind the pectoralis minor muscle
third division lies partially behind the pectoralis major and may run to the lateral border of the pectoralis minor
muscle extending to the lower border of the teres major for 4 or 5 em and then reach the pectoralis major muscle.
muscle. Another more simplified description is that the In summary, the pectoralis major muscle derives its
first division is above the upper border of the pectoralis blood supply in order of importance from (1) the pec-
minor muscle, the second behind the pectoralis minor toral branch of the thoracoacromial artery, (2) the lateral
muscle, and the third from the lower border of that thoracic artery from the axillary artery or from the
muscle to the teres minor muscle. The thoracoacromial thoracoacromial artery, and (3) from the superior
artery thus usually arises from the first division of the thoracic artery to a lesser extent. The blood supply is
axillary artery, although some authors state that it also obtained from the pectoral branches and perfo-
arises from the second division beneath the medial edge rators of the internal mammary artery. These vessels
of the pectoralis minor muscle. Regardless, numerous are of course always sacrificed in the mobilization of
variations of the branches of the axillary artery occur. this flap. The reader is referred to the excellent anatomic
The pectoral branch of the thoracoacromial artery injection studies of Freeman and colleagues (1981).
lies between the pectoralis major and the pectoralis These authors also review the historical background of
minor muscles, is enveloped in fascia that is contiguous this flap.
GENERAL PURPOSE FLAPS 407
l
ACROMIAL A.
DELTOID A.
THORACOACROMIAL A.
, SUPERIOR THORAC1IC A.
AXILLARY A.
'1
PECTORAL BRANCH I'
(THORACOACROMIAL A.) t
I f41.1
!
LATERAL THORACIC A.
1
I
I
}
/
(
,
LATERAL THORACIC
;;A,
A.
PECTORALIS MAJOR M.
PECTORALIS MINOR M.
D
FIGURE 8-2 Continued
GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous this incision and courses along the lateral border of the
Flap (Continued) (Fig. 8-2) pectoralis minor muscle, supplying both the pectoralis
major muscle and the pectoralis minor muscle. It anas-
(After Ariyan, 1979)
tomoses with the pectoral branch of the thoracoacro-
mial artery. If the lateral thoracic artery is not to be
E Further mobilization of the flap is shown. Its preserved, the muscle is transected somewhat more
attachments to the rectus fascia and the costochondral medially closer to the pectoral artery. Another deciding
cartilages have been transected. Perforating vessels as factor is the amount of muscle bulk that is desired, for
well as the pectoral vessels from the internal mammary example, if the tissue mass resulting from a radical
artery are ligated. Smaller vessels are cauterized. The neck dissection is to be matched, the width of the pec-
reflected flap demonstrates the pectoral artery and vein. toralis major muscle should be somewhat wider than
Somewhat laterally are the lateral and medial pectoral the sternocleidomastoid muscle that has been resected.
nerves. The medial nerve is lateral, and the lateral nerve If a double paddle-side by side-is to be used, preserva-
is medial. The superior portion of the lateral skin incision tion of the lateral thoracic artery is virtually necessary,
is optional. This incision can be turned medially and with the lateral paddle supplied by the lateral thoracic
reach the clavicle or the muscle flap brought under the artery and the medial paddle by the pectoral artery (see
skin through a wide open tunnel. An alternate method Fig. 8-3D).
is to elevate the distal end of the deltopectoral flap, if
such a flap is to be used concomitantly or later on.
F The flap is mobilized farther and brought under a
skin tunnel to pass over the clavicle. An alternate method
The horizontal fibers of the pectoralis major muscle, is to transect the skin along the dotted line or to
those that are attached to the humerus and that form develop a deltopectoral flap. The lateral thoracic artery
the anterior fold of the axilla, are transected somewhat has been preserved in this stem, showing transection
laterally to preserve the lateral thoracic artery, if deemed of the lateral fibers of the pectoralis minor muscle.
necessary. Care is taken not to injure the contents of Continued
the axilla. The lateral thoracic artery is thus medial to
GENERAL PURPOSE FLAPS
(
\ CLAVICLE
, \
PECTORALIS MAJG{R
HORIZONTAL FIBERS OF
THE PECTORALIS MAJOR
TO THE HUMERUS
E
PECTORAL SR.
LATERAL THORACIC A.
ESOPHAGUS
DERMAL GRAFT
THYROCERVICAL
TRUNK
VERTEBRAL A.
COMMON CAROTID A.
SUBCLAVIAN A.
INTERNAL THORACIC A.
THORACOACROMIAL A.
FIRST RIB
Pectoralis Major Myocutaneous • Hematomas and seromas at the donor site (Biller et
Flap (Continued) (Fig. 8-2) al., 1981).
(After Ariyan, 1979) • Hair-bearing portion may be a nuisance; it is best to
inform the patient regarding this possibility before
Complications the surgery .
• Necrosis of flap (especially tubed)-it is best to
• Loss of flap-usually only the distal portion. This immediately excise the necrotic portion and reap-
has been encountered in only two situations: in the proximate if at all possible, because necrosis tends
overweight female with pendulous breasts and when to spread.
side-by-side paddles were used without preservation
of the lateral thoracic artery. Even with loss, the skin
paddle serves as a dressing, permitting underlying N Depicted is a recurrence of oral carcinoma pre-
granulation tissue to develop. This has sufficiently viously treated by surgery and radiotherapy. Afistula is
protected the carotid vessels to avoid blowout. If present. The patient was then treated with chemotherapy
there is a suspicion of flap loss at the time of surgery, followed by wide surgical excision and resection of the
a possible precautionary measure would be to cover mandible.
the carotid vessels initially with a levator scapulae
muscle flap (see Fig. 22-36) and place this under the o The resected area was reconstructed with a tubed
pectoralis major flap. Total loss of the flap occurred pectoralis major myocutaneous flap. Ifthe tube cannot
in one patient because the lateral thoracic artery was be completely encircled with chest wall skin from the
not preserved. Fluorescein injected into the deep flap, a temporary split-thickness skin graft is used to
vasculature and visualized under ultraviolet light cover the bare area as a temporary dressing. This also
might have prevented this complication. avoids any compression of the axial vessels. Because
• Infection-to avoid a serious calamity when a fistula the patient had had a previous radical neck dissection,
develops, adequate cervical and chest wounds must the flap was necessarily external to the skin of the neck.
be appropriately drained (Hodgkinson, 1982). A portion of the internal and common carotid arteries
• Large flaps-any type tends to obscure early was exposed, and these arteries were adequately
recurrent disease. covered. by the muscular portion of the pectoralis
• Possible limited use of ipsilateral upper extremity, major flap. A double-type paddle flap (see Fig. 8-3B)
especially when combined with a classical radical was used to close the defect; the distal paddle for the
neck dissection when the lIth nerve requires inner mucosal lining and the proximal paddle for the
sacrifice (Schuller, 1980) skin coverage. Because the recipient area was heavily
• Bulk of flap possibly not desirable in some instances irradiated, the tubed pedicle was transected in stages:
• Fistula formation-if this is anticipated because of the first stage in 10 weeks, the second stage in another
difficulty and/or tension on suture lines, a suction month. Ariyan has reported transection of these
catheter is inserted into the reconstructed gullet for pedicles in 2 weeks.
decompression purposes. This catheter is brought
out via the cervical incision.
GENERAL PURPOSE FLAPS
FIGURE8-2 Continued
GENERAL PURPOSE FLAPS
PECTORALIS
MAJOR M.
RECTUS
FASCIA
LATISSIMUS DORSI M.
EXTERNAL OBLIQUE M.
FIGURE 8-3
GENERAL PURPOSE FLAPS
PECTORALIS
MAJOR M.
RECTUS
LATISSIMUS DORSI M.
,j FASCIA
EXTERNAL OBLIQUE M.
PECTORALIS
MAJOR M.
RECTUS
LATISSIMUS DORSI M. j FASCIA
1
EXTERNAL OBLIQUE M.
c
FIGURE 8-3 Continued
GENERAL PURPOSE FLAPS
(
PECTORALIS
MAJOR M.
,
~
RECTUS
LATISSIMUS DORSI M. I FASCIA
i
EXTERNAL OBLIQUE M.
PECTORALIS
MAJOR M.
RECTUS
LATISSIMUS DORSI M. FASCIA
EXTERNAL OBLIQUE M.
E
4
PECTORALIS
MAJOR M.
RECTUS
LATISSIMUS DORSI M. / FASCIA
EXTERNAL OBLIQUE M.
F
FIGURE 8-3 Continued
GENERAL PURPOSE FLAPS
PECTORALIS
MAJOR M.
RECTUS
LATISSIMUS DORSI M. FASCIA
EXTERNAL OBLIQUE M.
G
FIGURE8-3 Continued
GENERAL PURPOSE FLAPS
Deltopectoral Flap (Fig. 8-4) 2. Exercise caution when elevating flap at base to avoid
(After Bakamjian, 1965) injuring the perforator vessels. The flap includes the
fascia of the pectoral muscles, excluding the thin
Although there are now a large number of various flaps musculature investing fascia.
for reconstruction after major tissue loss in head and 3. Meticulous care should be taken in the handling of
neck surgery, the deltopectoral flap (Bakamjian, 1965) the flap.
still has a useful place in our armamentarium. It is a 4. Provide postoperative care to avoid kinking or
full-thickness (including the fascia of the pectoral mus- compression of the flap by dressing, drains, tubes, or
cles) anterior chest wall skin flap medially based, with tape of the tracheostomy tube.
its blood supply from the first through the fourth perfo- S. If the flap is to be passed beneath cervical flaps, the
rator vessels and branches of the internal mammary lower cervical incision must be horizontal and is
artery. usually the same incision as the superior incision of
the flap.
Characteristics and Advantages 6. Delay flap, if:
a. Tissue turgor is poor.
1. It is usually not delayed. b. Systemic disease is present (e.g., severe arterio-
2. It can be unilateral or bilateral. sclerosis, diabetes, or severe malnutrition).
3. The bilateral procedure can be simultaneous. c. Excessive length-however, Bakamjian does not
4. Usual length of the flap reaches the tip of shoulder necessarily use this as a reason for delay.
but it can be extended behind the shoulder or d. Scatter radiation over donor site.
inferior to the deltoid prominence or superior to 7. Usually incise distal esophagus in vertical plane for
the spine of the scapula. 1 to 2 em to enlarge the esophageal opening when
5. The deltoid portion is usually not hair bearing. the flap is used to reconstruct the esophagus.
6. The flap is usually outside radiotherapy fields; 8. Do not drape flap over the hardware that is used to
however, it may be in the field of scatter radiation stabilize the ends of resected mandible.
unless the donor site is lowered below the clavicles. 9. If there is a significant and objectionable dead space
7. Blood supply is excellent with dependent venous above the clavicle, resect the medial one third of
drainage. clavicle to coapt flap to underlying soft tissue and
8. The donor site is hidden, thus cosmetically vessels.
acceptable.
9. Flap can be rotated deep or superficial to cervical Types of Delay
flaps, depending on purpose.
10. Flap can be split longitudinally and distally and de- 1. Complete skin incision without elevation (preserves
epithelialized proximally (Krizek and Robson, thoracoacromial vessels).
1973). 2. Complete skin incision with elevation and return
(transects thoracoacromial vessels).
Disadvantages 3. Partial skin incision:
a. Leave small area along the axillary area for
This flap requires a second stage to close an orocuta- dependent venous drainage.
neous fistula unless an epithelial shave is performed. b. Leave small area along superior margin near
An epithelial shave is the removal of the epithelium of thoracoacromial vessels.
the flap where it comes in contact with the overlying
cervical flap. The failure rate is 9 % to 18 %. If the flap Reconstruction of Oropharynx,
is used to cover the carotid vessels, blowout of the Hypopharynx, and Portion of Cervical
carotid artery is a hazard if the flap fails. Esophagus
A
INT. MAMMARY AND PERFORATOR
ARTERIES
/
FIGURE 8-4
GENERAL PURPOSE FlAPS
BASE OF TONGUE
EDGE OF PHARYNX
FIGURE8--4 Continued
GENERAL PURPOSE FlAPS
\
\
ESOPHAGU
FIGURE8-4 Continued
GENERAl PURPOSE FlAPS
TUBED FLAP
FIGURE 8-5
GENERAL PURPOSE FLAPS
FIGURE 8-6
GENERAL PURPOSE FLAPS
(
/
FIGURE 8-7
GENERAL PURPOSE FLAPS
\
F
\
FIGURE 8-8
GENERAL PURPOSE FLAPS
A
\ WabnTIt
\
FIGURE 8-9
GENERAL PURPOSE FLAPS
Forehead Flap (Temporal Flap) or just below the arch. The superficial temporal artery
(Fig. 8-10) (After McGregor, 1963) must not be injured.
5. The tunnel may be superficial or deep to the zygo-
General Data matic arch. If deep, fracture the arch outward to avoid
pinching of the base of the flap between the arch
The forehead flap, a myocutaneous flap, and its modifi- and the temporalis muscle or resect the coronoid
cations can be used for a large number of reconstruc- process of the mandible.
tion procedures: cheek (inside and outside), floor of 6. When teeth are present, the flap can be pinched as
the mouth, nose, upper eyelid, chin covering for recon- it crosses the occlusion line.
structed mandible, portion of tongue, and alveolar 7. Another serious point of jeopardy is the crossing of
region. More often than not it can be nondelayed if both the flap over a Kirschner wire if there is undue
the superficial and temporal and posterior auricular tension or angulation.
arteries are included in its base and not extended beyond 8. The base or pedicle can be returned in 3 to 4 weeks
the midline. It is best to delay the flap if it extends but should be limited to only hair-bearing areas.
beyond the midline of the forehead, especially if a radical
neck dissection is performed (Cramer and Cult, 1969).
The flap may be in jeopardy if a radical neck dissection A, A 1 The forehead flap is outlined. Note that the
has been performed in which the feeding vessels of the contour follows the eyebrows and the forehead hair-
external carotid artery have been sacrificed, although line. This is more pleasing cosmetically. The lower
some surgeons report no difference at all (McGregor, incision of the flap must not extend beyond the level
1963). Another problem is the cosmetic deformity. In of the lateral canthus to avoid injury to the facial nerve.
younger patients, it is much less desirable, especially in The incisions are beveled to minimize the cosmetic
reconstruction procedures for tissue loss after trauma. deformity along the remaining edges of the forehead
Other flaps from the neck or pectoral region are much and scalp.
preferred. When using the forehead flap, less deformity The dotted horizontal line depicts the incision
is usually noted if the entire forehead is utilized. Follow through which the flap enters the oral cavity. A lower
the hairline. There may be a problem in males with point of entrance can also be utilized. If so, do not
subsequent receding hairlines. A split-thickness skin injure the facial nerve or the parotid duct system.
graft taken from the anterior chest wall if practical is best
for covering the donor site of the forehead. Numerous B A tunnel is formed through an incision just below
variations of forehead flaps are depicted in the follow- the zygomatic arch. This can be performed with
ing figures. Other varieties are in Figures 6-28, 6-29, Metzenbaum scissors or a large Kelly clamp. Effort
8-llA to G, 8-12, 14-10, and 15-10. Remember not to must be made to avoid injury to the facial nerve and
cause more deformity than what is being reconstructed. parotid salivarygland. The donor site and bare exposed
For example, use of a forehead flap to reconstruct a area of flap are covered with split-thickness skin. Skin
palate is hardly justified when a prosthesis will serve from the anterior chest wall, if not hairy, is a good
the purpose. cosmetic cover. The dotted line indicates the intraoral
position of the flap. Tailor the intraoral portion to
Highpoints avoid excess length and bulk.
1. The flap is usually not delayed if the posterior C The distal end of the flap is brought into the
auricular artery and the superficial temporal artery intraoral defect and sutured in place with 3-0 or 4-0
are included in the base and the flap does not extend nylon. It can be used to cover cheek, alveolar region,
beyond the midline of the forehead; otherwise, delay floor of mouth, tongue, and a somewhat posterior to
the flap, especially with radical neck dissection. tonsil region if it is wide enough. The flap is not
2. A full-thickness flap is taken down to periosteum of sutured to the tongue if only the buccal wall is
skull (pericranium) including the frontalis muscle. reconstructed. Suturing it to the tongue would tether
3. Use only a non-hair-bearing portion of the forehead the tongue and create a problem in mastication and
for intraoral reconstruction. The base does include swallowing. On the other hand, it may be necessary to
hair at the temporal region, but this is later returned. approximate the tongue to the flap if the tongue is the
4. Some surgeons bring the flap through the cheek, via only soft tissue available medially. The arrow delineates
a separate incision well below the zygomatic arch. the tunnel and a temporary fistula. The pedicle is
Care must be taken not to injure the facial nerve or sectioned along to the dotted line in 3 to 4 weeks, and
the ducts of the parotid salivary gland. Others prefer the base of the flap is withdrawn from the tunnel and
to tunnel the flap through an incision either just above returned to the forehead or discarded.
GENERAL PURPOSE FLAPS
SUPERIOR TEMPORAL A.
\ ,
\
/
c
FIGURE 8-10
The free vascularized flap would be the first choice there is pressure on the flap.) This method of intro-
for buccal wall reconstruction if the defect involves the duction is preferred by the author. The section of
skin. Jejunum (free graft vascularized) is a method to zygomatic arch is left attached to the overlying fascia
replace the mucosa and underlying soft tissue because and realigned after the base of the flap is returned.
it provides moist mucosa and may prevent scar con-
tracture. An alternate is dermal graft for inner lining.
Complications
D An alternate tunnel is deep to the zygomatic arch,
• Hemorrhage
which is fractured along the dotted line. (The coronoid
• Necrosis, especially at pressure points
process of the mandible may be likewise fractured if
• Facial nerve injury
GENERAL PURPOSE FLAPS
FIGURE 8-11
GENERAL PURPOSE FLAPS
H After 4 to 6 months, the pedicle of the flap is J The skin on the side of the face under which the
denuded of skin and buried. In this fashion the vascular pedicle will be buried is now elevated with
superficial temporal vesselsare preserved, and viability upper and lower skin flaps.
of the flap is ensured. This is safer than transecting the Continued
pedicle, because the only other source of blood supply
is at the margin of the flap. These margins have a very
poor blood supply because of previous irradiation. The
outside layer of skin is elevated by sharp dissection
from the pedicle. It is preserved at both ends and
retracted with stay sutures.
GENERAL PURPOSE FLAPS ~9
"'-- l" ,
j
I
j,'
FIGURE 8-12
GENERAL PURPOSE FLAPS
TRANSPOSED FLAP
A c
B D
FIGURE 8-13
GENERAL PURPOSE FLAPS
BIBLIOGRAPHY
Coleman CC Jr: Local flaps for reconstructions after head and neck
Acharya G, Johnson ML: Use of pectoralis major myocutaneous flap tumor surgery. Plast Reconstr Surg 42:225-231, 1968.
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Adams WM: The use of neighboring tissues in the correction of an Foundation.
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Andrews EB: Island naps in faciai reconstruction. Piast Reconstr Surg the pharynx and cervical esophagus following radical resection.
44:49-51, 1969. West J Surg 63:344, 1955.
Anson BJ, McVay CB: Surgical Anatomy, 5th ed, voi 2. Philadelphia, Conley JJ: The use of regional flaps in head and neck surgery. Ann
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Ariyan S: The pectoralis major myocutaneous nap. Plast Recoostr Conley JJ: One stage radical resection of cervical esophagus, larynx,
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Ariyan S: Further experiences with the pectoralis major myocutaneous Otolaryngol 58:546, 1963.
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Ariyan S, Cuono CB: Myocutaneous flaps for head and neck recon- Conley JJ, Parke RB: Pectoralis myocutaneous flap for chin augmen-
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Ariyan S, Cuono CB: Use of the pectoralis major myocutaneous flap Conway H, Stark RB, Joslin D: Cutaneous histamine reaction as a test
for the reconstruction of large cervical, facial or cranial defects. of circulatory efficiency of tubed pedicles and flaps. Surg Gynecol
Am J Surg 140:J03-JOG, 1960, Obslet 93:l85 1951.
J
Arufe HN, Cabrera VA, Sica IE: Use of the epaulette flap to relieve Corso PF, Gerold FP, Frazell EL: The rapid closure of large salivary
burn contractures of the neck. Plast Reconstr Surg 61:707-714, fistulas by an accelerated shoulder nap technic. Am J Surg 106:
1978. 691,1963.
Badran HA, et al: The laterai intercostal neurovascular free flap. Plast Cramer LM, Culf NK: Symposium on Cancer of Head and Neck.
Reconstr Surg 73:t7-25, 1984. St. Louis, CV Mosby, 1969.
Baek S, Bitler HF, Krespi YP, Lawson W: The lower trapezius island Davis GN, Hoopes JE: A new technique of delivery of the total fore-
myocutaneous flap. Ann Plast Surg 5:108-114,1980. head flap for intraoral reconstruction. Presented at the Society of
Baek S, Lawson W, Biller HF: Reconstruction of hypopharynx and Head and Neck Surgeons meeting, Aprtl1970.
cervical esophagus with pectoralis major island myocutaneous Dennis D, Kashima H: Introduction of the Janus flap. Arch Otolaryngol
nap. Ann Plast Surg 7:18-24, 1981. 107:431-435, 1981.
Baek S, Lawson W, Bilier HF: An analysis of 133 pectoraiis maior Dingman RO, Grabb WC, O'Neal RM, Ponitz RJ: Sternocleidomastoid
myocutaneous naps. Plast Reconstr Surg 69:460-467,1982. muscle transplant to masseter area. Plast Reconstr Surg 43:5-12,
Bakamjian VY: A two-stage method for pharyngoesophageal recon- 1969.
struction with a primary pectoral skin flap. Plast Reconstr Surg Dufourmentel C: La fermeture des pertes de substance cutanee limitees.
36:173-184,1965. Ann Chir Plast (Paris) 7:60-66, 1962.
Bakamjian VY: Totai reconstruction of pharynx with medially based Dufourmentel C: Traitement chirurgical des naevi pigmentaires benins.
deltopectoral skin flap. NY J Med 68:2771-2778,1968. Ann Chir Plast (Paris) 7:105-114, 1962.
Bakamjian VY, Culf NK, Bales Hw: Versatility of the deltopectoral Dufourmentel C, Talatt SM: The kite flap. In International Congress
flap in reconstructions following head and neck cancer surgery. of Plastic and Reconstructive Surgery, 5th ed. Melbourne,
Excerpta Medica International Congress, Series No. 174, Transac- Butterworth, 1971, pp 1223-1226.
tions of the Fourth International Congress of Plastic and Recon- Edgerton MT Jr: Reconstruction of hypopharynx and the cervical
structive Surgery, Rome, October 1967. esophagus after removal of cancer. In Proceedings of the Fourth
Baker DC, Shaw WW, Conley 1: Microvascular free dermis-fat flaps National Cancer Conference, 1960, p 685.
for reconstruction after ablative head and neck surgery. Arch Edgerton MT Jr, Snyder GB: Combined intracranial-extracranial
Otolaryngol 106:449-453, 1980. approach and use of the two-stage split flap technic for recon-
Bartlett SP, May JW, Yaremchuk MJ: The latissimus dorsi muscle: A struction with craniofacial malignancies. Am J Surg 110:595-602,
fresh cadaver study of the primary neurovascular pedicle. Plast 1965.
Reconstr Surg 67:631-635, 1981. Esser JFS: Studies in plastic surgery of the face. Ann Surg 65:297, 1917.
Barton FE, Spicer T, Byrd S: Head and neck reconstruction with the Esser JFS: Cheek rotation. Rev Chir Plast 3:298-300, 1934.
latissimus dorsi myocutaneous flap: Anatomic observations and Farr HW, Jean-Gilles B, Die A: Cervical island skin nap repair of oral
report of 60 cases. Plast Reconstr Surg 71:199-204,1983. and pharyngeal defects in the composite operation for cancer.
Bell MS, Barron PT: The rib-pectoralis maior osteomyocutaneous Am J Surg 118:759-763, 1969.
nap. Ann Plast Surg 6:347-355, 1981. Farrior RT: Cancer of the head and neck: Primary and reconstructive
Bertotti JA: Trapezius-musculocutaneous island flap in the repair of surgery. Arch Otolaryngol 71:891-905, 1960.
major head and neck cancer. Plast Reconstr Surg 65:16-21, 1980. Farrior RT: Rehabilitation by skin grafting. Arch Otolaryngol 83:120-
Biller HF, Baek S, Lawson W, et a1: Pectoralis major myocutaneous 134,1966.
island nap in head and neck surgery. Arch Otolaryngol 107:23-26, Finseth F: Commentary on the differing effects of isoxsuprine on
1981. muscle flap and skin nap survival in the pig. Plas! Reconstr Surg
Bowers DC: Double cross lip flaps for lower lip reconstruction. Plast 64:819, 1979.
Reconstr Surg 47:209, 1971. Freeman JL, Walker EP, Wilson JSP, Shaw HJ: The vascular anatomy
Bray DA: Clinical applications of the rhomboid flap. Arch Otolaryngol of the pectoralis major myocutaneous nap. Br J Plast Surg 34:3-10,
109:37-42, 1983. 1981.
Briant TOR, Gilbert RW: Refinement of the pectoralis major myocu- Furnas OW, Conway H: Correction of major facial defects by pedicle
taneous flap. J Otolaryngol13:387-390, 1984. naps. Plast Reconstr Surg 31:407, 1963.
Chretien PB, Ketcham AS, Hoye RC, Gertner HR: Extended shoulder Furnas DW, Furnas H: Absence of the lower part of the latissimus
flap and its use in reconstruction of the defects of the head and dorsi muscle: An important anatomical variation. Ann Plast Surg
neck. Am J Surg 118:752-755, 1969. 10:70-71, 1983.
GENERAL PURPOSE FLAPS
Gaisford JC: Reconstruction of head and neck deformities. Surg Clin Magee WP, McCraw JB, Horton CE, Mcinnis WO: Pectoralis "paddle"
North Am 47:295-322,1967. myocutaneous flaps. Am J Surg 140:507-513, 1980.
Goodwin WJ, Rosenberg GJ: Venous drainage of the lateral trapezium Maisel RH. Liston SL: Combined pectoralis major myocutaneous flap
musculocutaneous island flap. Arch Otolaryngol 108:411-413, with medially based deltopectoral flap for closure of large pharyn-
1982. gocutaneous fistulas. Ann Otol Rhinol Laryngol 91:98-100, 1982.
Guillamondegui OM, Larson DL: The lateral trapezius musculocuta- Mathes SJ, Nahai F: Classification of the vascular anatomy of muscles:
neous flap: Its use in head and neck reconstruction. Plast Reconstr Experimental and clinical correlation. Plast Reconstr Surg 67:
Surg 67: 143-150, 1981. 177-187,1981.
Guillane PJ: Muscle flaps in the head and neck. J Otolaryngol 8: Maves M, Phillippen LP: Surgical anatomy of the scapular spine in
132-137,1979. the trapezius-osteomuscular flap. Arch Otolaryngol 112:173-175,
Haar J: Personal communication, 1970. 1986.
Hancock OM: The repair of facial defects resulting from surgery for McGraw lB, Furlow LT:The dorsalis pedis arterialized flap: A clinical
locally advanced buccal carcinoma. Plast Reconstr Surg 20: 117, study. Plast Reconstr Surg 55:177-185,1975.
1957. McGraw lB, Magee WP, Kalwaic H: Uses of the trapezius and ster-
Harii K: Myocutaneous flaps: Clinical application and refinements. nomastoid myocutaneous flaps in head and neck reconstruction.
Richardson CS, Hanna DC, Caisford JC: Midline forehead flap nasal Terz JJ, Lawrence W Jr: Primary reconstruction of oropharyngeal sur-
reconstructions in patients with low browlines. Plast Reconstr gical defects with a forehead flap. Surg Gynecol Obstet 129:533-537,
Surg 49:130-133,1972. 1969.
Schechter GL, Biller HF, Ogura JH: Revascularized skin flaps: A new Thomas CV: Thin flaps. Plast Reconstr Surg 65:747-752, 1980.
concept in transfer of skin flaps. Laryngoscope 79:1647-1665, Tiwari RM, Gorter J, Snow GB: Experiences with the deltopectoral
1969. flap in reconstructive surgery of the head and neck. Head Neck
Schrudde J, Petrovici V: The use of slide-swing plasty in closing skin Surg 3:379-383, 1981.
defects: A clinical study based on 1,308 cases. Plast Reconstr Surg Tobin GR, Moberg AW, DuBou RH, et al: The split latissimus dorsi
67:467-481, 1981. myocutaneous flap. Ann Plast Surg 7:272-280, 1981.
Schuller DE: Limitations of the pectoralis major myocutaneous flap Tobin GR, Schusterman M, Peterson GH, et al: The intramuscular
in head and neck cancer reconstruction. Arch Otolaryngol neurovascular anatomy of the latissimus dorsi muscle: The basis
106:709-714, 1980. for splitting the flap. Plast Reconstr Surg 67:637-641, 1981.
Schuller DE: Latissimus dorsi myocutaneous flap for massive facial Tolhurst DE, Haesecker B, Zeeman RJ: The development of the
defects. Arch OtolaryngolI08:414-417, 1982. fasciocutaneous flap and its clinical applications. Plast Reconstr
Shapiro MJ: Use of trapezius myocutaneous flaps in the reconstruc- Surg 71:597-605, 1983.
tion of head and neck defects. Arch Otolaryngol 107:333-336, Von Deilen AW: Methods of immediate repair after major resections
1981. of the face and jaws. Plast Reconstr Surg 11:152, 1952.
Sharzer LA, et al: The parasternal paddle: A modification of the pec- Washio H: Retroauricular-temporal flap. Plast Reconstr Surg 43:
toralis major myocutaneous flap. Plast Reconstr Surg 67:7S3-762, 162-166, 1969.
1981. Watson JS, Lendrum J: One stage pharyngeal reconstruction using a
Sherlock EC, Maddox WA: The versatile deltopectoral skin flap in compound latissimus dorsi island flap. Br J Plast Surg 34:87-90,
reconstruction about the head and neck. Am J Surg 118:744-751, 1981.
1969. Wilson JS, Yiacoumettis AM, O'Neill T: Some observations on 112
Silverman DG, LaRossa DD, Barlow CH, et al: Quantification of tissue pectoralis major myocutaneous flaps. Am J Surg 147:273-279,
fluorescein delivery and prediction of flap viability with the 1984.
fiberoptic dermofluorometer. Plast Reconstr Surg 66:545-553, Wurlitzer F, Ballantyne AJ: Reconstruction of lower jaw area with a
1980. bipedicled deltopectoral flap and a Ticonium prosthesis: Case
Sisson GA, Goldstein JC: Flaps and grafts in head and neck surgery. report. Plast Reconstr Surg 49:220-223, 1972.
Arch Otolaryngol 92:599-610, 1970. Yoshimura Y, Maruyama Y, Takeuchi S: The use of lower trapezius
Smith CJ: The deltoscapular flap. Arch OtolaryngolI04:390-392, 1978. myocutaneous island flaps in head and neck reconstruction. Bf ]
Smith F: Flaps utilized in facial and cervical reconstruction. Plast Plast Surg 34:334-337, 1981.
Reconstr Surg 7:415-455,1951.
Lip Excision and Reconstruction
(Fig. 9-1) A An incision is made through the mucosa 0.3 to
0.5 em beyond the extent of the leukoplakia.
Planing of lip
B Following the vermilion border, or even including
Highpoints a small amount of skin if the leukoplakia has reached
the cutaneous margin, a flap of mucosa is separated
1. The entire exposed vermilion of either the lower or from the underlying muscle and excised.
upper lip or both may be excised for leukoplakia or
erythroplakia with immediate coverage using mucous C The remaining normal mucosa on the inner aspect
membrane advanced from the inner aspect of the of the lip is extensively undermined.
lip.
2. Obtain frozen section for any area suggestive of DUsing 5-0 nylon, the advanced mucosa is approxi-
carcinoma-toluidine blue stain may be of help. mated to the skin margin.
3. This operation may be combined with the shield
type of excision (see later) or the Abbe-Estlander E A "shield" type of incision is outlined with meth-
operation (see Fig. 9-4A to 0). ylene blue. If the lesion is malignant, 1 em of grossly
4. Specimen must be labeled "right" and "left" for normal tissue must be included on each side. The ver-
proper orientation of serial histologic study to rule milion edges on both borders are marked by a needle
out carcinoma. dipped in the dye. This aids in an accurate approxima-
tion of the vermilion edges following the excision. The
Complication excision is made through and through skin, muscle,
and mucous membrane. Grasping the lip between index
• Some flattening of the natural contour of the lip finger and thumb aids in the excision by stabilizing the
lip and controlling hemorrhage. Only after the com-
Shield Excision of lower lip plete excision are the vessels clamped and tied.
458
THE UPS
f
It
H
FIGURE 9-1
THE UPS
Elliptical Excision of Benign Lip lesion J The flap is rotated and sutured in position.
Extension of the incision is made to allow for closure of
Indication the donor site. The lateral skin margin is liberally
undermined .
• Small premalignant lesions and benign lesions
K The completed closure. Buried sutures of fine
D An elliptical skin and mucosal incision is outlined. chromic catgut or white silk are used subcutaneously.
THE UPS
A B c
J K
FIGURE 9-2
THE UPS
1. Use mucous membrane and muscle pedicle flaps. C The bipedicle flap is now rotated 90 degrees so
2. If donor site defect is large, dermal skin graft or free that the inner edge of the flap is sewn to the skin
buccal mucous membrane serves as an excellent margin of the defect, and the outer edge of the flap is
buccal inlay. sewn to the gingivobuccal margin of the defect. The
3. Flap and pedicles must be thick to preserve adequate pedicle is carefully tubed near its base and closed pos-
blood supply. teriorly so that there are no bare areas. A Barton band-
4. Barton bandage is necessary for cross oral pedicles. age is applied. The pedicles are severed after 2 weeks.
skin graft
A B
FIGURE 9-3
THE LIPS
FIGURE 9-4
THE LIPS
FIGURE9--4 Continued
THE LIPS 467
The Gillies technique is as follows: C The lower vermilion that was freed has been
rotated into the new commissure, forming a portion of
1. Excision of a small triangle of skin the upper lip. It is sutured inside and outside. The
2. Section of underlying muscle buccal layer of mucous membrane of the lower lip is
3. Advancement of mucous membrane now freed with scissors or knife.
FIGURE 9-5
THE LIPS
FIGURE 9-6
THE UPS
Modifications of Abbe-Estlander
After the usual eXCISion of the lesion, a lateral
Lip Operation (Fig. 9-7)
rectangular flap is advanced to close the center defect.
Reconstruction of Center Lower Lip
Defect D The resulting medial defect is closed with an
upper lip flap that includes the commissure. The com-
missure is preserved by following the technique in
A Rotation of upper lip flap to close a center lower Figures 9-4 and 9-5. In any event, an attempt is made
lip defect. to preserve the modiolus (hub) (modus muscularis),
which is the site at which the orbicularis oris is blended
B The commissure of the mouth is preserved. with other muscles associated with the commissure.
Operative details are in Figures 9-4 and 9-5. The modiolus is located lateral to the commissure
along the nasolabial fold. It is important in the main-
C When a crossed pedicle flap for center defects may tenance of a normal commissure (see Fig. 7-1).
not be tolerated by the patient or when general anes-
thesia is necessary, this type of transfer flap is used. E The completed closure.
During reaction from general anesthesia the patient Continued
may not be controllable, and the usual crossed pedicle
flap (A and B) is endangered.
i
i
FIGURE 9-7
THE UPS
Modifications of Abbe-Estlander
H A double Z-plasty (after May, 1949) is utilized to
Lip Operation (Continued) (Fig. 9-7) elongate and to sharpen the commissure. This is done
at least 3 to 5 weeks after the initial operation. Excision
Reconstruction of Upper lip Defect
of a small triangle of skin may be required between
flaps 4 and 2.
F Defects in the upper lip are closed with a rotation
flap from the lower lip. I Flaps 1 and 3 are rotated outward, whereas flaps 2
and 4 are rotated inward; thus, 2 and 4 are exchanged
G A new commissure is formed by the pedicle from with 1 and 3.
the rotated lower lip.
J Another method of correction for commissure
deformity is conversion of a V-type incision to a V. A Y
Correction of Rounded Commissure of
incision is made as depicted. Some skin may require
lips
excision on the lateral borders.
Indication
K Point 5 is then advanced to point 5'.
For the Gillies method see Figure 9-5A to D.
When the pedicle of a rotated lip flap forms the new
commissure, the rounded corner is correctable when
the modiolus has been sacrificed (see Fig. 9-7D).
THE LIPS
Reconstruction of Upper Lip with D Cross section depicts the position of tongue flaps.
Cheek Flap (Fig. 9-8) (After Paletta, 1954;
Bakamjian, 1971) E Close-up view of tongue flaps (1) and (2). A
diamond-shaped area of tongue muscle may be
Highpoints excised at the time of the division of the tongue flaps
to facilitate approximation of the tongue mucous
1. Wide resection of tumor is possible: this can include membrane.
a portion of the base of the columella and floor of
nose as well as full thickness of the upper lip. F, G The completed reconstruction.
2. Medial border of cheek flap follows nasolabial fold,
leaving underlying muscles intact.
3. New vermilion and mucous membrane of recon- The flap can be utilized to reconstruct the entire
structed lip are formed by tongue flap. columella. The base area near the base of the flap is
temporarily covered with split-thickness skin. This is
removed when the pedicle is transected and the base of
A Malignant tumor involves a major portion of the the flap is returned to the donor site. The bare area on
upper lip. The cheek flap is outlined, its medial border the contralateral side of the flap forming the columella
following the nasolabial fold. Resection includes all can be covered with a full-thickness or split skin graft
if necessary (see Fig. 6-230 and E).
THE UPS
A B
CHEEK FLAP
c D
FIGURE 9-8
THE LIPS
\
I
I
,
A B
c D
~,
-----
FIGURE 9-9
476 THE UPS
H
FIGURE 9-10
THE LIPS
FIGURE 9-11
THE LIPS
FIGURE 9-12
482 THE LIPS
A
,
l /'
Iv //
'/
Y
FIGURE 9-13
THE LIPS
Reconstruction of the Lower Lip By using a cooling outer and inner treatment the
(Fig. 9-14) (After Dieffenbach, 1834) upper half of the incision healed at the first connection;
the lower one, however, started to fester. Saliva and a
Although this atlas does not dwell in any detail on the part of the liquids frequently drained through this open-
historical aspects of head and neck oncologic surgery, ing. But after removal of the needles from the upper
a translation of Dieffenbach's original 1834 article part and after the lower incision was connected by firm
appears worthwhile and at least very interesting. pulling together with long strips of surgical tape, the
incision closed by itself completely within 14 days.
Reconstruction of the Lower Lip after After 3 weeks no disfigurement could be seen on the
the Extirpation of a Lip Cancer man. Because of the half-circle type of incision on the
soft parts underneath the corners of the mouth, two
First Case cones were formed, which, when united, helped the
appearance of the lower lip.
A 71-year-old man suffered for many years of a cancer After a year's time the man again came to me. On
of the lower lip, which subsequently changed into a the area of the operation another cancer had appeared.
large, growing, cauliflower-like tumor. The glands near I gave the patient Zittmann's Decoct (a kind of brand
the lower jaw and neck were healthy. An extirpation of name internal remedy) to drink for 4 weeks and then
the entire lower lip had to be made whereby the inci- operated again as in the above described manner. This
sions began at the corner of the mouth and led across time I was able to close the incision with five needles.
the chin, where they met in an acute angle. To close the The last of the needles were already removed on the
distance of the incisions it was necessary to remove the fourth day, but I still taped with long, thin surgical tape
internal organs up to the lower jaw. Then five inter- around the head and chin, as in a circle from chin to
twining stitches were done, which apparently com- head and back. After the healing process was assured I
pletely closed every point of the incisions. Some days again gave the patient the Zittmann's Decoct to drink
later the upper part of the fissure was closed and the for 4 weeks. I assume that no further problems arose
needles were removed, but the lower part festered. The because I have not heard from the man again.
appearing fissure was closed with strips of surgical
tape. In the meantime the general health of the patient Third Case
became worse. A starvation process set in with
diarrhea and the patient died in the fourth week after A strong 60-year-old woman from the country suffered
the operation. With the dissection some tubercles in for years from a cancer of the lower lip that encom-
the lungs were found, and the spleen was hardened passed most of the lip. The tumor had a cauliflower
with its upper area covered with a thick cartilaginous- type of appearance with the colors of red and white.
type skin. Especially unfavorable for the operation or success of it
seemed to be the solid (firm) connection of the tumor
Second Case with the jaw, a sure sign of deterioration (degeneration)
of the periosteum.
A 45-year-old country man of huge build suffered for By making two cuts in a wide circle around the
many years from a lip cancer, which gradually cancerous growth I gave the wound a shape on the
increased to such an extent that the largest part of the chin that ran to a point. Then I separated the cancerous
lower lip to the chin was transformed into cancerous mass from the bone and removed the loosened thickened
tissue in the size of a fist. All adjacent glands were periosteum by careful scraping. After this was done, I
healthy. After the patient was pretreated, I extirpated separated the cheeks on both sides of the lower jaw to
the cancer by two crescent-shaped incisions, which facilitate the joining of the edges of the wounds and
started at each corner of the mouth, continued at the proceeded to the joining. For that, six atraumatic sutures
outer limit of the tumor, and came together at an acute were necessary. I attached three heavy and three fine
angle under the chin; then I separated it from the gums needles, one after the other, and was pleased to see this
and the lower jaw. The periosteum was damaged in tremendous wound completely joined. Then I ordered
several places, and I therefore scraped it off. After that an inner and outer cooling treatment; healing took
I severed from the lower jaw the cheeks up to the front place so rapidly that on the second day already two of
edge of the masseter, and then put through the center the thin needles could be removed, on the third day the
of the edge of the incision a long, strong needle, around uppermost thick needle, and on the fourth day all the
which I wound thread ("atraumatic"). After a connec- others, after which I supported the young scar by two
tion was achieved at that point, the upper part of the long narrow pieces of surgical tape, which went around
fissure was completely connected by three needles, and the back of the head for several days, and I also ordered
the lower part by four needles wound with thread. poultices of lead water. Only right over the chin
THE UPS
remained for a few weeks a small festering wound that, was stopped I burned the diseased periosteum with a
however, closed completely shortly thereafter. A glowing iron. Then I again took the knife and made a
recurrence of the cancer has not taken place during the diagonal cut from each corner of the mouth an inch
last 4 years, and there is no sign of disfiguration to be into the upper lip toward the direction of the septum
seen on the patient. but not quite that far. With these incisions I formed two
flaps that were meant to form the lower lips.
Reconstruction of the Upper lip after It was to be assumed by the loss of so much sub-
an Operation of lip Cancer stance that the wound would not heal without lateral
incisions. First I placed a needle (length of a finger)
Fourth Case through the edges of the center part of the wound and
with the entwining of the needle and a pulling of the
Cancer of the lip appears chiefly on the lower lip; if it heavy thread I achieved a tension in the cheeks. But
appears on the upper lip it is usually fungus or a there was still an inch between the edges; thus I made
chancre that turned into a cancer or possibly a true a cut on both sides, two inches long, through the cheeks
cancer of the corner of the mouth stretching to include right in the center between the wound edges and the
the upper lip. It could also be cancer of the wing of the front edge of the masseter. Through each of these open-
nose that affected the upper lip. This was the case of ings I was able to place two fingers into the mouth cavity.
an 83-year-old weaver whose left side of his upper lip In this way the tensions were relieved, and I was
was affected. Through careful observation it was quickly able, with the pulling of the thread around the needle,
determined that this was not a true lip cancer but a to combine (close) the wound exactly. Then I placed a
skin cancer that began at the wing of the nose affecting row of needles (I believe about seven or eight) where-
the upper lip. Partly because of the advanced age of the upon I was able to close the huge hole.
patient and partly because of the dangerous nature of The conclusion of the operation was done whereby
the skin cancer I searched for a cure with mercuric I pulled the diagonal flaps of the upper lip downward,
chloride and then with "Hellmund's" ointment. But no combined them, and fastened their outer edges onto
cure came about and an extirpation of the affected the wound edge of the cheek skin, which now has
parts of the lip up to the nose had to be made. TWooval become a lip, with an atraumatic suture. Thus, a lower
incisions encircled the affected area, and after its lip was made through the cheek skin with the red
removal the corners of the wounds were united with substance of the upper lip.
five atraumatic sutures. As one now examined the patient one found his
Because of the age of the patient one did not expect appearance quite adequate. Only the two huge lateral
a healing process of the wound to occur and yet it openings made the patient look ugly because one could
occurred. The needles could be removed on the fifth see the mouth cavity and the tongue. If one separated
and sixth days and caused no reaction on the the jaws, one was able to look through the face as if a
surrounding areas. cannon ball had penetrated the face, because the lateral
cuts, through their tension, appeared almost round.
Fifth Case (Lower Lip) With a cool treatment followed, in a few days in most
places, a healing process of the various wounds so that
An almost 60-year-old, skinny, but otherwise strong, man in the third, fourth, and fifth days the needles could be
suffered for some years with a very large lip cancer, removed. Only on two places a festering occurred: First,
which turned all the lower lip from both corners into a densely over the chin and then a little higher where
huge carcinoma. The healthy upper lip was so unusually the corners of the red substance of the upper lip came
large that one could make two lips out of it. This together with the vertical wound. The corners them-
particular phenomenon was very welcome. selves were healing properly, though.
After the patient recuperated a little with the help of The lateral wounds, already in 8 days, have shrunk
the Zittmann cure, which took a few weeks, I operated two thirds in size, and their edges were covered with
on him. I went with the knife from the left corner of the granulation. Saliva and phlegm still flowed through
mouth along the jaw and ended 2 inches below the them. The surgical dressing was made with dry lint and
chin. The cut on the right side was the same and they over it, just as across the closed wound parts, long
joined in an acute angle. Now I started to remove the strips of surgical tape. This was done until the two
diseased mass; it was a handful of cauliflower type openings in the center of the lower jaw and the lip were
substance. The periosteum of the lower jaw was very healed. In the third week the opening on the left was
large and soft. closed, and in the fourth week the one on the right
The rest of the procedures were the following: I closed without complication. The appearance of the
loosened the cheek backward over the masseter and on man was normal; his mouth was a little small but
the bottom from the lower jaw. After the blood flow natural with the usual corners and a red lower lip.
THE LIPS
Reconstruction of the Lower Lip swollen, and no effects were noticed on the parotid
(Continued) (Fig. 9-14) (After gland and the submaxillary glands.
This last observation made the operation (one of the
Dieffenbach, 1834) most difficult) necessary. It was done in the following
ways: The patient was sat in a chair and an assistant
Reconstruction of the Lower lip from pulled his head a little toward the back. I placed the
the Cheeks after an Operation of a lip knife on the right side of the upper lip, where the cancer
Cancer with the Resection of a Part started, and cut first up into the upper lip, encircled the
of the Lower Jaw growth with a circular cut, turned outward toward the
cheek skin, then immediately went down far away
Sixth Case from the ear and chin and ended underneath the chin
in the center between the chin and the larynx. The cut
A 60-year-old man has suffered many years with a on the other side started on the left corner of the
cancer of the lower lip. This cancer covered the free mouth, did not go into the upper lip as far as the other
parts of the lower lip and did not reach the chin. On one, but went as far outward, and then went along the
both corners of the lip one-quarter inch of the red lip lower part of the lower jaw and met with the first cut
substance was still here. The operation was easily com- in an acute angle under the chin. These type of cuts
pleted. With a knife I first cut the left side of the lip, encircled the whole areas of the growth.
encircled elliptically the cancer, and enlarged the inci- Now with my left hand I grabbed the growth and
sion through the healthy lower soft areas to give the separated it from the lower jaw. The periosteum was
wound a good appearance and help with the closure. affected just as I thought. It was very thick, hard, and
On the right side I did the same thing. After the cancer fused with the growth. That there was much blood with
was scraped off the bones I loosened the soft areas such long incisions does not have to be mentioned. All
from the jaw. vessels in the areas were greatly enlarged because the
Now I proceeded with the closure. Even though a blood gushed not only from the larger arteries but also
tension built up with the entwining of the needle, the the entire parenchyma spurted with blood.
edges still combined so completely that lateral incisions As much as I was able to remove from the periosteum,
were not necessary. The tension became less after I I did. Then with tweezers I grabbed the inner edge of
inserted five additional needles. Then I cut the thread the wounds of the lips and cheek skin and cut every-
very short and the wound was cold bathed. where one-quarter inch off because the affected area of
These compresses were continued for some days the mucous membrane reached farther than that of the
and I made sure the patient was not allowed to speak. outer area of the face. Now I could find no more trace
His nourishment was taken with a quill. The success of of diseased spots in the soft areas.
this operation was excellent. After a few days the The worst part was the lower edge of the chin. It
needles were removed, whereupon I fastened tape over was curiously full of holes. It looked terrible. The upper
the chin and lip and washed it with lead water part of a human face with skin and meat and the lower
(Goulard). The appearance of the lower lip was part was a skeleton. This diseased area, the lower edge
completely normal. of the chin, I sawed off squarely across.
To unite the soft parts of the cheek skin, as done in
Seventh Case this type of operation, more skin was needed than was
available. To make the available skin more pliable I
A 44-year-old laborer was admitted to me with one of loosened it completely toward the back, not only from
the largest cancers of the lower lip I have ever seen. the lower jaw but also from the upper lip of the upper
The cancer had spread to almost all of the lower part jaw. These internal cuts reached beyond the masseter.
of the face. All of the lower lip, both sides of the upper Now I pulled the facial skin from both sides. Under-
lip, the soft areas of the chin plus the front and lower neath the chin somewhat of a unification was accom-
parts of the cheeks were affected. The growth was plished but from the chin edge to the mouth an area of
many inches and had an uneven wart type appearance. skin about three fingers wide was still missing. This
The color of this growth was various; some humps were missing skin had to be gotten from lateral incisions and
pale, others red, some smooth, others with scales. In thus decreasing the tension as well.
the areas between the humps a sticky, wet substance First of all the closure (unification) of the skin under-
was found. The growth had almost fastened itself to neath the chin was necessary. This was done com-
the teeth of the lower jaw and the gums were thus pletely with five atraumatic needles; then it became
affected with this cancer. They were no longer what tight, and the skin allowed itself only to be pulled over
one could call gums. The soft areas behind the teeth of the outermost edge of the chin. Now it was time to cut
the lower jaw were healthy. Not one single gland was the cheek skin, first on the left side the length of a
THE LIPS
finger and then on the right. The cuts started under the Almost all openings were filled with this granulation,
body of the malar bone, went slightly lower toward the and still mucus and phlegm flowed through when one
inside until the lower edge of the lower jaw, and sepa- day this granulation turned brown and changed into a
rated not only the skin but also the "buccinator" and cancer. The skin surrounding the area also turned brown
the mucous membrane of the mouth. Through these and everything looked very dim. I now applied the
openings one could place three to four fingers into the glowing iron to this growth and destroyed it. Internally
mouth cavity. I ordered the "littmann's Decoct" for the patient. His
With these lateral cuts, 2 inches away from the condition improved somewhat and the same procedure
needed closure, I was now able, with the help of strong is now being used. I will later announce the success of
mounting pins, to close this huge opening so that there this operation, because this case is very interesting and
was again only one mouth opening. The lateral cuts since it fits so well with these observations that I don't
now really gaped open. They were, so as not to expose wish to leave it out.
such great wounds to the air, gently covered with lint
and tape. Indication
After the patient was cleaned from the great amount
of blood, he was brought to bed and given the most • A one-stage procedure for the reconstruction of the
antiseptic treatment possible. On the lower part of the entire lower lip. It is obvious that a malignant neo-
face an ice pack was placed. So that the pressure was plasm of this size under most circumstances would
not too great and would not cause harm, the pack was require at least a unilateral radical neck dissection
hung on a wooden ring. This ring was above the and contralateral suprahyoid neck dissection and
patient's face fastened on both sides of the bed. probably a bilateral radical neck dissection. The neck
On the day after the operation the patient was amaz- dissection using this technique would require a second
ingly well. The soft parts were greatly swollen and red, stage because a simultaneous neck dissection would
but nothing unusual was to be noticed. The wound sacrifice the external maxillary artery and thus inter-
edges seemed to be closely glued together. Thirty fere with the major blood supply of the cheek flaps.
leeches were attached. Days afterward the swelling was Depending on blood supply, a free microvascular
lower, and today I took out the five lowest needles. flap could be an option.
Everything was closed so tightly that it was not necessary
to apply tape. The edges of the lateral openings were Highpoints
hard with growth, and the wound area was still covered
with necrosis type of tissue. We again attached leeches. 1. The entire lower lip and portion of the soft tissue of
On the eighth day of the operation the condition of the chin can be resected. The outer table of the
the patient was as follows: The general condition was mandible, if not directly involved, can be resected.
favorable, and no fever was there. The upper part of the If, on the other hand, the bone is directly involved,
face, nose, and eyelids was not swollen. Two thirds of then the entire bone must be resected and recon-
the wound (the needles were removed on the third, struction would thus require a distant transferred
fourth, and sixth days) had healed with the first closure. flap (e.g., pectoralis major myocutaneous flap; see
The upper edges of the incision were festering, and Fig. 8-2) to cover Kirschner wire stabilization of the
with narrow, long surgical tape were kept close together. mandible (see Fig. 14-5).
The lateral incisions cleaned themselves and showed 2. Preservation of both external maxillary arteries is
large granulations. The right one did not go through the done.
cheek any longer, since it had filled almost completely. 3. Extended mucosal flaps superiorly to the cheek flaps
From the left some mucus was still draining, and the are used to reconstruct the vermilion.
water that was sprayed into the mouth to clean pus and 4. A portion of the masseter muscle is used to fill in the
mucous still flowed from this wound in thick streams. defect medial to the masseter muscle.
Both bridges were still inflamed but not as bad as 5. Patency of Stensen's ducts is maintained.
before. To lessen this continuous inflammation and to 6. Outline the anterior border of the masseter muscles
reduce the festering of the center wound tepid Goulard before anesthesia by having patient contract the
extract as well as camomile tea was applied. muscles.
The condition of the patient was very favorable. His 7. Preserve a small portion of lower lip at the
strength suffered so little because of the operation that commissure.
he did not wish to remain in bed a few days after the 8. Preserve an edge of mucosa on the gingival side
operation. The upper part of the center wound, at the attached to the mandible to facilitate closure.
two lateral incisions, continued to fester strongly, and 9. Preserve facial nerve divisions and main branches
a large granulation filled the wound more each day. wherever possible.
THE UPS
FIGURE 9-14
THE LIPS
FIGURE9-14 Continued
THE LIPS
BIBLIOGRAPHY
Guerrero-Santos J: Use of a tongue flap in secondary correction of
Abbe R: A new plastic operation for the relief of deformity due to cleft lips. Plast Reconstr Surg 44:368-371, 1969.
double harelip: The classic reprint. Plast Reconstr Surg 42: Jesse RH: Extensive cancer of the lip. Arch Surg 94:509-516, 1967.
481-483, 1968. Lore JM Jr, Kaufman A, Grabau JC, Popovic DN: Surgical manage-
Ashley FL, McConnell DV,Machida R, et al: Carcinoma of the lip: A ment and epidemiology of lip cancer. Otolaryngol Clin North Am
comparison of five year results after irradiation and surgical 12:81-95,1979.
therapy. Am J Surg 110:549-551, 1965. Luce EA: Carcinoma of the lower lip. Surg Clin North Am 66:3-12,
Axhausen G: Technik und Ergebnisse der Lippenplastik. Leipzig, 1986.
Georg Thieme, 1941. McGregor IA: Reconstruction of the lower lip. Br J Plast Surg 36:
Bailey BJ: Management of carcinoma of the lip. Laryngoscope 40-47, 1983.
87:250-260,1977. Mahler D, Ben-Yakar Y, Baruchin A: Plication of the orbicularis oris
Bakamjian VY: Personal communication, 1971. muscle to repair partial paralysis of the lower lip. Ann Plast Surg
Baker SR, Krause CJ: Carcinoma of the lip. Laryngoscope 90:19-27, 8:224-226, 1982.
1980. Martin HE, MacComb WS, Blady JV: Cancer of the lip. Ann Surg
Bauer BS, Wilkes GH, Kernahan DA: Incorporation of the W-plasty in 114:226, 1941.
repair of macrostomia. Plast Reconstr Surg 70:752-756, 1982. May H: Plastic and Reconstructive Surgery, 3rd ed. Philadelphia, FA
Bernard C: Cancer de la levre inferieur opere par un procede nouveau. Davis, 1971.
Bull Soc Chir Paris 3:357, 1853. Meyer R. Failat AS: New concepts in lower lip reconstruction. Head
Bowers DG Jr: Double cross-lip flaps for lower lip reconstruction. Neck Surg 4:240-245, 1982.
Plast Reconstr Surg 47:209-214, 1971. Musgrave RH, Garrett WS Jr: Dog bite avulsions of the lip. Plast
Burget GC, Menick FJ: Aesthetic restoration of one-half the upper lip. Reconstr Surg 99:294-296, 1972.
Plast Reconstr Surg 78:583-593, 1986. Nakajima T, Yoshimura Y, Kami T: Reconstruction of the lower lip
Byers RM, Boddie A, Luna MA: Malignant salivary gland neoplasms with a fan-shaped flap based on the facial artery. Br ] Plast Surg
of the lip. Am] Surg 134:528-530, 1977. 37:52-54, 1984.
Clairmont AA: Versatile Karapandzic lip reconstruction. Arch Paletta FX: Cancer of the lip. From symposium on cancer of the head
OtolaryngolI03:631-633,1977. and neck. In Gaisford JC (ed): Total Treatment and Reconstructive
Conley]], Donovan B: New techniques for lower lip reconstruction Rehabilitation, vol II. St. Louis, CV Mosby, 1969.
in a melanoma patient. Otolaryngol Head Neck Surg 94: No.3, Paletta FX: Early and late repair of facial defects following treatment
1986. of malignancy. Plast Reconstr Surg 13:95-108, 1954.
Conley], Baker DC, Selfe RW: Paralysis of the mandibular branch of Pelly AD, Tan EP: Lower lip reconstruction. Br J Plast Surg 34:83-86,
the facial nerve. Plast Reconstr Surg 70:569-577, 1982. 1981
Dieffenbach Jf: Chirurgische Erfahrungen, Abb, 3, V4, Berlinl 15341 5aemann 0: Die Transplanlations-Methode der Herm, Prof. Dr.
pp 96-110. Burow. Dtsch Klin 20:221, 1853.
Earley M]: Peri-alar skin excision and lip advancement in the closure Su CT, Manson PN, Hoopes JE: Electrical burns of the oral
of lip defects. Br] Plast Surg 37:50-51, 1984. commissure: Treatment results and principles of reconstruction.
Ellis DAF, Miller RB: Rehabilitation of the paralyzed lower lip. Ann Plast Surg 5:251-259, 1980.
J Otolaryngol13:403-405, 1984. Van Dorpe EJ: Simultaneous repair of the upper lip and nostril floor
Estlander JA: Methode d'autop!astic de la joue au d'une levre par un after tumor excisions. Plast Reconstr Surg 60:381-383, 1977.
lambeau emprunte a I'autre levre. Rev Mem Med Chir 1:344, 1877. Villoria JMF: A new method of elongation of the corner of the mouth.
Filatoff W: Plastic a tige ronde. Westnik Oflalmol Avril-Mai, 1917. Plast Reconstr Surg 49:52-55, 1972.
Fujimori S: "Gate flap" for the total reconstruction of the lower lip. van Bruns V: Das Handbuch d. praktisch Chir. Tiibingen, Lauppsche
Br] Plast Surg 33:340-345, 1980. Buchhandlung, 1859.
Gage AA, Koepf S, Wehrle D, Emmings F: Cryotherapy for cancer of Wilson JSP, Walker EP: Reconstruction of lower lip. Head Neck Surg
the lip and oral cavity. Cancer 18:1646-1651, 1965. 4:29-44, 1981.
Gerold F: Personal communication, 1960.
Glenn MG, Goode RL: Surgical treatment of the "marginal mandibular
lip" deformity. Otolaryngol Head Neck Surg 97:462,1987.
10 CLEFT LIP AND PALATE
ROBERT J. PERRY
JOHN M. LORE, JR.
Cleft Lip (see Figs. 10-1 to 10-7) combined with a cleft palate is not performed for a
number of reasons: optimal age is different, and mor-
To understand the objectives in cleft lip repair one must bidity and mortality are increased, owing to possible
evaluate not only the deformity but also its relationship airway obstruction and blood loss.
to the normal anatomy.
Normal Anatomy (After Millard, 1968)
Types of Cleft Lip Deformities (Fig. 10-1)
Several classifications of cleft lip with or without cleft A Anterior view. The labeled structures and their
palate are popular. Generally, a cleft lip may be unilateral, relationships are the normal landmarks important in
bilateral, or median (rare) and present as a complete cleft lip repair.
cleft or in varying degrees as an incomplete cleft. Clefts
of the alveolar process and primary and/or secondary B Lateral view. An infant's upper lip is often full in its
palate may also occur. Simultaneous repair of a cleft lip lower two thirds, with a prominent "pout."
RIM
ALA
BASE
RIDGE}
PHILTRUM
NOSTRIL SILL . GROOVE
A
FIGURE 10-1
493
ClEfT LIPAND PAlATE
Unilateral Cleft lip Repair rience of the surgeon. As the child grows, the nasal tip,
(See Figs. 10-2 to 10-4) alar cartilage, and nasal septal surgery can be performed
at a later time. More than ever is the surgeon's oath of
Basic Deformities of Cleft Lip (Unilateral primum non nocere applicable. When not sure, seek
Complete) (Fig. 10-2) help.
1. Maxillary defonnity: anterior displacement with external There is considerable difference of opinion regarding
rotation of the premaxilla (the central portion of the the optimum time of operation. Although the repair
upper alveolar ridge and maxilla from which the can technically be done on the first day of life, the
upper incisors arise). earliest age that is reasonable is 10 to 14 days after
2. Lip deformity: decreased vertical height on cleft side birth, provided that the infant has started to gain
with variable tissue deficiency medially, preserved weight and has otherwise normal signs, especially the
two thirds of Cupid's bow and non-cleft-side philtral hemoglobin and hematocrit. The rule of "over 10" is a
column· and groove, and abnormal orbicularis oris good guide: over 10 weeks old, 10 Ib in weight, and 10
muscular insertion. g of hemoglobin. Three months of age is believed by
3. Nasal deformity: shortened cleft-side columella with others as the most opportune time.
attenuated and "slumped" lower lateral cartilage and Although cleft lip with or without cleft palate most
flared alar base and deviated nasal septum to the side often occurs in isolation, other anomalies may exist.
of the cleft with contralateral anterior dislocation. This incidence is 7% to 13% in isolated cleft lip and
2% to II % in cleft lip with cleft palate (Cohen, 1983).
Basic Objectives of Repair It is estimated that 1% of cleft lip with or without cleft
palate occurs as part of a syndrome (Bixler, 1981). A
1. Recognize, identify, and preserve normal landmarks complete medical history, family history, and physical
and as much tissue as possible. examination is mandatory.
2. Realign these normal landmarks into their normal
position both from the anterior aspect and the lateral Anesthesia
aspect:
a. Lengthen the lip on its deficient cleft side to the General endotracheal anesthesia is preferred with the
dimensions of the normal side. endotracheal tube brought out through the mouth across
b. Preserve the philtrum, Cupid's bow, the "pout," the midportion of the lower lip. Care must be taken that
and the mucocutaneous junction. no tension is placed on the upper lip or oral commissures.
c. Reconstruct the orbicularis oris muscular sphincter. If a local anesthetic containing epinephrine is employed
d. Correct the distortion of the alar base and columella to facilitate a drier operative field and a lighter plane
with undermining and mobilization rather than of anesthesia, one must not risk exceeding the maxi-
any cartilage incision. mum recommended dosage of epinephrine for the anes-
e. Some surgeons favor concomitant nasal tip correc- thetic agent used. Recall that a 1:100,000 dilution equals
tion using cartilage repositioning techniques 10 mg/mL.
(Salyer, 1986).
f. Widely separated maxillary elements may be Classification of Types of Repair of Unilateral
brought into optimum presurgical alignment with Cleft Lip
extraoral traction using simple taping techniques.
Techniques in cleft lip surgery have evolved slowly,
Precautions dependent on the analysis of long-term results in the
young and growing patient. Several methods of repair
In general, do not do the following: are still employed for the correction of the unilateral cleft
lip deformity, and with the exception of the straight-line
1. Damage or excise any nasal cartilage. closure, all introduce tissue from the lateral element to
2. Perform simultaneous cleft palate repair. fill a deficiency medially. The procedure of choice at
3. Excise any normal landmarks. this writing for both complete and incomplete forms is
the rotation advancement method of Millard, which
There are exceptions to these dicta depending on best preserves the natural landmarks while concealing
the procedure utilized as well as the skill and expe- the incisions within natural lines.
CLEFT LIP AND PALATE 495
COLUMELLA
~tNON-CLEFT-SIDE R ID.G.?
E~
g:::::!
CLEFT-SIDE RIDGE
I
iE GROOVE /
/ REMAXILLA
~\
C/J
~ ~
:::>co
()
{
APEX
.#
i
-JT. ELEMENT
FIGURE 10-2
CLEFTLIPANDPALATE
\
\
\
\
\
\
'\
c D
FIGURE 10-3
CLEFT LIP AND PALATE
B
FIGURE 10--4
CLEFT LIP AND PALATE 499
Complication
Through an incision in the upper gingivobuccal
• The most common iatrogenic complication is under- sulcus, the lateral element is then dissected from the
rotation of flap A. maxilla. At the same time the cleft-side alar base (flap
D) is released from its pyriform aperture attachment.
Attention is now turned to a careful dissection of the
C Flap B is now developed, again cutting on the bias orbicularis oris muscle bundles, freeing them both
to preserve as much muscle on the flap as possible. subcutaneously and submucosally so that when
The vermilion is trimmed by making an incision at a approximated across the cleft the orientation of their
right angle to the vermilion border at a point (8) at fibers will be changed from an abnormal near-vertical
which the vermilion becomes attenuated and at which direction to the normal horizontal direction. Flap B is
the resultant preserved length of the lateral element then advanced medially and sewn into the defect
when sutured to the medial element (flap A) will result created by the downward rotation of flap A, and the
in a normal balanced upper lip. The distance between lip is closed in three layers: muscle, skin, and mucosa.
this point (8) and the ipsilateral oral commissure (7) Flap 0 is then advanced medially to close the nostril
generally corresponds to the distance between the floor. A portion of this flap may be de-epithelialized
apex of Cupid's bow (2) and the oral commissure on and sewn to the base of the nasal septum anteriorly
the non-cleft side (6). The incision is carried up along with a permanent suture as a unilateral alar cinch.
the vermilion border to include the most superomedial
usable lip tissue and then curved laterally around the D The completed repair.
alar base. (The reference numbers refer to those shown
in A.)
ClEfT LIP AND PALATE
Bilateral Cleft Lip Repair (See Figs. 10-5 premaxilla may be deflected or rotated to one side
to 10-7) and may project anteriorly to a variable degree.
2. Lip deformity: variably sized prolabium containing
Results from the repair of the bilateral cleft lip are gener- no muscular elements and demonstrating no Cupid's
ally less satisfactory than those for repair of unilateral bow or philtrum and abnormal orbicularis oris mus-
cleft lip. Although bilateral cleft lips tend to demon- cular insertion in the lateral lip elements.
strate less asymmetry, the greater tissue deficiency in 3. Nasal deformity: very short columella and attenuated
the central element contributes to a more difficult and "slumped" lower lateral cartilages with flared
reconstruction. alar bases.
The approach to the bilateral cleft lip varies accord-
ing to the severity of the nasal deformity. In most com- Precautions
plete clefts and in some incomplete clefts, a staged repair
is indicated in which the prolabium is shared between In general, do not perform the following:
the severely short columella and the deficient central
lip element. One should become familiar with those 1. Excise prolabium or premaxilla.
techniques in which prolabial tissue is stored or "banked" 2. Create more asymmetry by repairing right and left
at the time of the initial lip operation, facilitating later sides in separate operations.
columellar reconstruction without reentry into a healed 3. Jeopardize prolabial blood supply with simultaneous
lip repair (Millard, 1977). The straight-line closure is lip and columella reconstruction.
presented as a popular solution to the bilateral cleft lip; 4. Use the redder prolabial vermilion in the vermilion
however, because the entire prolabium is used in the of Cupid's bow.
lip reconstruction, this method is better reserved for
those few cases with adequate columellar length. Problems
Techniques derived from unilateral cleft lip repairs
have been applied to the bilateral cleft lip and are par- 1. Projecting premaxilla. Presurgical manipulation of the
ticularly applicable to the incomplete form. The rotation- premaxilla with extraoral traction using simple taping
advancement technique (Millard, 1960, 1977) is shown techniques is performed to avoid the growth distur-
in Figure 10-7. bances often associated with a surgical premaxillary
setback. When the premaxilla is in optimal position,
Highpoints the lip closure will then facilitate additional molding
of the maxillary arch. For those rare patients refrac-
1. Restore and maintain the premaxilla in proper position tory to this conservative approach, surgical setback
in the upper dental arch. This facilitates bilateral lip is best delayed to age 6 years.
repair with minimal tension. (See problem 1, later.) 2. Small prolabium. Because the prolabium is used in the
2. Plan the lip repair with the appropriate nasal correc- staged reconstruction of both the lip and columella,
tion in mind. (See problem 2, later.) a preliminary lip adhesion may be indicated. In this
3. Recognize, identify, and preserve normal landmarks procedure, the orbicularis oris muscle bundles from
and as much tissue as possible. the lateral elements are attached to the cleft edges
4. Reconstruct the central portion of Cupid's bow with of the prolabium to expand the prolabial tissue as
vermilion from the lateral lip elements. necessary.
5. Restore the orbicularis oris muscular sphincter at the
appropriate stage. Optimal Age for Operation
Basic Deformities of Cleft Lip (Bilateral Gavage feeding techniques and improved neonatal care
Complete) (Fig. 10-5) have reduced the urgency of surgery in the bilateral
complete cleft lip and palate patient. Timing for surgery
There are three main deformities: follows the guidelines for the unilateral cleft lip repair
recommended earlier in this chapter.
1. Maxillary deformity: separation of the premaxillary
component from the lateral maxillary arches. The
CLEFT LIP AND PALATE 501
COLUMELLA
ALAR BASE
PROLABIUM
PROLABIUM
VERMILION
PREMAXILLA1
I
I
\\
" LATERAL
"ELEMENT
FIGURE 10-5
CLEFT UP AND PALATE
A Incisions along the vermilion borders are made as E The lateral flaps X and Yare trimmed and trans-
indicated by the dotted lines. Note that the flaps posed beneath the prolabium. The vermilion of the
indicated by X and Y include the mucocutaneous ridge prolabium Z is sutured to the posterior aspect of the
("white roll"). reconstructed upper lip forming an intraoral lining.
FIGURE 10-6
CLEFT LIP AND PALATE
FIGURE 10-7
CLEFT LIP AND PALATE
Cleft Palate (See Figs. 10-8 to 10-12) occlusion. In addition, hard palate closure before
age 6 years should involve minimal periosteal strip-
Clefts of the palate may occur alone or in association ping to reduce the possibility of midfacial growth
with complete unilateral or bilateral clefts of the lip. retardation.
An isolated cleft palate has an incidence of associated
anomalies as high as 13% to 50% (Cohen, 1983), and At present, narrow to moderately wide palatal clefts
as many as 8 % of cleft palates occur as part of recog- are closed at 10 to 14 months of age. For wide clefts
nized syndromes (Bixler, 1981). The need for a com- ( > 1 cm at the hard/soft palate junction), early velar
plete medical history, family history, and physical exam- (soft palate) closure with obturation of the hard palate
ination cannot be overemphasized. In many craniofacial defect until age 6 years is practiced at our center. Still
centers, this is performed by a geneticist trained in dys- larger clefts with significant tissue deficiency, such as
morphology. those found in the Pierre Robin sequence, may require
a primary pharyngeal flap to import regional tissue for
Types of Cleft Palate Deformities closure (Stark and DeHaan, 1960). For clefts with a two-
piece maxilla (associated with the unilateral cleft lip and
The incisive foramen divides prepalatal clefts (or clefts palate) or a three-piece maxilla (associated with the
of the primary palate) from palatal clefts (or clefts of bilateral cleft lip and palate), there is a growing interest
the secondary palate). Although prepalatal and palatal in presurgical orthopedic manipulation of the maxillary
clefts are embryologically distinct and occur individ- arch. This is an attempt to obtain a favorable alignment
ually in complete and incomplete forms, they frequently of the individual bony elements before palatal surgery.
are found simultaneously in the same patient.
Repair of Complete Cleft of Secondary
Reconstructive Goals Palate (After von Langenbeck, 1861)
(Fig. 10-8)
1. Closure of the oronasal fistula
2. Production of normal speech (normal nasality) Highpoints
3. Ensure normal occlusion and facial growth
4. Production of normal eustachian tube function 1. Use oral endotracheal intubation.
2. Extend head and neck with folded sheet under
Not only do the clefts vary significantly in width, but shoulders.
often there is a shortage of soft tissue and at times 3. Inject lines of incision with local anesthesia (lidocaine
inadequate muscular movement as well as a wider 1% with 1:100,000 epinephrine) for hemostasis.
than normal bony nasopharynx. 4. Use tension-free closure of nasal layer.
5. Preserve greater palatine arteries.
Optimal Age for Operation 6. Adequately mobilize lateral flaps without excessive
mucoperiosteal stripping.
The timing and choice of operation for cleft palate repair 7. Reconstruct levator veli palatini sling.
remain controversial because of difficulties in standard- 8. Carefully approximate nasal and oral layers, eliminat-
izing speech results, in assessing facia! growth over time, ing dead space, which can lead to fistula formation.
and in comparing patients with clefts who have vary-
ing degrees of tissue deficiency. Important considera- Positioning of Patient
tions influencing timing of repair are as follows:
1. Position patient for oral endotracheal intubation.
1. Speechdevelopment. From the viewpoint of the speech 2. Extend head and neck with folded towel beneath
pathologist, the palate should be closed early (I.e., shoulders. Recheck breath sounds for possible intu-
8 months) to enable the child to develop a competent bation of right mainstem bronchus.
velopharyngeal mechanism before the onset of speech 3. No head drape is used once patient is positioned.
production. 4. If mouth gag is used, recheck breath sounds once gag
2. Dental development. From the viewpoint of the ortho- is opened for possible endotracheal tube compression.
dontist, palatal closure should be delayed until an 5. Some surgeons prefer sitting at the head of the table
optimal relationship is established in the upper dental with the patient in Trendelenburg position; others
arch to ensure the development of normal dental prefer standing at the side.
CLEFT LIP AND PALATE 507
A B
Tensor veli
palatini m. Pterygoid bone
Hamulus of
I .
pterygoid , In!. pterygoid m.
FIGURE 10-8
A The bony anatomy is depicted, showing the origin of incision are injected with local anesthesia (lidocaine
of the internal pterygoid muscle, which marks the 1% with 1:100,000 epinephrine) for hemostasis and
plane of mobilization of the soft palate. This muscle to facilitate a lighter plane of general anesthesia.
also leads to the identification of the hamulus around The incision through mucosa and periosteum starts
which the tensor veli palatini courses. medial to the alveolar ridge. When the posterior end
Post. palatine
vessels
Tensor veli palatini m.
Hamulus
Palatopharyngeus m.
TENSOR APONEUROSIS
PTERYGOID HAMULUS
L PALATOPHARYNGEUS
GLOSSOPALATINUS
M. UVULAE
FIGURE 10-9
CLEFT UP AND PALATE
c
Septum
mucosa
Palatal mucosa
~,
, >
FIGURE 10-10
CLEFT LIP AND PALATE
A B
FIGURE 1 0-11
CLEFT LIP AND PALATE 51 7
c D
FIGURE 10-11
Pharyngeal Flap for Velopharyngeal ciency is a port whose cross-sectional area is approxi-
Insufficiency (Fig. 10-12) mately 20 mm2• In 1973, Hogan introduced the concept
of lateral port control during the construction of a
The production of normal speech requires periodic pharyngeal flap, limiting the port opening on either
closure of the velopharyngeal mechanism, a dynamic side of the flap to the size of a 4-mm (I2.6-mm2)
process influenced by the length, compliance, and catheter. Port size can then be adjusted further depend-
motion of the soft palate (velum) as well as by the ing on preoperative measurements of lateral pharyn-
coordinated action of the posterior and lateral pharyn- geal wall motion.
geal walls. Different procedures both static and dynamic
have been developed in an attempt to correct velopha- Highpoints
ryngeal insufficiency in the cleft palate patient to reduce
both nasal regurgitation and hypernasal speech. The 1. Prophylactic antibiotics are recommended.
pharyngeal flap (Schoenborn, 1876) remains the most 2. Develop a superiorly based flap from the posterior
popular surgical correction and is presented here. With pharyngeal wall and close the resultant defect.
improved diagnostic techniques such as nasopharyn- 3. Split the soft palate in the midline.
goscopy (Pigott et a!., 1969) and multiview videofluo- 4. Create paired, distally based nasal lining flaps.
roscopy, the pharyngeal flap can be appropriately de- 5. Sew the nasal lining flaps to the raw caudal surface
signed to obturate many velopharyngeal closure defects. of the pharyngeal flap.
Pharyngeal flaps may be either superiorly based or 6. Adjust the lateral ports.
inferiorly based. Ease of construction of the inferiorly 7. Insert a nasopharyngeal airway.
based flap makes it more suitable for patients in whom
visualization is difficult. The superiorly based flap can Postoperative Routine
bridge a larger gap and avoids friable adenoid tissue.
Recall that the normal action of the levator veli palatini 1. Admit the patient to an intensive care unit or step-
muscle is to elevate and retract the soft palate poste- down unit for the first 24 hours postoperatively to
riorly. The inferiorly based flap tends to pull the palate monitor the airway.
caudad out of the plane of velopharyngeal closure, 2. A nasopharyngeal airway is placed at the end of sur-
while the superiorly based flap maintains the palate in gery and removed on the first postoperative day after
a more physiologic position. verifying airway competency. In children, an uncuffed
Pressure flow studies (Warren, 1964) have demon- endotracheal tube is cut down, inserted, and secured to
strated that the threshold for velopharyngeal insuffi- the membranous nasal septum with a 2-0 silk suture.
CLEFT LIP AND PALATE
FIGURE 10-12
ClEFT LIP AND PALATE
BIBLIOGRAPHY Hollinshead WH: Anatomy for Surgeons, vall, The Head and Neck.
Albery EH, Bennett JA, Pigott RW, Simmons RM: The results of 100 New York, Hoeber-Harper, 1954.
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findings of endoscopic and radiological examination. Br J Plast rotation-advancement unilateral cleft lip repairs. Plast Reconstr
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Chicago, Year Book Medical Publishers, 1987, p 83. Plast Reconstr Surg 42:214-224, 1968.
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Plast Reconstr Surg 44:234-241, 1969. veli palatini function as a measure of velopharyngeal incompetence.
Bernstein L: Secondary reconstructive procedures for cleft lip and Plast Recontr Surg 44:155-160,1969.
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Bernstein L: The effect of timing of cleft palate operations on subse- Surg 61:787-789,1978.
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Blocksma R, Leuz CA, Mellerstig KE: A conservative program for Isshiki N, Morimoto M: Anterior cleft palate closure by turnover flaps.
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Plast Reconstr Surg 55:160-169, 1975. Jackson IT, Vandervord JG, Mclennan JG, et al: Bone grafting of the sec-
Bluestone CD: Eustachian tube obstruction in the infant with cleft ondary cleft lip and palate defonnity. Br J Plast Surg 35:345-353,1982.
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Brauer RO: A comparison of the Tennison and Le Mesurier lip repairs. deformity. Plast Reconstr Surg 66:38-44, 1980.
Plast Reconstr Surg 23:249-259, 1959. Jayapathy B, Huffman WC, Lierle OM: The Z-plastic procedure: Some
Brauer RO, Cronin TO: The Tennison lip repair revisited. Plast Reconstr mathematic considerations and application to cleft lip. Plast Reconstr
Surg 71:633-640,1983. Surg 26:203-208, 1960.
Brown JB, McDowell F, Byars LT:Double clefts of the lip. 5urg Gynecol Kernahan DA: The striped Y3/4A symbolic classification for cleft lip
Obstet 85:20,1947, and palate. Plast Reconstr 5urg 47:469-470, 1971.
Cohen MM Jr: Craniofacial disorders. In Emery AE, Rimoin DL (eds]: Kernahan DA, Bauer BS, Harris GO: Experience with the Tajima proce-
Principles and Practice of Medical Genetics. New York, Churchill dure in primary and secondary repair in unilateral cleft lip nasal
Livingstone, 1983, pp 593-607. deformity. Plast Reconstr Surg 66:46-53, 1980.
Craig RDP: The management of complete clefts of the lip and palate. Kernahan DA, Dado DV,Bauer BS: The anatomy of the orbicularis oris
Br J Surg 54:923-931, 1967. muscle in unilateral cleft lip based on a three-dimensional histologic
Cronin TO, Upton J: Lengthening of the short columella associated reconstruction. Plast Reconstr Surg 73:875-879, 1984.
with bilateral cleft lip. Ann Plast Surg 1:75-95, 1978. Kiehn CL, DesPerez JD, Brown F: Maxillary osteotomy for late correc-
Dempsey WC, Mayhew JF, Metz PS, Southern IE: Malignant hyper- tion of occlusion and appearance in cleft lip and palate patients.
thermia during repair of a cleft lip in a 6 month old infant, with Plast Reconstr 5m3 42:203-207, 1968,
survival. Ann Plast Surg 1:3t5-318,1978. Kiehn CL, DesPerez JD, Maes JM, Kronheim L: Temporal muscle
Dingman RO, Grabb WC: A rational program for surgical management transfers to the incompetent soft palate: A progress report. Plast
of bilateral cleft lip and cleft palate. Plast Reconstr Surg 47:239-242, Reconstr Surg 48:335-338, 1971.
1971. Kilner IP: Cleft lip and palate repair technique. 5t. Thomas Hasp Rep
D'Ottaviano N, Baroudi R, Keppke EM: Dental rotation in cleft lip. 25:117,1937.
Ann Plast Surg 1:407-410, 1978. Kluzak R: Thansplantation of rib growth cartilage: Experimental study
Edgerton MT, Dellon AL: Surgical retrodisplacement of the levator veli and possible use in primary cleft lip repairs. Plast Reconstr Surg
palatini muscle: Preliminary report. Plast Reconstr Surg 47:154-167, 49:61-69,1972.
1971. Kobus K: Extended vomer flaps in cleft palate repair: A preliminary
Epstein Ll, Davis WB, Thompson LW: Delayed bone grafting in cleft report. Plast Reconstr Surg 73:895-901,1984.
palate patients. Plast Reconstr Surg 46:363-367,1970. Langenbeck B: Operation on congenital total cleft of the hard palate
Fishman LS, Stark DB: The maxillary arch prior to surgical closure of by a new method. Plast Reconstr Surg 49:323-324, ]972.
a cleft lip. Plast Reconstr Surg 42:572-576, 1968. Le Mesurier AB: The treatment of complete unilateral harelips. Surg
Furlow LT Jr: Cleft palate repair by double opposing Z-plasty. Plast Gynecol Obstet 95:17-27,1952.
Reconstr Surg 78:724-736, 1986. McCabe PA: A coding procedure for classification of cleft lip and cleft
Gahhos R, Enriquez RE, Bahn SL, Ariyan S: Necrotizing sialometa- palate. Cleft Palate J 3:383-391, 1966.
plasia: Report of five cases. Plast Reconstr Surg 71:650-657, 1983. McConnel FMS, Zellweger H, Lawrence RA: Labial pits-cleft lip
Georgiade NG: Improved technique for one-stage repair of bilateral and/or palate syndrome. Arch OtolaryngoI91:407-411, 1970.
cleft lip. Plast Reconstr Surg 48:318-324,1971. McCoy FJ, Zahorsky CL: A new approach to the elusive dynamic
Greminger RF: Island soft palatoplasty for early reconstruction of the pharyngeal flap: Preliminary report. Plast Reconstr Surg 49:
posterior muscular ring. Plast Reconstr Surg 68:871-876, 1981. 160-164,1972.
Hagerty RF: Unilateral cleft lip repair. Surg Gynecol Obstet 106:119-122, McEvitt WG: Conversion of an inferiorly based pharyngeal flap to a
1958. superiorly based position. Plast Reconstr Surg 48:36-39, 1971.
Hagerty RF, Mylin WK: Facial growth and arch symmetry in the McWilliams BJ: The role of otolaryngological problems in speech
surgical prosthetic treatment of cleft lip and palate. Plast Reconstr disorders associated with cleft palate. Thans Am Acad Ophthalmol
Surg 68:682-688, ]981. Otolaryngol 73:720-723, 1969.
Hagerty RF, Mylin WK, Hess DA: Augmentation pharyngoplasty. Plast Maisels DO: Chronic lip fissures. Br J Dermatol 81:621-622,1969.
Reconstr Surg 44:353-356, 1969. Manchester WM: How t do it/colloquium: Surgical management of
Henderson HP: The "tadpole flap": An advancement island flap for bilateral cleft lip. Ann Plast Surg 1:509-512, 1978.
the closure of anterior fistulae. J Plast Surg 35:163-166, ]982. Marcks KM, Trevaski AE, daCosta A: Further observations in cleft lip
Hogan VM: A clarification of the surgical goals in cleft palate speech repair. Plast Reconstr Surg 12:392, 1953.
and the introduction of the latera] port control (LPC) pharyngeal Messengill R Jr, Pickrell K, Mladick R: Lingual flaps: Effect on speech
flap. Cleft Palate J 10:331-345, 1973. articulation and physiology. Ann Olo! Rhinol Laryngol 79:853,1970.
CLEFT LIP AND PALATE 521
Massengill R Jr, Walker T, Pickrell KL: Characteristics of patients with Randall P: A triangular flap operation for the primary repair of unilat-
a Pass avant's pad. Plast Reconstr Surg 44:268-270,1969. eral clefts of the lip. Plast Reconstr Surg 23:331-347,1959.
Millard DR Jr: A radical rotation in single harelip. Am J Surg 95: Randall P, Whitaker LA, LaRossa D: The importance of muscle recon-
318-322, 1958. struction in primary and secondary cleft lip repair. Plast Reconstr
Millard DR Jr: Refinements in rotation-advancement cleft lip tech- Surg 54:316-323, 1974.
nique. Plast Reconstr Surg 33:26-38, 1964. Rosedale RS: Pharyngeal flaps. Eye Ear Nose Throat Monthly 46:470-
Millard DR Jr: Extensions of the rotation-advancement principle for 478, 1967.
wide unilateral cleft lips. Plast Reconstr Surg 42:535-544, 1968. Salyer KE: Primary correction of the unilateral cleft lip nose: A 15-
Millard DR Jr: Closure of bilateral cleft lip and elongation of columella year experience. Plast Reconstr Surg 77:558-566, 1986.
by two operations in infancy. Plast Reconstr Surg 47:324-331, 1971. Schoenborn K: On a new method of staphylorrhaphy. Plast Reconstr
Millard DR Jr: A primary camouflage of the unilateral harelook. Surg 49:558-562, 1972.
Transactions of the 1st International Congress on Plastic Surgery. Shirokov EP: Carcinoma of the palate. Am J Surg 100:530-533, 1960.
Baltimore, Williams & Wilkins, 1957, pp 160-166. Stark RB: Cleft Palate: A Multidiscipline Approach. New York, Harper
Millard DR Jr: Adaptation of the rotation-advancement principle & Row, 1968.
in bilateral cleft lip. In Wallace AB (ed): Transactions of the Stark RE: Cleft lip-a timetable. Ann Plast Surg 8:107-117, 1982.
2nd International Congress on Plastic Surgery. London, Churchill Stark RD, DeHaan CR: The addition of the pharyngeal flap to primary
Livingstone, 1960. palatoplasty. Plast Reconstr Surg 26:378-387, 1960.
Millard DR Jr: Wide and/or short cleft palate. Plast Reconstr Surg Steffensen WH: A method for repair of the unilateral cleft lip. Plas!
29:40-57, 1962. Reconstr Surg 4:144, 1949.
Millard DR Jr: Cleft Craft, vol !, The Unilateral Deformity. Boston, Steffensen WH: Further experience with the rectangular flap opera-
Little, Brown & Co, 1976. tion for cleft lip repair. Plast Reconstr Surg 11:49, 1953.
Millard DR Jr: Cleft Craft, vol II, Bilateral and Rare Deformities. Tennison CW: The repair of unilateral cleft lip by the stencil method.
Boston, Little, Brown & Co, 1977. Plast Reconstr Surg 9:115,1952.
Millard DR Jr: Cleft Craft, vol Ill, Alveolar and Palatal Deformities. Thompson JE: An artistic and mathematically accurate method of
Boston, Little, Brown & Co, 1980. repairing the defect in cases of harelip. Surg Gynecol Obstet
Millard DR, Batstone JHF, Heycock MH, Bensen JF: Ten years with 14:498-505, 1912.
the palatal island flap. Plast Reconstr Surg 46:540-547, 1970. Uchida J-J: A new approach to the correction of cleft lip nasal defor-
Mina MMF: Styloid, velar, and pharyngeal muscles in cleft palate. J. mities. Plast Reconstr Surg 47:454-458,1971.
Otolaryngol 8:179-190,1979. Veau V: Division Palatine. Paris, Masson, 1931.
Nishimura Y: Cleft lip repair. Chir Plastica 4:109-114, 1978. Veau V: Bec-de-Lievre. Paris, Masson, 1938.
Noordhoff MS: Reconstruction of vermilion in unilateral and bilateral von Langenbeck B: Operation der angeborenen totalen Spaltung des
cleft lips. Plast Reconstr Surg 73:52-60, 1984. harten Gaumens nach einer neuer Methode. Dtsch Klin 8:231,
Ogino Y, Ishida H: Secondary repair of the cleft-lip nose. Ann Plast 1861; also Plast Reconstr Surg 49:323-324, 1972.
Surg 4:469-480, 1980. Ward PH, Goldman R, Stoudt RJ Jr: Teflon injection to improve
Orticochea M: A review of 236 cleft palate patients treated with velopharyngeal insufficiency. J Speech Hearing Disord 31:267-273,
dynamic-muscle sphincter. Plast Reconstr Surg 71:180-186, 1983. 1966.
Paradise JL, Bluestone CD, Felder H: The universality of otitis media Wardill WEM: Technique of operation for cleft palate. Br J Surg
in 50 infants with cleft palate. Pediatrics 44:35-42, 1969. 25:117-130,1937.
Peet E: The Oxford technique of cleft palate repair. Plast Reconstr Warren DW: Velopharyngeal orifice size and upper pharyngeal
Surg 28:282-294, 1961. pressure-flow patterns in cleft palate speech: A preliminary study.
Pigott RW, Bensen JF, White FD: Nasoendoscopy in the diagnosis of Plast Reconstr Surg 34:15,1964.
velopharyngeal incompetence. Plast Reconstr Surg 43:141-147, Wynn SK: Primary nostril reconstruction in complete cleft lips. The
1969. round nostril technique. Plast Reconstr Surg 49:56-60, 1972.
Potter J: Cleft palate-fifty years on. Ann Plast Surg 10:12-14, 1983. Yules RB: Cinefluorography, speech, and dynamic respirometry in
Potter J: As I remember-William Wardhill. Ann Plast Surg 9:344- preoperative and postoperative pharyngeal flap patients. Trans Am
347, 1982. Acad Ophthalmol Otolaryngol 73:724-727, 1969.
11 PERIORBITAL REGION
Many of the principles outlined are from Mustarde (1969). Additional anatomy is depicted in Figures 11-12B
and Bl and 11-12 D and G and Figure 6-4.
Anatomy (Fig. 11-1)
EXT. SECTION
MEDIAL CANTHAL
L1G.
lATERAL RECTUS M.
lACRIMAL GROOVE
APONEUROSIS OF
lEVATOR PALPEBRAE SUP M.
TARSUS SUP.
ORBICULARIS M.
TARSUS INF.
ORBICULARIS M.
FORNIX
ORBITAL SEPTUM
FIGURE 11-1
523
524 PERIORBITAL REGION
FIGURE 11-2
PERIORBITAL REGION
Reconstruction of Lids (Continued) 6. In repairing lid defects, the layer closure of the inner
(See Figs. 11-3 to 11-10) and outer incisions should not be directly in the same
plane (halving technique). This is more theoretical
Alternate and Additional Concepts than practical.
1. Some surgeons believe that portions of the full- Neoplastic lesions of the lower lid are basal cell car-
thickness layers of the upper lid can be safely utilized cinoma (90%), squamous cell carcinoma, and meibo-
to reconstruct the lower lid using the rotated (switch) mian gland carcinoma. The operating microscope helps
or pedicle flap technique. This would be the reverse in delineating the extent of a tumor when normal
situation as depicted in Figure 11-5L to OJ. With meibomian orifices are visualized. The latter two types
larger flaps from the upper to the lower lid or vice can metastasize, but basal cell carcinoma rarely does.
versa, a "sharing" procedure is utilized (Hughes, 1954;
Cutler and Beard, 1955; see Fig. 11-6). The impor- Reconstruction of Lower Lid (Fig. 11-3)
tant principle in any modification of this technique
is that the lid margin of the donor lid is not tran- Figure 11-3depicts in outline fashion the basic principles
sected or violated (see Fig. 11-6). This feature may of lower lid reconstruction for vertical defects following
be the reason why Mustarde and other surgeons have the "quarter" rule of Mustarde. Details of technique for
abandoned this method-it is actually a failure of large lower lid defects are shown in Figure 11-4.
application of surgical technique rather than a failure
of the basic method itself.
2. When there is only skin loss of the lids, free graft A Vertical lid defect and "shield-type" incision are
from the opposite lid (opposite side if necessary) or shown.
from the postauricular region or a thick split -graft
(freehand) is used. B This horizontal lid defect requires transposed
3. When utilizing the Fricke upper lid flap (see Fig. tissue or rotated flaps. See Figures 11-9D and E and
11-90 and E), the entire length of the skin of the 11-14E and F.
upper lid should be used to avoid disparity when
closing the donor site.
4. Both these surgeons (McCoy and Smith) avoid the Reconstruction of Lower Lid With 25% Defect
Mustarde technique of a lateral cheek flap (see Fig.
11-4) to reconstruct the lower lid. The lateral cheek For suturing details refer to Figure 11-2Bto D.
flaps may result in a downward pull on the recon-
structed lower lid. To aid in the prevention of this
problem, refer to Figure 11-4, which demonstrates C, Cl Shown is primary closure of a 25% defect
that the lateral side of the excised parallelogram is when both canthal areas are intact. (In elderly patients
longer and more oblique than the medial side. up to 30% of the lid may sometimes be resected and
5. When excising skin of the lower lid, Smith empha- a primary simple closure performed.)
sizes the importance of having patients open their Continued
mouths widely to evaluate the downward traction
on the lower lid to prevent ectropion.
PERIORBITAL REGION 527
25% DEFECTI _
FIGURE 11-3
PERIORBITAL REGION
Reconstruction of Lower Lid (Continued) Reconstruction of Lower Lid With 25% Defect at
(Fig. 11-3) Lateral Canthus
(2 Depicted is a pentagon-shaped excision (leone) D, D2 Shown is a 25% defect at the lateral canthal
that is similar in some respects to the shield-type exci- region. This usually requires a lateral canthoplasty (D1).
sion in A. The gross margins are at least 1 to 2 mm for Either the inferior or superior crus or both crura of the
basal cell carcinoma. Frozen sections are obtained on lateral canthal ligaments are transected. A medial
all three margins of the surgically removed specimen canthoplasty is not used because of possible injury to
as well as from the margins of the surgical wound to lacrimal apparatus.
be certain that the resection is adequate. If any of these
frozen sections are positive, additional excisions are done
Reconstruction of Lower Lid With 30% Defect
until frozen sections are free of tumor. If the lesion is
squamouscell carcinoma (rare), then up to 5-mm margins
are recommended. The use of stay sutures on the lid E Shown is a 30% defect.
margins is of great aid to stabilize the lid during the
excision. El A lateral cantholysis is again usually necessary
except in the elderly, in whom there is more tissue
(3 The completed closure is shown. laxity.
Continued
PERIORBITAL REGION 529
C2 C3
D2
H1
Resection of large Basal Cell Carcinoma • Fold and edema of rotated cheek flap
of lower Lid With Reconstruction Using • Failure of nasal graft, especially the cartilage
lateral Cheek Flap (Fig. 11-4) (After
Mustarde, 1969) A Depicted is a tumor requiring resection of almost
the entire lower lid, sparing the canaliculus. The area
Highpoints of resection with a large cheek flap and back cut (1) is
outlined.
1. A full-thickness resection is used.
2. Immediate reconstruction is done with a lateral A 1 Schematic outline of procedure emphasizes five
cheek flap. important features of the incision for the cheek flap.
3. Total release of a cheek flap in front of the ear with
right angle back cut at distal end of incision of 1. The medial incision of the excised triangle is almost
cheek flap is done when two thirds or more of the vertical; the lateral incision is longer and oblique.
lower lid is resected. 2. Adequate undermining is done below and espe-
4. Lower lid resection includes an elongated inverted cially lateral to the apex of the excised triangle.
parallelogram or "shield" below the tumor to ensure 3. A cutback (1) incision is made just below the lobule
proper advancement of cheek flap. of the ear.
5. The sides of this parallelogram or shield are unequal 4. A vertical relaxing incision on the cheek flap may be
in length and direction: the medial side is shorter necessary with an excision of small triangles (2) to
and vertical; the lateral side is longer and slanted increase the length of the cheek flap. The cheek flap
obliquely downward and medially. This is done consists of skin and subcutaneous tissue but not the
to prevent a downward pull of the reconstructed parotid fascia. The facial nerve and its branches are
lower lid. thus spared.
6. The cheek flap is extended slightly upward at the 5. The portion of the incision forming the cheek flap is
lateral canthus and the release extends 1 cm below curved slightly upward toward the level of the brow
the apex of the excised parallelogram. (3).
7. The deep portion of the cheek flap is sutured to the
orbital rim, especially at the lateral canthus to prevent B The tumor is excised with a full-thickness resection
downward tension on the reconstructed lid. and a free graft consisting of septal cartilage, and
8. Lining of the newly reconstructed lid is ideally attached mucosa is sutured in place as a replacement
achieved by utilizing a free-mucosal chondral graft for the tarsus and conjunctiva. One or two continuous
from the nasal septum. 6-0 nylon pullout sutures (4) are utilized. No knots are
9. Do not injure the lacrimal punctum and canaliculus tied on the conjunctival surface. To increase support
if this is compatible with adequate resection of the inferiorly 5-0 or 6-0 catgut sutures may be necessary.
primary tumor; otherwise, resect these areas. Trouble-
some epiphora mayor may not occur, and this can C The inner subcutaneous tissue of the rotated cheek
be corrected later if need be by the utilization of a flap is sutured (5) to the periosteum of the infraorbital
conjunctival flap (see Fig. ll-llC). portion of the maxilla to prevent a downward pull on
10. Margins of tumor must be adequately identified the newly reconstructed lower lid. Similar sutures (6)
with sutures or staining with silver nitrate for frozen are also used to support the flap at the lateral canthal
sections. region by fixing the sutures superiorly along the lateral
11. Refer to page 526 for alternate and additional orbital margin.
concepts.
~ Long 5-0 silk sutures are used to approximate the
Complications cheek flap to the mucocartilage graft. For the remain-
der of the skin closure 5-0 nylon is used. The pullout
• Nylon pullout sutures may break: take care in re- sutures securing the septal graft are depicted (4) .
moving them .
• Downward droop of new lid: perform lateral
canthoplasty.
PERIORBITAL REGION
FIGURE 11-4
PERIORBITAL REGION
Reconstruction of Upper Lid (Fig. 11-5) to two quarters of its length, with a rotation of
(After Esser, 1919; Mustarde, 1969) the lateral cheek flap to close the donor site of
the lower lid.
Highpoints d. Defect greater than three quarters to total loss
is reconstructed by a lower lid flap up to three
1. Upper lid reconstruction must encompass the follow- quarters of its length preserving the medial
ing characteristics: quarter of the lower lid, thus avoiding any injury
a. Ability to cover and to protect the cornea during to the punctum and lacrimal apparatus.
sleep 8. The vascular hinge for lower lid flaps a, b, and c
b. Ability to elevate if at all possible; hence it must under No. 7 is placed laterally, whereas flap d
have some neuromuscular function under NO.7 is placed medially.
c. Must be lined with smooth mucous membrane 9. Avoid kinking of vascular supply in pedicle when
to protect cornea flap is rotated.
d. Must be rigid enough to maintain its shape and 10. Refer to basic principles of lid reconstruction (see
curvature to protect the cornea p.526).
3. Lower lid or portion thereof is best suited for
reconstruction whenever possible. Reconstruction of Upper Lid With 25% Defect
4. Use all layers of lower lid.
5. Preserve vascular supply to rotated lower lid: pedicle
in smaller flaps should be 5 mm wide and in the A A 25% defect repair is depicted. The lidsare divided
larger flaps 6 mm wide. into quarters for clarity. Direct three-layer closure is
6. Suture tarsal plate of rotated lower lid to remaining performed following the technique in Figure 11-2B to
portion of levator palpebrae superioris muscle or D. Ifthe defect is only slightly greater than 25% of the
its aponeurosis (see L). lid, several additional millimeters can be gained in the
7. As with lower lid, the principle of quarters is appli- elderly patient by a lateral cantholysis (canthotomy)
cable (see p. 526). (see Fig.11-3Dl). In a younger patient, it is best to rotate
a. Defect up to one quarter (25%) is accomplished a flap from the lower lid.
by direct closure (no rotated flap from lower lid
is necessary). Al The completed closure is shown. The 6-0 nylon
b. Defect greater than one quarter and up to two conjunctival suture (1) and the gray line fine silksuture
quarters is reconstructed by up to one-quarter (2) are depicted.
lower lid flap, with direct closure of donor site Continued
of lower lid.
c. Defect greater than two quarters and up to three
quarters is reconstructed by a lower lid flap up Refer to Figure 11-6 for an alternate technique.
PERIORBITAL REGION 535
25% DEFECT
A
FIGURE 11-5
PERIORBITAL REGION
Reconstruction of Upper Lid (Continued) Reconstruction of Upper Lid With 60% to 75%
(Fig. 11-5) (After Esser, 1919; Mustarde, Defect
1969)
Medially Based Flap (Close to 75% Defect)
Reconstruction of Upper Lid with 50% to 60%
Defect (After Mustarde, 1969) When the defect in the upper lid is close to 75% loss,
a medially based flap is necessary, because there is not
This group is divided into two techniques: sufficient length laterally for a rotated lower lid flap.
1. Fifty to 60 percent defect is closed with pedicle of J Defect and calculation of the flap are depicted. The
flap based and swung laterally. calculation is the same as in G, but it is obvious that
2. Sixty to 75 percent defect is closed with pedicle of there is not sufficient length laterally; hence, it is rotated
flap based and swung medially. from the medial side. Distance 3-4 is the width of the
flap after one-quarter length of the lid has been sub-
Laterally Based Flap tracted (distance 2-3). Point 4 on the medial portion of
the lower lid flap is to be transposed to point 4' on the
G A defect somewhat greater than two quarters is lateral edge of the upper lid defect. Caution must be
depicted. Fine hooks simply put normal tension on the taken not to involve that portion of the lower lid flap
cut edges but do not attempt to decrease the defect with the canaliculus. At times the outline of the flap
by a quarter. Therefore, quite a different mathematical must be shifted slightly laterally to preserve this vital
plan is used to calculate the position and width of the apparatus.
flap from the lower lid as compared with the smaller
defects. This is first done by marking the correspond- K The flap is outlined and elevated medially, and the
ing width of the defect on the edge of the lower lid remaining portion of the lower lid with the vascular
with a dye (points 1 and 2). Then this marked defect pedicle is advanced medially by a zygomatic and cheek-
is reduced by a distance equal to one quarter the entire relaxing incision, as shown in Figures 11-3F to Hand
length of the lower lid, the subtraction being done on 11-4. This closes the defect of the donor site.
the lateral side of the marked defect. This is the distance In no case is the canaliculus included in the flap.
between points 2 and 3. Point 3 then becomes the
location of the pedicle of the lower lid flap that is to be Kl The closure is depicted. A standard three-layer
rotated from the lateral portion of the lower lid. This closure is performed as described in Figure 11-2B to D.
prevents injury to the lacrimal apparatus. The muscle layer closure must be carefully performed
to restore motor function to the transposed flap. It may
H The flap is outlined. Distance 3-4 is equal to dis- be necessary to suture the muscle or the connective
tance 1-3 in G. Point 4 on the lateral portion of the tissue of the flap to the aponeurosis of the palpebrae
lower lid flap is to be transposed to point 4' on the superioris muscle (see Fig. 11-5L).
medial edge of the upper lid defect. The conjunctival pullout sutures (5) are taped to
the skin.
I To close the donor site, an advanced lateral cheek Continued
flap will usually be necessary (except in the elderly
when more lax skin is present). Refer to Figures 11-3F
to Hand 11-4. Transection of the pedicle is performed at 2 V2 weeks
after the technique shown in Figure 11-50 to El.
11 The closure is the standard three-layer approxima-
tion (see Fig. 11-2). Transection of the pedicle is per-
formed at 2 weeks (see Fig. 11-50 to E1). The nylon
pullout conjunctival sutures (5) are taped to the skin.
PERIORBITAL REGION 539
FIGURE 11-6
FIGURE 11-7
PERIORBITAL REGION
B E
c F
FIGURE 11-8
PERIORBITAL REGION
A The line of excIsion with lateral extension for E The flap is in place. Depending on the extent of
advanced flap is depicted. the defect at the lateral canthus, the base of the flap
"X" can be returned to the donor area at a second
B The skin flap is advanced. A relaxing incision (dotted stage. Sutures must be carefully placed to avoid injury
line) may be necessary to avoid a dog-ear. to the globe. Edema of the lower lid margin can occur
if this margin is too wide.
C The completed closure is shown.
E
FIGURE 11-9
PERIORBITAL REGION
Eyelash Reconstruction (Fig. 11-10) failure. Thus, an island flap of hair-bearing scalp can
be used based on a branch of the superficial temporal
There is some difference of opinion regarding the advis- artery and vein. Avoid a donor site that may become
ability of eyelash replacement for the lower lid; yet, bald later.
there is less question as to the advisability of upper
eyelash replacement. A Depicted is the temporal region donor site with
Several methods are described, especially regarding
the incision placed in a relatively horizontal plane. The
the donor site (e.g., eyebrow, temporal region, or post-
hairs thus will be in the same plane when transferred
auricular region). to the lid margin. Two or three rows of hairs are excised.
Highpoints B The hair folliclesextend upward in an oblique direc-
tion, and care must be taken that the incision (dotted
1. Evaluate proper direction of hair and maintain this
line) for the graft follows this same angle; otherwise,
direction in graft. the follicles will be injured.
2. Do not injure hair follicles-these are upward obliquely
and hence an incision deep to skin must follow this
C The free graft (about 2 mm in width) consists of
angle. two or three rows of hairs with follicles.Although some
3. Trim excess adipose tissue from graft.
adipose tissue is necessarily excised when the graft is
4. Avoid donor site that may become bald later.
removed, as much of this fat istrimmed with fine scissors
as is possible. The rounded black protuberances of the
Complications
follicles must be preserved.
• Failure of graft-repeat. D An incision parallel and slightly outside or distal
• ScarrIng with inturning of new lashes against the
(1.0 to 2.0 mm) to the free lid margin is made deep
cornea; such hair will require removal by electrolysis.
enough to accommodate the free graft. Care must be
taken that the direction of the hair is in the correct
Eyebrow Reconstruction
plane. Sutures through both lid edges and the graft
are carefully placed without injury to the globe.
Reconstruction of the absent eyebrow can be usually
achieved following a technique similar to that used for
the grafting of an eyelash, except that the graft is wider The original hairs may fall out with new growth
and through-and-through sutures are not used. The occurring in about 3 weeks. These hairs will require a
wider the graft, however, the greater the possibility of periodic trimming.
PERIORBITAL REGION
B
552 PERIORBITAL REGION
FIGURE 11-11
PERIORBITAL REGION
Medial Canthoplasty and Repair with the probable formation of a mucocele of the lacrimal
of Related Injuries (Fig. 11-12) sac. A dacryocystorhinostomy (see Fig. 11-13) would be
indicated. In either event all such associated deformities
Highpoints must be corrected concomitantly. The procedure described
in the following illustration depicts only repair of the
1. Disruption of the medial canthal ligament may be medial canthal ligament and reduction and fixation of
associated with other local deformities: fresh naso-orbital fractures.
a. Naso-orbital fracture
b. Injury to the nasolacrimal apparatus: puncta, cana-
liculi, lacrimal sac, and nasolacrimal duct B, B1 Surgical anatomy of the medial canthal
c. May be bilateral (palpebral) ligament and associated lacrimal apparatus
2. If such injuries are present, all should be corrected is shown. Bl is a coronal section through the medial
concomitantly, including a dacryocystorhinostomy canthal ligament. The medial canthal ligament splits
(see Fig. 11-13), if indicated. into a thicker anterior section and a much thinner pos-
3. More seriously, intracranial injuries may be present, terior section, thus enveloping the lacrimal sac. Horner's
and, if so, these take precedence over any repair in muscle lies just deep to the posterior section of the
the region of medial canthus. medial canthal ligament. The anterior section is attached
4. Protect cornea during operation. to the anterior lacrimal crest behind the plane of the
cornea; the posterior section along with Horner's muscle
is attached to the posterior lacrimal crest. In B, the
A Typical deformity in the left medial canthal region anterior section of the ligament has been ruptured in
characterized by displacement of the medial canthus its midportion. However, other variations of disruption
primarily laterally and slightly downward and forward. of the ligament can occur. The disruption may be more
The canthus itself is rounded and blunted and may laterally at a point just over the proximal portions of
be partially obscured by redundant tissue of the lids. the canaliculi. Here the ligament is thinner. Repair in
Distances a and b are the normal relationships, whereas this situation must approximate the upper and lower
distance b' is longer than b and a' is shorter than a. origins of the ligament from the upper and lower lids.
Although this deformity may be entirely and solely due Another type of disruption of the ligament may involve
to rupture of the medial canthal ligament, fracture of an avulsion of a portion of the underlying bone with
the medial wall of the orbit can also contribute to this a small fragment of bone attached to the medial end
clinical picture. Radiographs are performed and, if of the ligament. This affords an excellent point for the
indicated, laminograms. through-and-through wire suture, to be described.
Laterally, the ligament is attached to the medial angles
of the two tarsal plates. Medially, it arises from the
If the trauma is some weeks or months old and asso- frontal process of the maxilla in front of the lacrimal
ciated with persistent swelling at the medial canthal groove.
region, especially below the level of the medial canthal Continued
ligament, injury to the lacrimal apparatus has occurred
PERIORBITAL REGION
FIGURE 11-12
PERIORBITAL REGION
F G
FIGURE 11-13
PERIORBITAL REGION
Correction of Scar Contracture of For severe ectropion of the lower lid secondary to
the Lids and Ectropion (Fig. 11-14) scarring and tissue loss, a bipedicle flap (Tripier) from
the upper lid may be of help.
c D
FIGURE 11-14
PERIORBITAL REGION
Temporary Tarsorrhaphy (Weeks) F After the lids have been approximated and the
exact opposing sites for the tarsorrhaphy have been
This procedure is utilized when there is facial nerve marked with the point of a knife, 6- to 8-mm mucocu-
paralysis after facial nerve surgery or parotid surgery taneous rectangular areas are excised, leaving a thin
when return of function is expected. strip of epithelium on both ciliary and conjunctival edges
A simple temporary method of corneal protection, of the lid margins. The cilia are thus not injured, and
for example, during surgery, is the use of a contact lens. the normal lid contour is preserved.
A longitudinal incision 2 mm deep is made in the
Highpoints base of each bare area. When the lid edges are approx-
imated, this incision facilitates flaring of the wounds
1. This procedure is used to correct alignment of upper with more surface area for healing. Through-and-through
and lower lids. horizontal mattress sutures of 4-0 silk guarded with
2. Excise a small longitudinal area (6 to 8 mm) of muco- small polyethylene tube booties are inserted and tied
cutaneous intermarginal tissue to form a bare area. snugly. The tarsorrhaphy can be sutured above the
3. Incise the base of each bare area to open wounds. eyebrow.
c o E
FIGURE 11-15
PERIORBITAL REGION
FIGURE 11-16
PERIORBITAL REGION
FIGURE 11-17
A The areas excised are shown via a Caldwell-Luc A mastoid curet or osteotome may be necessary to
operation (see Fig. 5-2). The opening into the antrum excise thicker portions of bone. If possible, leave the
is made as large as possible so that adequate visual- anterior and posterior ethmoidal arteries intact. The
ization of the ethmoidal labyrinth and roof of antrum lamina papyracea is thus also excised. Do not resect
is possible. bone above the ethmoidal vessels, which approximates
the level of the cribriform plate (see Fig. 6-4A and B),
B With the use of various types of forceps, a com- or more posterior than the posterior ethmoidal artery,
plete ethmoidectomy is performed up to the anterior because damage to the optic nerve may result.
wall of the sphenoidal sinus. (This approach is similar to Continued
the transantral ethmoidal sphenoidal hypophysectomy.)
568 PERIORBITAL REGION
FIGURE 11-18
PERIORBITAL REGION
Resection of Adenoid Cystic Although local flaps (e.g., forehead [see Fig. 8-10])
Carcinoma of the Lacrimal Gland may be used to cover the surgical defect, the donor site
on the forehead may be a significant cosmetic defor-
(Fig. 11-19)
mity, especially in the young patient. The alternative is
the use of a split-thickness graft to cover the defect,
Highpoints
rather than the forehead flap.
1. Diagnosis is verified by permanent histologic sections
because of the magnitude of the surgery.
2. Resect the roof and lateral wall of the orbit.
3. Perform orbital exenteration.
4. Schedule postoperative radiotherapy.
FIGURE 12-1
573
THE EAR
B An ellipse of skin is excised in the posterior area of intact cartilage in this area will interfere with
auricular sulcus, the major portion of the excised skin the formation of the new antihelix. A slight curve in
being from the auricle itself. Depending on the degree the incision is very desirable.
of the deformity, the width of skin excised may be
from 0.5 to 1.5 cm. D The lateral leaf of the auricular cartilage must be
so mobilized that the final stages of everting the two
C A posterior auricular skin flap has been developed, leaves forming the new antihelix are achieved virtually
leaving the perichondrium intact. This flap is freed 4 to without reliance on the mattress sutures. However, the
6 mm beyond the dye marks, thus allowing sufficient cartilage of the helix is not incised.
space to place the cartilage sutures. The incision in the If the medial portion of the body of the auricular
cartilage is made along the dye marks, taking care that cartilage appears too wide, a small ellipse may be
the perichondrium and skin on the anterior surface are excised as shown by the dotted line. Again, it is desir-
not incised. This is most important, because both peri- able to have a slight wave in this incision so that the
chondrium and skin act as a hinge. If the index finger new antihelix thus formed will have a more graceful
is placed opposite the knife while the cartilage incision curve. To minimize a sharp edge in the antihelix, several
is made, and a watchful eye is kept for the white glis- parallel incisions in the cartilage are made rather than
tening perichondrium on the anterior surface, all will a single incision. These incisions are made only through
go well. This incision should be carried to the upper and a portion of the cartilage not through the full thickness
lower limits of the main body of the auricular cartilage; of the cartilage.
otherwise, the procedure will fail, because even a small Continued
FOSSA TRIANGULARIS,
CRUS HELICIS
TRAGUS
A B
FIGURE 12-2
THE EAR
L M
D E
FIGURE 12-3
THE EAR
FIGURE 12--4
THE EAR
Complications
FIGURE 12-5
THE EAR
B Primary closure results in minimal deformity. The flap is turned in to the defect.
C When the tumor involves both the helix and the J The distal and lateral margins of the flap are
crus of the antihelix, a large triangular, full-thickness sutured to the edges of the defect. The inferior edge of
area must be excised. the defect is closed by approximation of the auricular
skin edges, or an epithelial shave of the flap can be
D Immediate reconstruction is performed with the performed. This area will be opened later to receive
use of a postauricular full-thickness skin flap. The flap the skin flap when it is transected in 3 to 4 weeks. Any
is severed along the dotted line in 3 to 4 weeks, postauricular bare areas are covered with split-
leaving sufficient length to roll the end on itself to thickness skin.
form a new helix and serve as cover for the posterior
aspect of the flap. The donor site is closed either by
Excision of Hemangioma of the
advancing the edges or by split-thickness skin graft.
Face Involving Lobule of the Ear
E With small tumors limited to the mid region of the
auricle (e.g., the antihelix), an island is resected through K The skin with the hemangioma is excised from
and through in the shape of an ellipse. the ear lobule and the preauricular region. Flap 1 is
eventually rotated to point 2.
F The defect.
L An infra- and postauricular skin flap is mobilized
G Primary closure follows the natural curve of the and rotated to cover the bare area on the lobule. The
antihelix. The helix will appear distorted and pinched. preauricular defect is closed by the technique of a face
lift in which the skin of the face is mobilized, staying
H Large tumors in the region of the antihelix may superficial to the parotid fascia.
require a postauricular skin flap for a more acceptable
cosmetic result. A curved full-thickness skin flap one M The closure.
THE EAR
A B c D
L
FIGURE 12-6
THE EAR
Type I Type II
N o
superficial temporal a.
internal maxillary a.
postauricular n.
sternomastoid m.
FIGURE 12-7
tion of the inferior cheek flap. This flap was split: the recurrent malignant melanoma with focal extension
upper portion for the anterosuperior defect and the lower into the ear cartilage, surgical margins free of tumor
section for the posteroinferior defect. The skin graft that and metastasis to four lymph nodes: one at the
is used to cover the scalp defect was sutured to the pos- posterior border of the mid portion of parotid gland
terior edge of the cheek flap. Jackson Pratt suction drains (at site of previous biopsy), the second posterior to
were used for the neck dissection while a pressure dress- the first lymph node, the third in the preauricular
ing consisting of Durafoam and antibiotic ointment area, and the fourth in the intraparotid lymph node
covered the skin graft, which was secured with a cling (close to the preauricular area)
bandage and Elastoplast. 6. Twenty-seven lymph nodes from the neck dissection
were negative for metastasis.
Final Pathology Diagnosis
There was no facial paralysis postoperatively. A
1. Lymph node negative for metastasis, clinically prosthetic ear was constructed by Dr. David Casey
supraclavicular (Fig. 12-8).
2. Fragment of muscle and fibroadipose tissue with
fibrosis and inflammation, negative for tumor, clini-
cally cranial portion of trapezius A Postoperative status.
3. Lymph node negative for metastasis, clinically
intraparotid B Pinna prosthesis in place.
4. Lymph node negative for metastasis, clinically
retrovascular C Normal pinna contralateral side.
5. Ear with surrounding skin, right excision, parotidec-
tomy, and neck dissection-1.7-cm subcutaneous
A B
c
FIGURE 12-8
THE EAR
Radical neck dissection resulted in good function 1 House WF, Hitselberger WE: Endolymphatic subarachnoid shunt for
Meniere's disease. Arch Otolaryngol 82:144-146,1965.
year postoperatively with no evidence of disease. The Kaplan HL, Norris JE, Freeman BS, Brown WG: Relapsing polychon-
patient had minimal pain in the shoulder with dritis: Report of a case. JAMA 180:164-166, 1962.
extended motion of the arm not affecting his quality of Katz AD: Preauricular sinuses: A congenital hereditary anomaly. Am
life and continued on interferon. J Surg 110:612-614, 1965.
Three years later, a positron emission tomographic Kurozumi N, Ono S, Ishida H: Non-surgical correction of a congenital
lop ear deformity by splinting with Reston foam. Br J Plast Surg
scan was negative for metastatic disease (see the section
35:181-182, 1982.
on melanoma by Dr. Karakousis in Chapter 3). Lewis JS: Temporal bone resection in treatment of tumor. ]n English
GM (ed): Otolaryngology, vol 5. Philadelphia, Harper & Row,
1986, pp 1-12.
BI BLiOG RAPHY Lewis JS, Page R: Radical surgery for malignant tumors of the ear.
Adams GL, Paparella MM. EI Fiky FM: Primary and metastatic Arch Otolaryngol 83:114,1966.
tumors of the temporal bone. Laryngoscope 81:1273-1285, ] 971. Lewis JS, Parsons H: Surgery for advanced ear cancer. Ann Otol
Alex JC, et al: Localization of regional lymph nodes and melanomas 67:364, 1958.
of the head and neck. Arch Otolaryngol Head Neck Surg 124: Luckett WH: A new operation for prominent ears based on the
135-140, 1998. anatomy of the deformity. Surg Gynecol Obstet 10:635-637, 1910.
Argamaso RV, Lewin ML: Repair of partial ear loss with local com- McNicoll WD: Eustachian tube dysfunction in submariners and
posite flap. Plast Reconstr Surg 42:437-441, 1968. divers. Arch OtolaryngoI108:279-283, 1982.
Ariyan S, Sasaki CT, Spencer D: Radical en bloc resection of the Medina JE, Park AO, Neely JG, Britton BH: Lateral temporal bone
temporal bone. Am J Surg 142:443-447, ]981. resections. Am J Surg 160:427-433, 1990.
Bailin PL, Levine JL, Wood BG, Tucker HM: Cutaneous carcinoma Mladick RW, Horton CE, Adamson JE, Cohen BI: The pocket prin-
of the auricular and periauricular region. Arch Otolaryngol 106: ciple: A new technique for the reattachment of a severed ear part.
692-696, 1980. Plast Reconstr Surg 48:219-223,1971.
Bagdasarian RS, Barcer SR: Surgery for the congenitally malformed Mustarde JC: The correction of prominent ears using simple mattress
external ear. Ear Nose Throat J 62:12, 1983. sutures. Br J Plast Surg 16:170-176, 1963.
Brent B: The correction of microtia with autogenous cartilage grafts: Myers EN, Stool S, Weltschew A: Rhabdomyosarcoma of the middle
II. Atypical and complex deformities. Plast Reconstr Surg 66: 13-21, ear. Ann Otol 77:949-958, 1968.
1980. Nelson WR, Kell JF Jr, Kay S: Temporal bone resection and radical
Brown lB, Fryer MP, Morgan LR: Problems in reconstruction of the neck dissection for basal cell carcinoma with metastases. Surg
auricle. Plast Reconstr Surg 43:597-604, 1969. Gynecol Obstet 115:585-592, 1962.
Byers RM, Smith JL, Russell N, Rosenberg V: Malignant melanoma of North JF, Broadbent NRG: Correcting the flat helix. Br J Plast Surg
the external ear. Am J Surg 140:518-521, 1980. 30:310-312, 1977.
Coleman CC Jr: Removal of the temporal bone for cancer. Am J Surg Ohlsen J, Vedung S: Reconstructing the antihelix of protruding ears
112:583, 1966. by perichondrioplasty: A modified technique. Plast Reconstr Surg
Conley JJ, Novack AJ: The surgical treatment of malignant tumors of 65:753-762, 1980.
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Dehner LP, Chen JTK: Primary tumors of the external and middle ear. Otolaryngol 92:106-113, 1970.
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the shape of ears. Laryngoscope 72:915-924, 1962. rim grafts. Ann Plast Surg 9:475-478, 1982.
THE EAR
Ward CE, Lock WW, Lawrence W Jr: Radical operation for carcinoma Wright JW Jr, Taylor CE: Tomography and the facial nerve. Trans Am
of the external auditory canal and middle ear. Am J Surg 82:169, Acad Ophthalmol Otolaryngol 72:103-110, 1968.
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Woolf RM, Broadbent TR: Repositioning of prominent ears. Ann Plast
Surg 1:154-162, 1978.
13 FRACTURES OF FAE
BONES
JOHN M. LOR~,JR.
DOUGLAS W. KLOTCH
595
FRACTURES OF FACIAL BONES
tact with electrolytes containing hydrogen and oxygen Reduction of Fractured Nose
(thus leading to metallosis) and when damaged by fric- (Fig. 13-2)
tional forces (Muller et aI., 1963). Vitallium (a cobalt-
chromium-molybdenum-nickel alloy) is reportedly Highpoints
resistant to corrosion and can remain in situ indefinitely
(Venable et aI., 1937). 1. Early reduction within 24 hours is done if feasible
The minifixation plate (Thorp-Synthes) has revolu- despite edema (unless massive).
tionized the fixation of facial fractures and has virtually 2. Clinical evaluation is far more important than radio-
replaced wire fixation. However, in certain situations graphs.
when the variety of miniplates is not available, wire 3. Topical or local anesthesia is used except in an
fixation can be used. Figure 13-1 gives examples of the unmanageable child.
various types of mini plate fixation. Later in this chapter 4. The simpler the method of reduction, the better.
other applications of the miniplates are shown. More 5. Preoperative and postoperative photographs are
details of this type of fixation can be obtained from the advised, as well as notation and evaluation of a
Manual of Internal Fixation in the Crania-Facial Skeleton, history of unconsciousness.
edited by J. Prein with contributions by D. W. Klatch,
P. N. Manson, B. A. Rahn, and W. Schilli.
FIGURE 13-1 Examples of the various types of miniplate fixation. (Courtesy of Synthes Corporation, West Chester,
PA.)
FRACTURES OF FACIAL BONES
A c
FIGURE 13-2
FRACTURES OF FACIAL BONES
Reduction of Fractured Nose Teflon or Silastic can be helpful (see Fig. 6-13F). Although
(Continued) (Fig. 13-2) some surgeons use an Asch forceps to realign the
septum, the author believes that this instrument can
Depression of Nasal (Frontal) Process cause mucosal damage to the septum.
of Right Maxilla
F Reduction of the nasal septum is performed using
D The elevator is inserted in the right naris with the the elevator with the broad side against the convex
broad surface against the lateral nasal wall. deformity. Medial pressure is exerted. Ash-type forceps
are not recommended.
E The elevator is low in the nasal pyramid. The thrust
is in an outward and lateral direction. Again, prying G Nasal packing using a one-half inch gauze strip
is to be avoided; no counterpressure on the nose is impregnated with antibiotic ointment is placed in one
indicated. naris to overcorrect the deformity. Such packing is also
used in severely comminuted fractures of the external
bony vault.
The nasal septum is usually displaced in fractures of
the external bony framework. Maintenance of reduc- H An aluminum, foam rubber-covered splint, plaster,
tion is difficult, because the cartilage tends to snap out or dental molding compound is used when severe
of position like a piece of spring sheet metal. Packing comminution is present or when there is a possibility
may be helpful. Eventually many of these patients require of misalignment. External sheets of lead and silicone
submucous resection of the septum or septoplasty if with through-and-through sutures are rarely needed
the nasal obstruction is severe. Internal splinting with (see Fig. 11-12F).
FRACTURES OF FACIAL BONES
D E
Fracture of Condylar Process- with the shorter end lying along the outer surface of
Outline (see Fig. 13-3) the teeth. The longer end is passed below and then
above this outer wire, forming a small loop of sufficient
By and large the consensus in fractures of the condylar length to allow for final twisting and the formation of
process is conservative closed manipulation under anal- a hook. The short outer end of the wire is raised forward
gesia or general anesthesia. This is followed by inter- each time the long interdental end is first placed between
maxillary fixation, using arch bars connected with rubber the teeth. This aids in the placement of the interdental
bands or interdental wires (see B, C, and G). This tech- end in the under and over positions. This procedure is
nique may lead to trismus. In children there may be a repeated on the maxillary teeth and on the opposite side.
question regarding interference with the growth center,
and some surgeons suggest open reduction. This is per-
formed through a preauricular incision (see Fig. 17-1), C Small pointed pliers or a heavy needle holder is
taking extreme care not to injure the facial nerve. used to twist the loops. The loops are first pulled forward
Intraosseous wires through drill holes proximally and and outward before twisting is begun. The loops on
distally are then inserted. These wires must be heavy the mandible are bent downward, and the loops on
enough to avoid subsequent breaking of the wires. the maxilla are bent upward to form hooks around
which rubber bands are placed (G).
Complications of Mandibular Fractures
D Intramedullary fixation is done with a Kirschner
• Infection wire. The neural canal is to be avoided when drilling
• Nonunion the holes. Exposure of the fracture site is similar to that
• Malunion depicted in Figure 13-6B to F. See Figure 13-22 for the
• Malocclusion use of compression-type plates.
• Ankylosis of temporomandibular joint
E After the Kirschner wire is inserted, malleable silver
See Figures 14-9 and 14-lOA to C for additional or stainless steel wire is inserted through drill holes to
mandibular procedures. maintain approximation. This type of internal fixation
is left in place permanently. If a Kirschner wire is not
used, the interosseous wire should be in the form of a
A A Barton-type bandage is an excellent temporary
figure-eight pattern, or two wires should be used.
support. It allows oral suction to be done easily and
can be released quickly if necessary. Kling is an admirably
F Another method of fixation with a Kirschner wire is
suited material for the bandage. A plaster Barton-type to insert the wire through a small stab wound in the
bandage is also excellent (Bartkowski, 1982). The ante- chin and use a Kirschner wire drill to pierce the thick
rior extension over the chin is avoided if there is danger cortical bone and thence through the medullary canal.
of posterior displacement.
G The Kirschner wire is shown in position. It may be
B Interdental wire 25 em in length is used. The used in conjunction with Erich arch bars when neces-
material may be either Angle's standard brass ligature sary to maintain proper reduction and occlusion. The
wire (0.508 mm) or stainless steel wire size NO.4 or Kirschner wire may be removed or left in situ when the
No. 26. fracture heals. Straight Kirschner wire should not be
used for fixation of fractures or reconstruction of the
With a single wire, multiple loops are formed around ascending ramus, because the wire may migrate supe-
four teeth starting with the first or second molar and riorly into the skull.
working forward. The wire is placed around the molar
FRAGURES OF FACIAL BONES
FIGURE 13-3
FRACTURES OF FACIAL BONES
FRACTURES OF MANDIBLE
Douglas W Klatch
Highpoints
Incisions
FIGURE 13-6
FRACTURES OF FACIAL BONES
Fracture Types
FIGURE 13-7 Lag screw for oblique fractures. FIGURE13-9 Tension band splint and stabilization plate.
FRAcruRES OF FACIAL BONES
FIGURE 13-12 Reconstruction plate (bridging plate) for Open Repair for Angle Fractures
comminuted fractures.
1. Noncomminuted: May be applied with intraoral
approaches but generally require transbuccal screw
Open Repair of Body Fractures application. When comminution and significant dis-
location occur, extraoral approaches are generally
1. Noncomminuted: advised. The less experienced surgeon with minimal
a. Nonoblique fractures may be treated with the assistance should gain experience with extraoral
following: approaches unless fractures are simple and can be
(1) Tension band splint and stabilization plate: repaired by the single linea obliqua plate placement
when no comminution and stable teeth in the described below.
mandibular arch
(2) Tension band plate and stabilization plate
(a) Monocortical placement of the tension
FIGURE 13-16 Miniplate repair of angle fracture FIGURE 1 3-1 7 Tension band plate and 2.0-mm
(Champy). mandible plate for angle fracture.
FRACTURES OF FACIAL BONES
Open Repair for Condylar Fractures (2) Repair with single mandibular plate (2.0 mm).
Be careful not to use thinner 2.0-mm midface
1. Fracture type: deviated, displaced (severe displace- plates because these may fracture.
ment produces telescoped fracture), and dislocated c. Mid condylar
a. Indications for open repair: (1) Requires retromandibular, trans parotid, sub-
(1) Deviation greater than 45 % mandibular (Risdon), or combined approach
(2) Dislocation of the condylar head d. Low condylar (subcondylar) (Fig. 13-20)
(3) Displacement where there is no bone contact (1) It frequently may be approached intraorally.
or telescoping of the fracture segment. Tele- (2) When associated with ascending ramus frac-
scoping will result in an open bite deformity ture, it may require a long fracture or recon-
if not corrected. struction plate.
(4) Bilateral unstable condylar fractures (3) Comminuted fragments may be either linked
(5) Concomitant midface fractures increase need together with several smaller plates and united
for condylar repair to help position and support with a stabilization plate or bridged with a
the midface as well as to help establish the reconstruction plate.
length and width of the facial anatomy.
2. Fracture location: intracapsular, high condylar, mid Open Repair of Coronoid Fractures
condylar, low condylar (base of condyle) (Fig. 13-19)
a. Intracapsular: 1. Rare fractures occur without association with com-
(1) Generally treat with rapid mobilization. minuted mandibular fractures.
(2) There is no role for ORIF. a. If isolated and nondisplaced, no repair is required.
b. High condylar b. If dislocated and affecting occlusion, then fixation
(1) Preauricular incision with small plates is needed. Fragments may be
pulled into the maxillary tuberosity and cause
trismus or inability to obtain occlusion.
Mechanical Principles
a. The use of bridging plates (2.4 mm) may be con- 1. Ideally, placement of the fixator at the tension side
sidered with at least four screws in each segment. will provide greatest stability (gap stability).
b. Very atrophic cases may be repaired with smaller 2. Tooth roots may not allow placement of the plate at
long plates such as the universal fracture plate the tension (alveolar) side.
designs (2.0 mm) (see Fig. 13-21). 3. The inferior alveolar nerve canal should be avoided
(no man's land).
4. These limiting factors generally require plate place-
Compression Plating for ment on the less ideal compression side (basilar or
Treatment of Mandibular inferior position) of the mandible.
Fractures (Fig. 13-22)
Douglas W Klatch and Joachim Prein B A special plate and screw design provide the neces-
sary interfragmentary compression, which enhances
This is a historical description as in the previous edition stability and allows for primary bone healing.
of this atlas. Refer to Fractures of the Mandible for 1. The gliding screw principle is provided by the
more current plating principles and systems. development of a screw hole that is thicker on its
outer end; it functions as an inclined plane. The
Indication spherically designed screw head can easily glide
along this hole to provide a compression force.
• To establish absolute stability, providing anatomic
2. Screws closest to the fracture are placed eccentri-
repositioning with restoration of occlusal and func-
cally by a specially designed drill guide that allows
tional relationships
for positioning of the screw hole 0.8 mm from the
thinner aspect of the screw hole. This eccentric place-
Advantages ment allows the spherical screw head to contact the
• Early mobilization of mandible, decreasing trismus inclined wall of the hole and to provide a force in
post stabilization the direction of travel of the screw.
• Immediate return to normal route of alimentation 3. The large arrow in the diagram (B and B1) indicates
• Early return to work without limitations the direction of the compression force developed
• Normal access to airway without interference of inter- when tightening the screw placed in the eccentric
maxillary fixation position.
• Rapid primary, not secondary, bone healing 4. All other screws placed by the thinner aspect of the
plate hole are in the neutral position. The screw head
Disadvantages does not contact the incline located at the thick
wall of the plate hole, and no compression force is
• Facial scar developed. Screws placed in the neutral position
• Surgical procedure requiring special instruments and provide stabilization of the plate without providing
skills compression.
• Removal of stainless steel plates after a year
FRAaURES OF FACIAL BONES 611
MUSCLES OF MASTICATION
\
FORCE OF MASTICATION
TENSION SIDE j
~¢INCLINED PLANE
.. ~
A ~PRESSORS OF
MANDIBLE
ERNST LIGATURE
B
.
.. - We.bnT~
B1
FIGURE 13-22
81 The screw position is shown after correct fixa- C The objective of any method for repairing a
tion. The innermost screws (closest to the fracture) are mandibular fracture is to restore the patient's occlu-
placed in the eccentric position. Note that the screw sion and mandibular function. Therefore, the patient
head contacting the gliding screw hole produces inter- must be placed into correct occlusion before opening
fragmentary compression in the direction of the two the fracture and applying internal fixation. This may be
arrows. The outer screws are placed in the neutral achieved by application of conventional arch bars or
position. No contact of the screw head with the gliding by placement of Ernst ligatures. The choice of fixation
(inclined) portion of the screw hole occurs, and no is dependent on the location of the fracture.
compression force is developed. It is important to place Continued
the screwsclosest to the fracture eccentrically to provide
for the greatest interfragmentary compression. It is
essential to place all other screws neutrally to avoid
distraction of the compression force already developed.
FRACTURES OF FACIAL BONES
Compression Plating for plate (DCP). The tension band splint is an arch
Treatment of Mandibular bar that is fixed to at least two stable teeth at
Fractures (Continued) (Fig. 13-22) either side of the fracture.
b. Lag screws may be utilized for oblique fractures
A minimum of two Ernst ligatures is required, one (see J).
on each side of the mandible. Placement of cold-cure c. The dynamic bendable defect-bridging (OBOB)
acrylic around the twisted ends of wires helps to stabi- plate is used for areas in which there is marked
lize them and to maintain normal occlusal relationships comminution or bone loss or in places in which
during the procedure. the placement of the straight ocr may jeopardize
the inferior alveolar nerve (see I).
1. The Ernst ligature is a figure-eight self-tightening 2. Fractures in edentulous patients may be ideally
ligature placed around two stable teeth-two in the repaired by rigid internal fixation, but a minimum of
maxillary arch and two in the mandibular arch. approximately 6 mm of cortical bone is required to
2. Ligatures are placed on corresponding maxillary and apply internal fixation for patients with atrophic
mandibular teeth and then twisted together to place mandibles. The procedures used may include the
the patient into intermaxillary fixation. following:
3. Ernst ligatures generally provide stable occlusion for a. The six-hole eccentric dynamic compression plate
fractures posterior to the teeth. They are also ade- (EOCP) (see H)
quate for anterior fractures in which good occlusal b. Lag screws for mandibles with oblique segments
relationships existed preoperatively and in which c. OBOB plate for comminuted fractures or areas in
teeth are stable for maintaining fixation. For patients which there is bone loss or severe atrophy of the
with preexisting malocclusion or multiple unstable mandible and in which placement of the straight
teeth or for patients with concomitant midface frac- EOCP may jeopardize the nerve (see L)
tures, conventional arch bars stabilized with acrylic 3. Fractures occurring posterior to the tooth row (Le.,
provide for better fixation of occlusion. angle fractures) may be repaired with the following:
a. The tension band plate (two-hole OCP) in combi-
nation with a four-hole OCP as a stabilization
D Special reduction forceps have been developed to plate (see G)
aid in precise application of internal fixation. These b. The lag screw for oblique fractures (see J)
forceps are placed at the inferior cortical rim. c. Six-hole EOCP (see H)
d. OBOB plate for comminuted fractures or situations
1. Forceps allow for reduction of fractures.
in which placement of a straight plate (OCP or
2. Special compression rollers should be used for
EOCP) might jeopardize the nerve (see I)
fractures in which tension band splints or tension
4. Injuries with large segmental bone loss may be
band plates cannot be applied. They are especially
bridged with the OBOB plate. There must be at least
useful in the reduction of angle fractures and are
four screws to fix the plate to each bony segment
essential for the correct application of the eccentric
(see L).
dynamic compression plate (EDCP, not pictured).
3. Forceps allow for establishment of a preload that
compresses the two ends of the fracture together.
This interfragmentary force is maintained by the E Incorrect method. The correct bending of the plate
special dynamic compression plate design. to fit to the contour of the mandible is important.
Incorrect bending (1) of the plate will tend to distract
The addition of compression rollers allows for better
the lingual cortex and (2) produce instability. Arrows
distribution of the interfragmentary force for fractures
in (2) depict this distraction.
occurring at the angle. They also are necessary to
provide for the correct distribution of the preload
El Correct method. In combination with the eccen-
before applying the EDCP.
trically placed inner screw providing interfragmentary
compression beneath the plate, slight overbending (3)
Outline of Procedures for Rigid Internal of the plate allows for lingual cortical compression.
Fixation This is depicted by the arrows in (4). This slight over-
bending technique is required to allow for equal distri-
1. Fractures occurring within the tooth row may be bution of the interfragmentary compression force along
repaired by one of the following: the fracture line.
a. A tension band splint (see F) may be used in Continued
combination with a six-hole dynamic compression
FRACTURES OF FACIAL BONES
3 4
~)
E1
It/abn! '"
SLIGHT OVERBENDING OF PLATE PROVIDES COMPRESSION AT OUTER AND INNER CORTICES
FIGURE13-22 Continued
FRAcnJRES OF FACIAL BONES
Compression Plating for tector at all times. Again, the hole should be irrigated
Treatment of Mandibular after the tap is removed.
Fractures (Continued) (Fig. 13-22) 10. The appropriately measured 2.7-mm diameter screw
is then placed in each of these eccentrically drilled
Fracture in Row of Teeth and tapped screw holes. Before tightening the screws,
the thumb screw of the reduction forceps (see 0)
Highpoints should be loosened and the pliers held manually,
which allows maintenance of the preload without
1. Patients may be anesthetized via nasotracheal intu- restricting the development of interfragmentary com-
bation. pression as the screws are tightened.
2. The oral cavity should be copiously irrigated. 11. The remaining outer two screws at either side of the
3. Closed reduction of the fracture is performed. fracture are placed in the neutral position (see Bl).
4. The tension band splint is then placed as previously These increase the stability of the plate system.
described and is stabilized with cold-cure acrylic. 12. Only tight screws are functional and should remain.
5. The occlusion must be held in a fixed relationship a. All loose screws should be removed to prevent
before opening the fracture and placing the plate. osteolysis and subsequent infection at the loose
Ernst ligatures (see C) are usually adequate, but arch screw hole.
bars may be necessary if the occlusal relationships b. Careful drilling and use of irrigation with careful
are unstable. tapping prevents loose screws.
6. A cervical incision is placed well below the mandible 13. Hemovacs are utilized to provide drainage. The
(see Fig. 13-6) in the appropriate lines of "facial" wounds are closed. At the end of the procedure the
expression to limit scars. temporary intermaxillary fixation is removed. The
a. The ramus mandibularis should be preserved, tension band splint, however, remains until 6 weeks
but sacrifice of the facial artery and vein may be postoperatively, at which time it is removed.
required to gain exposure. Likewise, the cervical 14. Patients can be placed on a soft diet immediately,
branch of the facial nerve may be divided with- as tolerated.
out producing residual disability. However, the 15. Good oral hygiene is important while the tension
platysma muscle should be carefully approximated band splint is in place.
at the time of closure, because it contributes to
the depressor of the lower lip. Fracture Posterior to Row of Teeth
b. The inferior cortex of the mandible is exposed,
but only a limited stripping of anterior periosteum Highpoints
should be performed (only enough for plate
placement) . 1. After closed reduction is achieved, occlusion can
7. The reduction forceps (see 0) are placed at the infe- generally be held into a fixed position by means of
rior cortex with 8- to lO-mm long and 2.7-mm wide Ernst ligatures (see C).
screws. They are positioned approximately 1 em 2. The fracture is exposed via a skin incision approxi-
from the edge of the fracture. These forceps allow mately 3 em from the angle of the mandible.
for an anatomic reduction and provide for a pre- 3. Reduction forceps with rollers are attached to the
load before the application of interfragmentary com- inferior edge of the mandible (see 0).
pression via the compression plates. 4. The two-hole ocr tension band plate is first applied
8. The six-hole OCP is then slightly overbent (see El) at the alveolar cortical side, and the screws are placed
to allow for compression of both the inner and in the eccentric position utilizing 2.7-mm screws, as
outer cortices of the mandible. previously described.
9. The plate is then held into its position by special 5. The four-hole (OCP) stabilization plate is placed at
plate-holding forceps. With the special eccentric the inferior aspect of the mandible. The inner screw
drill guide, a 2.0-mm drill bit is used to drill the holes (closest to the fracture) are placed eccentrically,
screw holes. Care must be taken to irrigate copiously with the outer holes placed in the neutral position.
during the drilling procedure. First, the innermost Before tightening the inner screws, the thumbscrew
holes are drilled in the eccentric position (see B). of the reduction forceps is loosened so as not to
These are the holes that are closest to either side of restrict the plate function.
the fracture (see Bl). The depth gauge is then 6. Layered closure with placement of Hemovacs is com-
placed through the plate hole as well as bone hole pleted, and the intermaxillary fixation is removed at the
to measure the screw length. The bone holes are procedure's end. The patient may be placed on a dental-
then tapped with a 2.7-mm tap, using a tissue pro- soft diet immediately after fluids are well tolerated.
FRACTURES OF FACIAL BONES
F The repair of fractures occurring in a row of teeth G Fixations of fractures posterior to the row of teeth
is achieved by the use of the tension band splint in (i.e., angle fractures) use the tension band plate (two-
combination with the stabilization plate. The tension hole OCP) and stabilization plate (four-hole OCP). When-
band splint is a small piece of arch bar fixed to at least ever possible the surgeon should use this technique,
two stable teeth on either side of the fracture. It can be because the placement of the tension band plate at
further stabilized by placing cold-cure acrylic around the alveolar side with the combination of stabilization
the arch bar and wires that fix the bar to the teeth. plate at the inferior side provides the maximal gap
Care must be taken not to allow the acrylic to contact stability.
the gums. The tension band splint functions similarly Continued
to the cable in a suspension bridge and greatly helps
to increase the gap stability at the tension side of
the mandible. The six-hole dynamic compression plate
(OCP) provides interfragmentary compression and
stabilization.
FRACTURES OF FACIAL BONES
Compression Plating for 3. The EOCP is bent with slight overbending (see E1).
Treatment of Mandibular The inner screw holes are placed eccentrically as
Fractures (Continued) (Fig. 13-22) described previously, allowing for interfragmentary
compression. Next, the outermost 45-degree angle
Fractures at Angle of Mandible screw holes are placed eccentrically. Before these
screws are tightened, the thumbscrew of the reduc-
An alternate method of internal open intraoral fixation tion forceps should be loosened to allow for the
of noncomminuted, straight line fractures at the angle development of the inner fragmentary compression
of the mandible has been described by Niederdellmann force by the plate without restriction. The middle 45-
with a follow-up of 50 patients. Usually one, at times degree angle screws may be placed in either the
two, and rarely three lag screws are employed. The pro- neutral position, if there is good distribution of the
cedure is basically an intraoral transbuccal operation, compression force around the fracture line, or in the
which eliminates wide extraoral exposure of the frac- eccentric position, if more compression is needed at
ture site. The author has no personal experience with the alveolar cortical side.
this method. 4. The wounds are closed with Hemovac drains and
removal of intermaxillary fixation as previously
Use of Eccentric Dynamic Compression described.
Plate
H, Hl, H2 Repairs of fractures distal to the posterior
The EOCP has outer screw holes either at the 45-degree
tooth row (i.e., angle fractures) utilizing the EDCP.
angle (see H) or the 90-degree angle (see Hl) to the
longitudinal axis of the plate. The 90-degree EDCP (Hl)
represents an older design. The newer 45-degree EOCP Use of Dynamic Mandible Defect-
has the outer two screw holes at a 45-degree angle to Bridging Plate
the long axis of the plate. When using the 45-degree
plate, screws placed eccentrically in these holes produce Occasionally, the fractures distal to the posterior teeth
a force at 45 degrees to the longitudinal axis of the are extremely comminuted and there is concomitant
plate. Therefore, when this plate is placed inferiorly, bone loss. There may also be a difficulty with atrophic
the two inner screws (holes are oriented along the axis mandibles that do not allow for the application of either
of the plate) are first placed to provide for interfragmen- EOCP or the tension band plate stabilization plate
tary compression beneath the plate. When the outer methods. The reconstruction plate (OBOB), which is
45-degree screws are placed at the eccentric position, bendable in three dimensions, can provide for stabiliza-
they provide a pressure force at 45 degrees to the long tion of bony fragments for these patients.
axis of the plate, thereby providing alveolar cortical com-
pression and a more even distribution of the interfrag- Highpoints
mentary compression force along the entire fracture
line, which subsequently increases gap stability, and 1. Minimal compression can be provided.
the resultant stabilization is strengthened. 2. Preferably, four screws should be placed at either
side of the fracture.
Highpoints 3. This is the least stable of the plate systems and should
be utilized only when necessary.
1. The EOCP is utilized for fixing angle fractures when 4. Approximately 6 mm of available cortical bone is
there is an inability to use the two-plate system. The necessary to apply this system.
surgeon must be aware that the EOCP is not as 5. The stabilization of occlusal relationships, exposure,
stable as the tension band plate stabilization plate and, if possible, reduction with reduction forceps is
fixation method. achieved. Frequently, the reduction forceps are not
2. The steps for closed reduction include stabilization beneficial if severe comminution exists.
of occlusion, exposure of fracture, and application of 6. It is helpful to use an aluminum template to plan how
reduction forceps with rollers as described in G. the three-dimensional OBDB plate should be bent.
FRACTURES OF FACIAL BONES 617
H2
t~~·~O-G1
75° EDCP
DBDB PLATE
ECCENTRIC DYNAMIC COMPRESSION PLATE (75° OR 90°) RECONSTRUCTION PLATE
( ALSO FOR EDENTULOUS MANDIBLE)
FIGURE13-22 Continued
7. Generally, all screws are placed in the neutral posi- the patient's diet too rapidly; generally, the patient is
tion; however, slight interfragmentary compression kept on a dental-soft diet for approximately 6 weeks.
can be achieved if screws are placed eccentrically:
After the termination of the placement of the OBOB
plate, the wounds are closed as previously described I Repair of fractures posterior to the row of teeth
with Hemovac drainage and intermaxillary fixation (i.e., angle fractures) is shown using the dynamic bend-
may be removed. Care must be taken not to advance able defect-bridging (DBDB)plate.
Continued
FRACTURES OF FACIAL BONES
Compression Plating for S. A 2.G-mm drill guide sleeve is then placed into the
Treatment of Mandibular hole to allow for drilling of a 2.G-mm hole in the
Fractures (Continued) (Fig. 13-22) inner cortex.
6. The outer cortex is drilled with the hole counter-
Fracture in the Edentulous Mandible sunk to allow the spherical screw head to fit with-
out fracturing or displacing the bone.
Fractures occurring in the edentulous mandible are 7. The depth gauge is utilized to measure the screw
ideally suited for repair via rigid internal fixation. Pre- length so the screw will grip the entire length of the
existing dentures or splints are rarely needed, because inner cortex.
direct repair of bony fragment without establishing 8. The inner cortex is now tapped to 2.7 mm, and the
intermaxillary stabilization produces good functional appropriately measured 2.7-mm screw is placed.
results. 9. The two other screws are also positioned in the
same fashion to provide for interfragmentary com-
Highpoints pression and torsional stability.
10. Intermaxillary fixation may then be removed and
1. The fracture can usually be reduced without stabiliz- the patient placed on a dental-soft diet for about
ing occlusal relationships. 6 weeks. Generally, after that time normal diets can
2. The mouth is irrigated, and an appropriate incision be resumed.
with exposure of the mandible is performed.
3. The reduction forceps are placed on the inferior cortex
(if there are two fractures, use two forceps) (see D). J The lag screw principle is the foundation for the
It is important to utilize adaptation rollers to reduce establishment of interfragmentary compression for
the fracture when the EDCP is to be applied. oblique fractures. The screw may be used by itself to
4. The EDCP should be slightly overbent and held into . fix long oblique fracture segments occurring within
position with a bone-holding forceps. The screws are the mandible. Preferably, three screws should be used
placed as previously described by first placing the to fix an oblique segment to stabilize the rotational
inner screw holes eccentrically. Second, the outer forces and to provide for adequate rigid fixation.
4S-degree screws are placed eccentrically as previ-
ously described. The middle 4S-degree holes should K Short oblique fracture fragments may be repaired
generally have screws placed in the neutral position. by the combination of the lag screw and the stabiliza-
S. The wounds are closed with Hemovac drains in place. tion plate. Here, the lag screw placed through the
The patient may eat a dental-soft diet as tolerated. It plate in the neutral position provides interfragmentary
is important not to have the patient wear the lower compression. Allof the other screw holes through the
denture for at least 6 weeks. When swelling sub- six-hole Dcr are placed in the neutral position, with
sides, the lower denture may be worn, and, gener- tapping of both cortices as previously described. When
ally, patients can resume their normal diet at that using the lag screw with stabilization plate, no holes
time. should be drilled eccentrically, otherwise this willforce
6. Comminuted fractures involving the edentulous overriding of the bone fragments and loosening of the
mandible may also be repaired by utilizing the DBDB lag screw, with loss of interfragmentary compression.
plate. It is applied as previously described (see I).
LAG SCREWS
L
K BRIDGING OF LARGE MANDIBULAR
DEFECTS
2. Have at least four screws at each side of the defect. 6. Preferably provide adequate soft tissue coverage.
3. Establish a fixed occlusal relationship before bending However, plates will tolerate being exposed usually
the plate. without extrusion if only a secondary closure is
4. Do not overbend the plate. Use the special pliers so possible.
as not to weaken the plates. Use an aluminum tem- 7. Primary or secondary bone grafts may be utilized
plate (made from the resected mandible) to guide in . depending on the injury and defect. The plate pro-
bending the plate so as to lessen manipulation that vides a relatively stable bridge for large defects and
would cause undue weakening of the plate. allows for reconstruction of anatomic relationships
5. The plate may be used with or without primary bone and functions. If primary bone grafts are utilized,
grafting (cancellous, cortical, osteomyocutaneous, or adequate vascularized tissue must surround the
free vascularized). graft and plate.
8. The surgeon must provide a layered closure of
wounds with watertight closure of mucosa.
L Bridging of large mandibular defects with the Hemovacs are placed. No pressure dressing should
DBOBplate is shown. be placed over the flap covering the plate to avoid
necrosis of tissue.
9. A preoperative bolus of antibiotics appropriate to
The following steps should be observed when utiliz- cover oral flora with a 7-day postoperative course
ing the OBOB plate: is recommended. Good oral and wound care is
imperative.
1. Reestablish and maintain occlusal relationships 10. Patients must not wear a functional denture over a
before placing the plate. plate, although they might place the denture over
2. Utilize an aluminum template whenever possible the plate for cosmetic purposes. The diet should be
to allow for more accurate bending of the plate. Try restricted to soft foods (e.g., chopped meats, chicken,
not to rebend the plate, which will cause weakening. fish, soft vegetables). After successful bone healing
3. Use a plate long enough to provide at least four the .patient may wear functional dentures, and a
screws at each stump. regular diet may be resumed.
4. Drill (2.0 mm), measure depth, tap 2.7 mm, and
place 2.7-mm screws as previously described. For an alternate method of repair using Kirschner
5. Remove any loose screws. wires and tie wires see Figures 14-5 and 14-6.
FRACTURES OF FACIAL BONES
B D E
. Temporalis m.
FIGURE 13-23
FRACTURES OF FACIAL BONES
Wabmtr
FIGURE 13-24
Occasionally, when the medial infraorbital rim frac- To obviate this problem, a figure-eight suture with the
ture is oblique and cannot be corrected nor the reduc- ends twisted on the medial side is used. The crossing
tion maintained, open reduction and interosseous wiring of the figure-eight suture is located within the fracture
may be required. Simple through-and-through wires site. A small hook is used to feed the wires within the
may tend to cause overriding of the medial fragment. fracture site.
FRACTURES OF FACIAL BONES
FIGURE 13-25
FRACTURES OF FACIAL BONES
Wabr1iR
E F
FIGURE 13-26
FRAOURES OF FACIAL BONES
"Tent Peg" Method of Reduction C A small incision is made over the fractu re site of
and Fixation of Facial Bone the lateral orbital rim. Fibers of the orbicularis oculi
Fractures (Fig. 13-27) (Straith, 1958) muscle are separated, taking care not to injure either
sensory or motor nerve fibers. With the use of a Kirschner
Indication drill, a Kirschner wire is inserted through a previously
made stab wound into the cortex of the bone above
Occasionally, a fracture in the zygomaticofrontal region the fracture site. The depth of insertion is from 0.5 to
of the orbital rim is so high and the superior edge of the 1.0 em. The wire is placed so that the buried end is at
fracture is so close to the cranium itself that intra- an angle toward the fracture site and the projecting
osseous wiring through drill holes would require that end away from the fracture site. The wire is cut with
the twisted ends of the wire be placed within the orbit. about 1.5 em projecting beyond the skin surface.
To avoid this, small sections of Kirschner wire inserted
in an angle serve as pegs around which the intraosseous D Stainless steel wire No. 0 is looped around the peg
wire is secured. This method is seldom referred to, yet and drawn into the wound with a clamp. If desired,
it is worthwhile to keep in one's armamentarium when the wire may be drawn through with a needle at each
mini plates are not available. free end.
FIGURE 13-27
FRACTURES OF FACIAL BONES
Open Reduction of Complete This wire is looped over the rim and passes into the
Fracture of Upper Dental Arch region of the canine fossa. A needle may be necessary
of Maxilla (Le Fort I or Guerin) to guide the two ends of the wire along the anterior
(Fig. 13-28) wall of the maxilla into the mouth. The displaced frac-
ture is then reduced and held in place by an assistant,
See page 596 for examples of the various types of mini- with upward pressure on the mandible closing the
plate fixation. mouth. The two ends of the wire may be secured to
There are a number of methods of reduction and either a lower arch bar or an upper arch bar. When
immobilization of this type of fracture. Depicted are secured to a lower arch bar, occlusion is immediately
two methods: achieved and maintained when the mandible is intact.
The main caution is the fact that the jaw is wired
1. Suspensory wires (see C through F) closed, and this should not be performed while the
a. From infraorbital rim patient is under general anesthesia because of the
b. From lateral orbital rim danger of aspiration.
2. Direct intraosseous wiring (see G)
F G
FIGURE 1 3-28
FRACTURES OF FACIAL BONES
FIGURE 13-29
FRACTURES OF FACIAL BONES
FIGURE 13-30
FRAOURES OF FACIAL BONES
A Illustration depicts an internal fixation of this "ideal" These are fractures that have a typical posterocortical
fracture with Y and L mini plates at anterior and medial dislocation with an open bite.
FIGURE 13-31
FRACTURES OF FACIAl BONES 637
FIGURE13-31 Continued
E -Internal fixation is done with L-plates for the lateral F Shown is the Le Fort III fracture with zygomatic
vertical buttress and adaptation plate infraorbitally and fracture on the left with its usual displacement. Expo-
for the nasoethmoidal region. Inset shows fixation sure is via a modified face-lift incision. The technique is
with one Y-plate instead of two miniplates. fixation with mini plates.
FRAcruRES OF FACIAL BONES
Highpoints Frontal sinus fractures that involve the inner table with
very minimal displacement associated with evidence of
1. Avoid unnecessary removal of teeth. cerebrospinal fluid leak present a dilemma as to whether
2. Maintain correct occlusion; if arch bars or interdental the frontal sinus should be explored. The question rests
wires are necessary, they should be connected only on whether the nasofrontal duct is obstructed, and, if
after the danger of aspiration is over. so, whether this could contribute to meningitis and
3. Tracheostomy may be necessary if there are severe possibly subdural abscess or intracranial "air." Each
lacerations of the tongue. patient should be evaluated individually, preferably
4. Reduce nasal fractures concomitantly. with neurosurgical consultation. Skull radiographs and
CT, both coronal and axial views, for evidence of air-
There is a fracture through the nasal floor and hard fluid levels in the sinus and of intracranial "air" as well
palate with a lateral extension into the antrum. Soft as for assessing the neurologic status of the patient aid
tissue injury and nasal fractures are usually extensive. in the decision as to whether surgical intervention may
Careful evaluation of lacerations of the tongue is manda- be indicated. Massive antibiotics, which cross the blood-
tory for repair, and usually elective tracheostomy is the brain barrier, as well as decongestants and corti co-
safer step. Reduction can be more easily achieved with steroids are utilized. Repeat radiographs aid in follow-
miniplates. ing these patients. Follow-up should continue for months
after the injury.
Larrabee and associates (1980) have reported on a
A Two through-and-through angulated drill holes review of S4 patients treated for frontal sinus fractures.
are placed, one on each side of the fracture site. Regardless of various medical and surgical treatment
These are located anteriorly as high as possible to modalities, there were a large number of suppurative
avoid injury to the roots of the teeth. The drill holes complications. The problem appeared to be obstruction
exit in the hard palate. It is important that reduction of the nasofrontal duct leading to meningitis, subdural
be maintained during the placement of the second abscess, and osteomyelitis. Their conclusions are quoted
drill hole. in the following text and refer to all types of fractures
involving the frontal sinus, whether anterior or
8, ( Stainless steel wire No. 0 or malleable silver posterior tables.
wire No. 30 is then inserted through the drill holes
with the loop placed anteriorly. The free ends are 1. Exploration with reduction should be strongly
pulled tight and twisted intraorally. If there is any considered in every case of frontal sinus fracture,
question of malocclusion, arch bars or interdental even in apparently isolated anterior table injuries.
wires are used and connected with rubber bands (see 2. Routine obliteration in frontal sinus trauma carries a
Fig. 13-3). significant complication rate and should be avoided
in favor of open reduction if possible.
3. The complication rate in fat obliteration is lower
than that with methyl methacrylate or Surgicel.
FRACTURES OF FACIAL BONES
FIGURE 13-32
If the fracture is several days or weeks old and the One of the problems in evaluating cerebrospinal
cerebrospinal fluid leak has stopped, conservative fluid leak cessation is whether it is due to a seal off of
management is advised, because manipulation may the tear in the dura or to an obstruction in the naso-
well open the precarious adhesions that have sealed frontal duct.
the dural leak and thus lead to meningitis. These Fractures of the walls of the frontal sinus are often
patients must be followed very carefully regarding very difficult to detect on routine radiographs. Depres-
evidence of a blocked nasofrontal duct. A frontal sinus sion of the anterior wall of the frontal sinus can be
trephine (see Fig. 5-6) may be necessary as an initial completely missed on a lateral radiograph of the frontal
procedure. Later on, if necessary, an osteoplastic frontal sinus. CT is really the only radiologic study that will
approach may be warranted (see Fig. 5-8A to E). If satisfactorily evaluate the position of the bones of the
there is an associated Le Fort fracture and the maxilla frontal sinus fracture.
is still floating, conservative treatment would include Decompress the orbit in the event of entrapped air
a Barton bandage carefully placed and maintained, within the orbit, especially with evidence of fractures
possibly reinforced with plaster (Bartkowski and of the lamina papyracea of the ethmoid and/or frac-
Krzystkowa, 1982). The Barton bandage may slip on a tures of the frontal sinus. CT is excellent to delineate
patient with dentures. Consideration of the cosmetic the extent of the air as well as any cloudiness of the
deformity must be secondary to the danger of menin- ethmoidal sinus, which may indicate hemorrhage. Close
gitis and/or blindness. Reconstruction at a later date observation in the hospital is recommended until the
can be achieved in some patients with onlay autoge- patient's condition stabilizes.
nous bone grafts.
FRACTURES OF FACIAL BONES
FIGURE 13-33
FRACTURES OF FACIAL BONES
PERIOSTEUM
F G
is explored. stat)
• Glaucoma or predisposition to glaucoma
L With direct-type fractures of the floor of the orbit • Hyphema-accumulation of blood in the anterior
that are associated with one or more fractures of the chamber of the globe
orbital rim and zygomatic arch, various types of addi- • Cataract formation
tional interosseous wires may be necessary. Depicted • Injury to optic nerve and/or its arterial supply and
are fractures that are approximated and fixed with venous drainage
FRACTURES OF FACIAL BONES
FIGURE13-33 Continued
FRACTURES OF FACIAL BONES
External Traction for Depressed nuts are then tightened on each bolt securing the
Facial Fracture (Fig. 13-34) plate in position. The ends of the bolts are guarded
with sections of plastic or rubber tubing.
Occasionally, there is a need to maintain forward external 5. The Lane plate now serves as the point of external
traction in the management of a depressed facial frac- traction to which wires and rubber bands may be
ture. Plaster head caps and various other frames and secured.
devices have drawbacks, not the least of which is dis- 6. Traction is continued for about 3 weeks.
comfort for the patient. Depicted is a technique utiliz-
ing tibial bolts and an eight-hole Lane plate. equipment
readily available in most operating rooms. A There is a comminuted fracture of the left infra-
Two situations arise when such external traction is orbital rim with depression of the left malar bone and
helpful. One is when there is severe comminution of separation of the left frontomaxillary suture line and
the fragments, making a point of forward fixation diffi- zygomatic arch. Because of the comminution of the
cult to maintain. This is demonstrated in A and B. The medial portion of the infraorbital rim, it is not possible
other situation is in a delayed reduction for a midface to maintain adequate reduction despite the usual
fracture (e.g .. Le Fort II or Ill) when reduction, although wiring methods. External traction is necessary.
achieved, cannot be satisfactorily maintained, as in C
to E. B The tibial bolts and lane plate are in position.
Another method of securing superior external trac- Through a small incision over the infraorbital rim, '-0
tion is the use of a football or crash helmet. This has wire is secured through drill holes to the major depressed
been utilized in one patient with satisfactory results. fragment. The wire is brought out through the skin
Still another and more practical method is the use of and secured to the Lane plate. Other wires may be
miniplates (see p. 596). necessary to correct medial or lateral displacement.
1. Smaller incisions are made at the lateral edge of D After the suspending wires are secured to the
both brows over the stable portion of the zygomatic upper dental arch bar and the other fracture sites are
processes of the frontal bone. reduced and wired as depicted, the midface fragment
2. A drill hole is made 3 to 4 mm deep in the lower cannot be maintained in a forward position. The tibial
portion of each zygomatic process of the frontal bone bolts and lane plate are then utilized, forming a pur-
with a drill several sizes smaller than the diameter chase site for external traction. A Kirschner wire is
of the tibial bolts. passed through the frontal processes of each maxilla
3. Tibial bolts with three nuts are then screwed tightly and bent in triangular fashion. The Kirschner wire is
into the drill holes. One nut is used as a lock nut to then connected with 1-0 wire or heavy rubber bands
secure the tibial bolt to the bone. The head (distal to the Lane plate. To aid in correct occlusion, the upper
end) of the tibial bolt is cut off. dental arch bar is approximated to the lower dental
4. An eight-hole Lane plate is then slipped over the arch bar.
ends of the tibial bolts with one nut above and one
nut below the plate. Both tibial bolts are bent slightly E Shown is an anterior view of the bent Kirschner
to the midline to accommodate the plate. The two wire through the nose.
FRACTURES OF FACIAl BONES 641
c D E
FIGURE 13-34
FRAGURES OF FACIAL BONES
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14
Excision of Cysts of the Mandible 3. Scrupulously remove all remnants of cyst wall if the
wall fragments. Use electrocautery if all else fails.
Cysts of the mandible are similar to the odontogenic 4. Devitalized teeth require root canal therapy.
cysts of the maxilla (see Fig. 5-12). They are benign,
arising from embryonic epithelial roots or remnants, Radicular Cyst (Fig. 14-1)
and hence have an epithelial lining. However, squa-
mous cell carcinoma has been seen to arise from these A radicular cyst (dental root or dentoperiosteal) may
cysts. When they recur, careful histologic evaluation is occur as the result of an apical abscess or at the site of
necessary. a previous extraction. As the cyst enlarges, it may
decompress through a small perforation in the most
Highpoints prominent portion. With the large radicular cyst, there
is considerable bone absorption and danger of fracture.
I. Preserve teeth and mandibular nerve if resection of This type of cyst may be either entirely filled with
cyst wall is not compromised. liquid or semisolid.
2. Attempt to remove cyst intact.
653
cvm AND TUMORS INVOLVING THE MANDIBLE
c o
FIGURE 14-1
CYSTSAND TUMORS INVOLVING THE MANDIBLE
Dentigerous Cyst (Fig. 14-2) spongy with blood-filled spaces, and they are prone to
severe bleeding during surgical exploration. The sur-
A dentigerous cyst represents an anomaly of the teeth geon must beware! Conservative management appears
and, hence, on an x-ray film, teeth in various stages of to be the treatment of choice, consisting primarily of
development are noted within the cystic cavity. thorough local curettage.
Highpoints
A A horizontal incision is made at the most
1. Preserve teeth and mandibular nerve if resection of dependent level of the tumefaction. The overlying
cyst wall is not compromised. bone is removed with fine bone forceps or a diamond
2. Attempt to remove cyst intact. bur, or if it is very thin it may be undermined and
3. Scrupulously remove all remnants of cyst wall if the outfractured with a nasal freer.
wall fragments. Use electrocautery if all else fails.
4. Devitalized teeth require root canal therapy. B The edges of the bony defect are trimmed with
rongeurs, taking care not to break the cyst wall.
Complications
C Using a fine nasal freer, the cyst wall is separated
• Fracture of mandible from the bony cavity. If the cyst wall fragments, every
• Recurrence remnant must be carefully removed. The wound is
• Injury to viable teeth packed with a D.5-inch strip of gauze soaked with
nitrofurazone liquid or iodoform. If possible, the mucosa
Aneurysmal Bone Cyst is approximated with nylon, and the gauze strip drain
is brought out through the most dependent portion of
In the head and neck, these cysts are rare, occurring for the wound, attempting more primary healing. Other-
the most part in the mandible in patients younger than wise, the healing is by secondary intention, requiring
age 2D and more often in females than males. They also up to 4 months, depending on the size of the defect.
occur in the vertebrae and long bones. The cause of
these cysts is obscure; they may develop possibly D Depicted is the neurovascular bundle, which, if
secondary to trauma with arteriovenous fistula or false feasible, is preserved; however, the bundle is sacrificed
aneurysm. Characteristically, their gross appearance is if necessary.
CYSTS AND TUMORS INVOLVING THE MANDIBlE
FIGURE 14-2
CYSTSAND TUMORS INVOLVING THE MANDIBLE
FIGURE 14-3
CYSTS AND TUMORS INVOLVING THE MANDIBLE
1. Segmental resection of mandible is usually indicated B A cross-sectional view depicts the local invasive
in any large benign tumor. characteristics of an ameloblastoma. The area resected
2. Immediate reconstruction of mandible is performed is outlined by the dotted line.
utilizing bent Kirschner wire or Steinmann pin with tie
wire on each end (see Figs. 14-5 and 14-6), secondary C The full-thickness cheek flap is turned laterally by
bone graft (see Fig. 14-9), a compression plate (see incising the gingivobuccal gutter and the attachments
Fig. 13-22J to L), or a free microvascularized bone of the buccinator muscle to the mandible. The external
graft (see Chapter 24). maxillary artery and anterior facial vein are ligated and
3. Continuity of mandibular division of facial nerve is divided as close as possible to the capsule of the sub-
preserved in cheek flap. maxillary gland. This preserves the mandibular division
4. Although rare, an ameloblastoma can be malignant, of the facial nerve, since the nerve is superficial to
and a complete histologic evaluation must be made. these vessels. The insertion of the masseter muscle on
The tumor must not be violated, otherwise recurrence the mandible requires sectioning, depending on the
is almost certain. extent of the tumefaction, to expose adequate margins
5. If there is any question of malignant change in the of the mandible.
frozen section, then at least a suprahyoid (levels I-II) The visor flap can be reflected higher to expose the
or preferably a supraomohyoid (levels I-II-III) (JEM) notch of the mandible, using small Deaver retractors.
or a standard radical neck dissection (levels 1-I1-III- This requires additional dissection as well as transection
IV) (JML) should be performed. of the masseter muscle. The mandibular notch is thus
exposed, and the mandible can then be transected
Usually, adequate exposure can be obtained by a hori- just below the notch, leaving the coronoid process and
zontal oblique incision following a natural skin crease the condyle in place. The condylar portion thus serves
4 em below the body of the mandible. The incision is a as an anchor for a bent Steinmann pin, which is secured
visor-type incision that extends 2.5 to 5 em across the in place using a tie wire (see Fig. 14-5D). It must be
midline to the opposite submandibular area. This inci- emphasized that the Steinmann pin must be bent and
sion is similar to the one depicted in Figures 14-9B and secured with the tie wire; otherwise a straight wire
14-lOA. The lateral extension of the incision reaches unsecured in the condyle, or in any remnant of the
the lobule of the ear and thence up to the area of the ascending ramus of the mandible, could migrate
tragus as necessary. Care must be taken not to injure through the glenoid fossa into the cranial cavity. A
the main trunk of the facial nerve and its branches. The complete segmental resection of the mandible could
visor flap (Schweitzer) thus contains the muscles of also be reconstructed with a free vascularized fibular
facial expression, with the overlying branches of the graft (see Chapter 24) or a plate equipped with a
facial nerve and the portion of the parotid salivary gland. condylar head (see Fig. 14-6D).
The plane of dissection is anterior to the mandible
without violating any capsule surrounding the tumor D Depending on the nature of the lesion, a satisfac-
or the tumor itself. The masseter muscle is thus exposed, tory margin of normal bone is left with the specimen.
as depicted in Figure 14-4C and D. The visor flap con- In an ameloblastoma 2 cm is considered safe. This
cept allows for avoiding the incision in the lower lip; horizontal portion is transected with a Gigli or sagittal
thus there is no "lip split." plane saw near the angle, with partial transection of
the masseter muscle. A lower incisor tooth has been
removed to facilitate transection anteriorly. The saw
A This horizontal extension must be at least 4 cm cut is thus away from the root of the more medial
below the edge of this horizontal portion of the tooth. This aids in maintaining the viability of the
mandible to avoid injury to the mandibular division of remaining tooth. Any teeth that are fragmented are
the facial nerve, which hangs like a hammock below removed. When the angle of the mandible is resected,
the ramus. An alternate incision is a lip split along the the stylomandibular ligament is transected (see
dotted line, which affords additional exposure if Figs. 17-3D and 22-33C and D).
absolutely necessary. Another alternate incision rather Continued
than a midline lip incision is an incision that starts
CYSTS AND TUMORS INVOLVING THE MANDIBLE
Parotid gland
\
Submaxillary salivary gland
FIGURE 14--4
CYSTS AND TUMORS INVOlVING THE MANDIBLE
Mand. br.
facial n.
Masseter m.
Sublingual gl.
Parotid gl.
Mylohyoid m.
Submandibular duct
Digastric m.
Sublingual artery
t
Glossopharyngeal n.
on stylopharyngeus
There are four other factors that dictate the method- 1. Fibula-used for segmental or virtual total recon-
ology of reconstruction, two of which depend on the struction of the mandible. This is one of the better
etiology of the defect and whether it is (1) secondary to free bone grafts with or without a skin island: there
trauma or (2) secondary to ablative surgery and two may be some limitations of the skin island owing to
others that depend on whether the reconstruction is (1) short septocutaneous vessels.
best done immediately or (2) delayed. a. Good length
All these factors are interconnected and related. For b. Straight and can be tailored
example, mandibular defects due to trauma may have c. Thick cortical bone; thus it will accept various
more local soft tissue for coverage than do defects due types of plates and screws for interosseous
to ablative surgery for neoplastic disease; at times it is fixation.
just the opposite. In the latter group, there are variations; d. Accepts osteointegrated implants
that is, there will be more soft tissue available after 2. Radial forearm flap-bone is very thin; hence this
reconstruction for ameloblastoma than for malignant can only be used as an ancillary support, such as in
neoplasms. Immediate reconstruction using a consider- a marginal resection of the mandible or in combina-
able amount of "hardware" or with inadequate soft tion with a Steinmann pin or plate.
tissue coverage is more likely to result in poor wound 3. Iliac crest-can also be used as free non vascularized
healing and possible infection and osteonecrosis. flap (see Fig. 14-9E)
CYSTS AND TUMORS INVOLVING THE MANDIBlE
the tie wires and should be slightly larger than the 19. The horizontal bar of the template should follow the
tie wires. curvature of the mandible. This is very important
12. Tie wires are 5.0 stainless steel (the ones that are to achieve proper bite.
used for closure of the sternum-just remove the
needle). Complications
13. Two tie wires are used on either end.
14. Kerf's grooves are cut into the ends of the mandible • Broken Kirschner wire: this is usually a result of too
where the pin can be set in and further secured small a diameter of wire; it is of little concern as long
(see Fig. 14-902). as the tie wires remain intact. The Steinmann pin is
15. Measure segment: measure and shape a template now substituted for the Kirschner wire to minimize
using a thin Kirschner wire, which is molded to an breakage. The Steinmann pin can break. A broken
exact replica of the segment removed. This would Kirschner wire or Steinmann pin does not require
be the two ends and the inferior edge of the segment removal. Enough fibrous tissue is formed by the
removed. Angles are critical. Be careful that the time this occurs to maintain the bite.
proximal angle follows the remaining portion of • Externally exposed pin (seldom): avoid tight closure
the body angle and/or ascending ramus. of overlying skin flaps.
16. Horizontal holes are drilled in both ends of the • Migration: this has not occurred with the bent
mandible with a bit that is one size smaller than Steinmann pin or Kirschner wire with tie wires. This
the Steinmann pin to be used. could be a serious problem if the Steinmann pin is
17. The Kirschner wire is then checked for proper fit- not bent and secured with tie wires. Migrating wire
ting and also for the occlusion. The Kirschner wire could conceivably injure any vital structure (e.g.,
template may be modified to achieve the perfect vessels, eye, and brain).
occlusion. • Postoperative radiation therapy over a Steinmann
18. The Steinmann pin is now bent to follow the shape pin can result in slough of the overlying skin and
of the template Kirschner wire using either basic exposure of the wire.
tools (locking pliers and pliers) or a special tool • Minimal drift and minimal malocclusion may occur.
(see Fig. 14-5E).
CYSTSAND TUMORS INVOLVING THE MANDIBLE
FIGURE 14-5
CYSTS AND TUMORS INVOLVING THE MANDIBLE
D The drawing shows reconstruction of virtually the E This device is used for bending Steinmann pins
entire hemimandible. The coronoid process has been (built for Lore and Parks by Palma Tool and Die,
resected with preservation of the condyle. Only one tie Lancaster, NY).
CYSTS AND TUMORS INVOLVING THE MANDIBLE 671
E
FIGURE 14-5 Continued
CYSTSAND TUMORS INVOLVING THE MANDIBLE
FIGURE 14-6
CYSTS AND TUMORS INVOLVING THE MANDIBLE
8 patients 8 patients
Reconstruction of the Mandible Using ing portion of the mandible be maintained during the
Plates With or Without Free Autogenous insertion and fixation of the graft.
Nonvascularized Bone Grafts (Fig. 14-8)
Highpoints: A, C, D
Free nonvascularized autogenous bone grafts for
mandibular reconstruction are usually applicable 1. Adequate exposure is possible proximally and
under two circumstances: distally to the defect. Periosteum of the mandible to
be reconstructed is usually preserved.
1. As the primary procedure when the defect is small 2. Adequate measurement of the defect is possible: the
and the pathology is benign. The oral cavity must plate is placed over the intact mandible and holes
not be entered to avoid contamination of the wound are drilled proximally and distally to the defect.
if a graft is used. Fixation of the graft can be done Templates can be used for this step, which is done
with an onlay plate (A). before resection.
2. As a secondary procedure after stabilization of the 3. There must be at least two screws at each end.
transected mandible with either a mandibular plate 4. There must be good soft tissue coverage.
or a Steinmann pin (B and C). Oral cavity must not 5. To achieve and maintain good occlusion, temporary
be entered. intermaxillary fixation can be used during the place-
ment of the plate; this is optional.
Iliac bone (see Figs. 3-5 and 3-6) is preferred. Rib 6. Free nonvascularized bone graft must not be done at
(see Fig. 3-5) could be used for very short segments as the primary procedure when the oral cavity is entered.
a superior margin overlay for a marginal mandibular There is a danger of osteomyelitis.
resection. The sources of autogenous bone (e.g., ster- 7. Do not denude bone graft.
num, spine, scapula, or clavicle) are not usually used 8. Internal fixation is preferred using plates, wires, or
for reasons ranging from too thin cortical bone to the screws.
possible violation of the neck (clavicle) if there is a pos- 9. The length of a free nonvascularized bone graft must
sibility of a malignant lesion with cervical metastasis. be no greater than 5 em because of a problem of
It is important that the correct occlusion of the remain- cortex "disintegrating."
CYSTS AND TUMORS INVOLVING THE MANDIBLE
A B
c D
FIGURE 14-8
CYSTSAND ruMORS INVOLVING THE MANDIBLE
FIGURE 14-9
sected mandibular stumps are examined for evidence vertical limb of the Steinmann pin. Small tie wires
of bone marrow involvement by tumor. If positive, placed through drill holes help keep this portion of the
additional mandible is resected or disarticulation is wire in position.
performed. Depicted is an edentulous patient in whom Gunning-
type splints are fixed to the mandible and maxilla.
B The upper horizontal incision is carried across to Only if fixation with Steinmann pin and tie wires is not
the opposite side (B1) and is placed well below the stable and there is a question of adequate and reason-
chin so it does not overlie the Steinmann pin and ably good occlusion should the splints be applied. This
reconstructed mandible. The upper chin flap is then has not usually been necessary.Circumferential wires
raised as a visor without transecting the lip (see Fig. fix the lower splint to the mandible. A Rowe-type peri-
14-10 and also Fig. 16-61). alveolar introducer is being inserted through the alve-
olar processof the maxilla to facilitate wire fixation for
C After the ablative surgery, the free ends of the the Gunning splint. Be certain that the bent anterior
mandible are spaced and locked and with a Steinmann portion of the Steinmann pin conforms to or is slightly
pin bent in the manner depicted. Note that the pin smaller than the portion of the mandible removed.
has a forward bend to simulate the projection of the This avoids skin tension over the wire.
chin (see 01 and Figs. 14-5 and 14-6). A groove (kerf, Continued
see 02) is cut in each end of the mandible for the
CYSTS AND TUMORS INVOLVING THE MANDIBLE
H
FIGURE 14-9 Continued
CYSTS AND TUMORS INVOLVING THE MANDIBLE
Resection and Second-Stage It is strongly recommended that the CO2 laser not
Reconstruction of Anterior Portion be used in any of the resections related to the neo-
of Mandible Using Iliac Bone Graft plastic lesions as depicted in this chapter, as well as in
(Continued) (Fig. 14-9) Chapter 15. Three disasters resulted in recurrence and
advanced disease and two in early death (performed
Reconstruction elsewhere) .
FIGURE 14-10
Forehead flap
Tongue
tongue
-contralateral
side
skin paddle
genioglossus m. -ipsilateral
side
geniohyoid m. pect. major
flap
Lateral View
F G
H
FIGURE 14-10 Continued
CYSTS AND TUMORS INVOLVING THE MANDIBLE
o Hyoid bone
FIGURE 14-11
C Diagrammatic surface view shows the portion of D A classic radical neck dissection is performed (see
the tongue, floor of mouth, and alveolar ridge that is Fig. 16-3) except if there are no clinically positive
resected. Because the lesion is located anteriorly, the nodes in the upper internal jugular chain. If this is the
resection of the alveolar ridge extends beyond the case, then the spinal accessory nerve is preserved.
midline. Continued
CYSTS AND TUMORS INVOLVING THE MANDIBLE
Submax.salivary gland
Hyoid bone
\
FIGURE14-11 Continued
CYSTS AND TUMORS INVOlVING THE MANDIBLE
F G
Marginal Resection of Mandible, Partial digastric triangle, that is, the submaxillary salivary gland
Glossectomy, and Radical Neck Dissection and lymph nodes in continuity if possible with the
for Carcinoma of the Floor of the Mouth radical neck dissection. The lingual and hypoglossal
(Continued) (Fig. 14-11) nerves are also sacrificed. All the previously mentioned
muscles that are attached to the hyoid bone are
resected close to the hyoid bone, leaving the bone
I A sagittal plane or coping saw is used to resect the
intact.
inner cortex and alveolar ridge of the mandible. The
coping saw is ideal, because its flexibility permits it to
follow the natural contour of the bone; however, this N Reconstruction is begun by stabilizing the mandible
saw is rarely available anymore. The outer cortex is using a short section of a Steinmann pin inserted in
stabilized with a bone-holding forceps, with care taken either end of the exposed marrow cavity. A piece of
not to fracture the bone. This horizontal cut is through stainless steel or malleable silver wire is passed through
the base of the tooth socket. If a portion of any tooth the holes and twisted tight.
remains in the retained mandible, it is removed. The Continued
cut is best done to clear all teeth. However, enough
mandible is left for support. It is at this point of the operation that a decision is
made regarding the use of a transposed distant flap.
J TO L The angle and extent of the mandibular This decision is based on a number of factors:
resection are shown in these schematic drawings of
the mandible. In J the outer aspect is demonstrated; K
1. General condition of patient as to ability to tolerate
is an end-on view; L shows the inner aspect.
additional operating time
2. Availability of sufficient soft tissue to cover the
M The incision is then carried across the posterior
mandible or, if totally resected (segmental resection),
third of the tongue anterior to the circumvallate papillae.
to cover the Steinmann pin or Kirschner wire
This incision reaches the saw cut behind the region of
3. Evaluation as to whether a transposed flap will lessen
the last molar tooth. the fixation of the tongue and lessen the possibility
of an oral cripple
The remaining portion of the mandible is retracted
outward, again with extreme care not to fracture the If a transposed flap is utilized, the pectoralis major
bone, exposing the structures between the resected myocutaneous flap is preferred. Additional length of
portion of the tongue and the inner resected portion of this flap can be achieved by removing the medial third
the mandible. These include the sublingual gland and of the clavicle, if necessary (see Fig. 19-9).
adjacent muscles, that is, the hyoglossus, genioglossus, A radial forearm cutaneous osseous flap could be used
geniohyoid, and mylohyoid. All these structures are for lining of the oral cavity and mandibular support.
removed in continuity with the standard neck dissec- However, there may not be enough soft tissue bulk.
tion. The anterior and posterior bellies of the digas- Support, if necessary, may be accomplished with a
tricus muscle as well as a portion of the stylohyoid mandibular plate. At the second stage a free autoge-
muscle are likewise included with the contents of the nous bone graft could be used (see Fig. 14-8C).
CYSTS AND TUMORS INVOLVING THE MANDIBLE
FIGURE14-11 Continued
CYSTS AND TUMORS INVOlVING THE MANDIBLE
Sako K, Marchetta FC: The use of metal prostheses following anterior Stanley RB, Rice DH: Osteogenesis from a free periosteal graft in
mandibulectomy and neck dissection for carcinoma of the oral mandibular reconstruction. Otolaryngol Head Neck Surg 89:
cavity. Am J Surg 104:715-720, 1962. 414-418,1981.
Sanerkin NG: Malignancy, aggressiveness, and recurrence in giant Stenstrom SJ: New technique for intraoral rami section of mandible.
cell tumor of bone. Cancer 46:1641-1649, 1980. Plast Reconstr Surg 43:135-140, 1969.
Schwartz HC: Osteonecrosis of the jaws: A complication of cancer Thompson ERE: Sagittal genioplasty: A new technique of genio-
chemotherapy. Head Neck Surg 4:251-253,1982. plasty. Br J Plast Surg 38:70-74, 1985.
Shore NA, Schaefer MC: Temporomandibular joint dysfunction. NY Triedman U: Osteogenic sarcoma of the mandible. Am J Surg
State J Med 78:2S4-2SS, 1978. IIO:S80-584,1965.
Sharp GS, Helsper JT: Radiolucent spaces in the jaws. A new guide Ziegler JL, Wright DH, Kyalwazi SK: Differential diagnosis of Burkitt's
in diagnosis. Am J Surg 118:712-725, 1969. lymphoma of the face and jaws. Cancer 27:503-514, 1971.
Shramek JM, Rappaport I: Panoramic radiography in head and neck
pathology. Laryngoscope 80: 1797-1808, 1970.
Silverglade LB, Alvares OF, Olech E: Central mucoepidermoid tumors
of the jaws: Review of the literature and case report. Cancer
22:6S0-753, 1968.
15 ORAL CAVITY AND
OROPHARYNX
The discussion of basic mandibular resection and recon- a histologic abnormality characterized by atypical cells
struction in Chapter 14 also included oral cavity and arranged in a disorganized pattern involving various
oropharyngeal malignant neoplasms. The references to degrees of thickness within the still benign epithelium.
Chapter 14 are as follows: Lichen planus has been associated with squamous
cell carcinoma, occurring either simultaneously or at a
Floor of the mouth: pages 678 to 682, Figure 14-9 later date. Whether there is a causal relationship between
Floor of the mouth and tongue: pages 682 to 695, these two entities is a moot question. A careful exami-
Figures 14-10 and 14-11 nation of all cutaneous surfaces should be performed
Parapharyngeal space: see Chapter 23 when lichen planus is suspected.
Other approaches to the oropharynx are in Chapters 14, There may be an etiologic relationship between
20,21 (see Fig. 21-5), and 23. Candida albicans and leukoplakia. Cawson (1966) has
supported this theory by experimental work in the chick
embryo, showing that Candida implanted on respiratory
Excision of Dysplasia (Leukoplakia) epithelium will cause squamous metaplasia and keratosis.
and/or Erythroplasia (Erythroplakia) Thus, in the medical management of leukoplakia every
of Tongue and Buccal Mucous effort should be made to treat Candida if it is present.
Membrane (Fig. 15-1) Local use of mycostat (Nystatin) in the form of vaginal
suppositories placed in the oral cavity or by oral sus-
When areas of "leukoplakia" and "erythroplakia" (both pension-I mL (100,000 units], dropped in the mouth
clinical, not histologic, terms) fail to respond to the four times daily and held in the mouth for as long as
conservative treatment of oral and dental hygiene, possible before swallowing-appears warranted. This
vitamin B complex, and elimination of irritants such as antifungal agent may likewise be used systemically, yet
alcohol and smoking, local surgical excision is indi- its absorption into the plasma is minimal. Ketoconazole
cated. Retinoids, calcipotriol, and bleomycin applied (hepatic toxicity) is another septicemic antifungal
topically have been variably successful in the treatment agent with rather rapid plasma levels.
of oral leukoplakia.
Highpoints
Discussion
1. Full-thickness mucous membrane excision is needed.
The differential clinical diagnosis of leukoplakia, or a 2. Primary closure is done.
white patch, runs the gamut, indicating some type of
keratosis, fungus infection, or lichen planus as well as
other less common disease processes. Hence, all white A, B The area of leukoplakia along the lateral border
patches are not precancerous. There is a high probability of the tongue is excised. Closure is facilitated in a staged
of this condition especially in the user of tobacco fashion as the excision proceeds. This aids in retraction
whether through the smoking form (cigarettes, cigar, and hemostasis.
pipe) or the smokeless form (snuff or chewing tobacco).
The cytologic and histologic examination is thus vital, C, D Leukoplakia on the undersurface of the tongue
because either leukoplakic or erythroplakic lesions can is excised in a similar fashion, taking care not to obstruct
be various forms and degrees of atypia, dysplasia, Wharton's duct with any sutures.
carcinoma in situ, or squamous cell carcinoma with
microinvasion, or in some areas they can be associated E, F Using similar technique, a lesion of the buccal
with frank invasive squamous cell carcinoma. mucous membrane is excised. For large areas involving
Atypia is a cytologic abnormality characterized by this region, wide undermining of mucous membrane
hyperchromatic nuclei and an increased nucleocyto- allows primary closure. Interference with Stensen's duct
plasmic ratio, whereas dysplasia (in various degrees) is is to be avoided.
698
ORAl CAVIlY AND OROPHARYNX
FIGURE 15-1
ORAl CAVITY AND OROPHARYNX
I
j
FIGURE 15-2
ORAl. CAvrTY AND OROPHARYNX
B The incision is carried deep to the anterior G If feasible, a single midline closure is preferred to
branches of the lingual arteries, sparing them if avoid the four-point closure depicted in F.
possible.
ORAL CAVITY AND OROPHARYNX
FIGURE 15-3
ORAl CAVI1Y AND OROPHARYNX
I
'. I.
"
~1
/
~
FIGURE 15-4
ORAL CAVITY AND OROPHARYNX
Median Labiomandibular
Glossotomy (Trotter Approach to similar exposure can be obtained with the transhyoid
approach. The exposure of the tip of the epiglottis is
Base of Tongue, Pharynx, and Base
excellent. Resection of the entire posterior wall of the
of Skull) (Continued) (Fig. 15-4) hypopharynx and oropharynx is quite easily
performed, including a portion of the nasopharynx.
D The tongue and suprahyoid region are then tran- Deaver retractors on either side of the split tongue
sected exactly in the midline, with the line of incision afford excellent exposure. Additional exposure can be
extending downward along the mylohyoid raphe. If obtained by extending the incision on one side of the
the malignant lesion is large, the incision is made epiglottis. Closure of a pharyngeal defect is performed
along the floor of the mouth between the mandible using a dermal graft.
and the tongue. The mandible then can be reflected
farther laterally to afford more exposure-the so-called F The lingual wound is closed in three layers using
"mandibular swing" (see Fig. 23-7). If the lingual nerve 4-0 nylon for the mucosa and 2-0 chromic catgut for
is in the way, it is transected and then reanastomosed the muscular layers.
at the time of closure.
G The mandibulotomy is approximated and fixed
E Depicted is a large benign bulky tumor, which is using a short bent section of Kirschner wire or Steinmann
resected along the dotted lines. It is unlikely to be of pin. For added strength in muscular patients a recon-
minor salivary gland origin because these tumors struction plate may be used (see Fig. 13-22A). The
"practically never arise exactly in midline" (Batsakis). wire fixation is preferred with insertion in drill holes in
Malignant salivary gland tumors (e.g., adenocystic the medullary portion of the bone. Two wire sutures
carcinoma), depending on their size, may require at tied or twisted and buried in the kerfs complete the
least a hemiglossectomy or total glossectomy. Because fixation. The suprahyoid muscles along the mylohyoid
they arise on the lateral border of the tongue and raphe are then approximated in layers.
spread by direct extension, margins are difficult to
ascertain, hence the radical resection of the primary
tumor. Lymphatic spread is between 14% and 16% Atrophy of a portion of the tongue can occur if the
whereas vascular spread is significant (40% [Spiro D. By incision in the tongue has not been in the midline or if
retraction of the soft palate, exposure of the posterior a radical neck dissection has been performed with sac-
wall of the hypopharynx and oropharynx can also be rifice of the external carotid artery or the lingual artery.
achieved for resection of large lesions. However,
ORAL CAVIlY AND OROPHARYNX
Resection of Stage Tl Carcinoma Two possible steps are then available: One is to resect
of the Midline of the Floor of the the contents of the triangle at the primary operation.
Mouth (Fig. 15-5) The other is to observe the submandibular area after
the reimplantation of the ducts. If the findings persist,
Highpoints namely, enlargement of the submandibular glands,
then a suprahyoid dissection is usually indicated. If a
1. Wide local incision is done to include the distal ends frozen section indicates metastasis, then a complete
of Wharton's ducts. radical neck dissection is the treatment of choice.
2. Depth of resection depends on the extent of disease. The depth and lateral extension of the neoplasm
3. Frozen sections on margins and depth of specimen determine the area to be resected. The first muscle to
are required. be encountered directly inferior is the genioglossus and
4. Transected ends of Wharton's ducts are reimplanted deep to that is the geniohyoid and the mylohyoid and
through stab wounds lateral to the resected area. skin under the chin (see p. 732).
5. If the lesion is affixed to or overlying the inner table Take care not to sacrifice both anterior branches of
of the mandible, a marginal resection of the mandible both lingual arteries. It is better not to sacrifice either
is performed. An extension of the operation is then lingual artery if commensurate with adequate resec-
indicated as depicted in Figures 14-11A to H and ls-GA tion. There are few, if any, vessels of the tongue that
to £1. cross the midline. This may devitalize the tip of the
6. Carcinomas that are resectable are not usually treated tongue when the resection is extended inferiorly and
with radiation; there is too much movement and no posteriorly for T2 lesions.
better survival than if treated surgically.
B
FIGURE 15-5
ORAl CAvrrv AND OROPHARYNX
1. Extended resection of carcinoma of the floor of the B The margin of the mandible is resected with a
mouth and juxtaposed tongue may result in a number sagittal plane saw along with the floor of the mouth
of disabilities owing to the absence of a labioalveolar and adjacent tongue. A frozen section is done to
gutter: evaluate adequate depth of resection. A portion or all
a. Difficulty in swallowing the sublingual gland is also excised, usually with
b. Difficulty in wearing a suitable denture sacrifice of the lingual nerve and the submandibular
c. Difficulty in speech (Wharton) duct. The duct is identified at its cut end for
2. Reconstruction may be achieved with split-thickness final suturing to the cut mucosa edge.
epidermal or dermal grafts, tongue flaps, or trans-
posed flaps from the forehead (see Figs. 8-lOA to 0
and 14-10) or from the cervical region as an apron A rubber or soft plastic section of tubing similar in
flap (see Fig. 8-6A and B), a deltopectoral flap (see size to a No. 24 rectal tube with a circumference of
Fig. 8-4A and B) or a pectoralis major myocutaneous about 3 cm is used as a stent for the skin graft. Split-
flap (PMF) (see Fig. 8-2A), or a combination of these. thickness epidermal skin 0.018- to 0.022-inch thick or a
A radial forearm flap is another method of recon- dermal graft of 8 to 10 cm is wrapped around the sten!,
struction (see Chapter 24). The depicted inlay graft with the raw surface outward with the epidermal graft.
or buried stent procedure is a refinement of the skin With the dermal graft, the deeper layer is outward. The
graft technique. The choice of procedure depends advantage of dermis over epidermis is that the dermis
primarily on the extent of the initial procedure. contracts much less and assumes the characteristics of
3. This inlay graft technique may be used primarily or mucosa more so than epidermis. Dermalon adhesive is
secondarily. The primary method is depicted in A utilized to secure the graft to the stent with a few
through G, the secondary method in H and I. interrupted 4-0 chromic catgut sutures for support. Do
4. It can be utilized only when the mandible is pre- not stretch the skin graft over the stent, because this
served or with marginal resection of the mandible would tend to lessen the thickness of the graft.
and may be combined with a radical neck dissection
if sufficient tongue remains. C Before the stent with graft is buried, any sharp
5. When the lesion is less than 1.5 to 2 cm, a radical edges of the cut mandible are smoothed with a rasp.
neck dissection is usually not performed in the The mucosal edges of buccal wall are then approxi-
absence of clinically palpable lymph nodes. mated to the mucosa of the tongue using 4-0 nylon.
6. Serial computed tomography (CT) with bone windows
and an algorithm may be helpful to evaluate involve- D, E Three circumferential sutures of 3-0 nylon are
ment of the mandible. Direct invasion of the cortex then placed through the tongue musculature, around
is rarely encountered. Firm fixation detected on phys- and beneath the stent and mandible, and tied over a
ical examination is more important than the CT. gauze sponge or dental roll soaked with liquid nitro-
Magnetic resonance imaging (MRI) serves to evaluate furazone (Furacin) or an antibiotic ointment. This
periosteum with cortex and marrow (see Fig. 15-8 maneuver tends to eliminate any dead space and
and the section on bone imaging in Chapter 3). adapts all the tissue together.
Primary Technique El To minimize obstruction to the submandibular
salivary gland duct, the cut proximal end of the duct
A Depicted is a cross section of a carcinoma of the is sutured with three 5-0 nylon sutures to the cut edge
floor of the mouth juxtaposed to the mucosa at the of the mucosa.
inner edge of the alveolar ridge. Radiographs do not Continued
reveal bone involvement. There is no gross deep
ORAL CAVITY AND OROPHARYNX
CIRCUMFERENTIAL
SUTURE
MUCOSA
Wab~
FIGURE 15-6
ORAL CAVITY AND OROPHARYNX
Inlay Graft to Floor of Mouth for approach. The indications and circumstances are the
Carcinoma (Continued) (After Corso same except that scarring has already occurred with
some fixation of the tongue and absence of the
and Gerold, 1962) (Fig. 15-6)
labioalveolar gutter.
F, G In 1 week to 10 days the circumferential sutures H Depicted is the skin incision along the inner edge
are removed and an incision is made directly over the of the mandible; the location and the length corre-
stent. The incision goes through the overlying mucosa spond to the absent gutter. Dissection is continued
and the underlying skin graft. The stent is removed, upward along the inner aspect of the mandible to the
thus exposing the skin graft. No additional molds or oral mucosa without perforating the mucosa.
stents are necessary.
I Once the area is completely exposed, a similar
stent with skin graft is buried. The circumferential
Secondary Technique sutures are not necessary. The skin is closed in layers.
The stent is then removed in 7 to 10 days, as shown in
Although the same technique applied for primary recon- F and G.
struction is feasible in a secondary reconstruction,
Corso and Gerold (1962) have utilized an external
ORAL CAVITY AND OROPHARYNX
Resection of Malignant Tumors of area may be negative, yet lower in the neck may be
the Oral Cavity and Oropharynx positive for metastatic carcinoma. If metastasis is pres-
With Extension Above Into the ent, then the classic radical or modified radical neck
dissection is done. Currently, many surgeons use selec-
Nasopharynx and Below to the tive neck dissections. The other indication for the
Hypopharynx With Cervical suprahyoid neck dissection is when this is combined
Metastasis With or Without with oral cavity lesions when a radical neck dissection
Involvement of the Mandible is done on the ipsilateral side and there is concern about
Including the Parapharyngeal Space the contralateral side relative to metastatic disease.
Bilateral radical neck dissection is almost always staged.
Surgical resection in these areas is modified depending Emphasis is placed on the importance of wide mar-
on the location and extent of the neoplasm. The gins at the site of the primary resection to minimally
accessibility of the neoplasm determines, for the most include (1) the ulcer, (2) the indurated surrounding
part, the surgical approach. The scope of the ablative area, (3) any additional extent as suggested by CT or MRI,
surgery must not be reduced for any reconstructive and (4) at least some of the edematous surrounding
procedure with the assumption that postoperative area and possibly all of the edematous area if feasible.
radiotherapy will "handle it." There is a marked differ- Emphasis is also placed on the spread of disease to the
ence of opinion regarding the treatment of the primary parapharyngeal space (see Chapter 23).
tumor, whether it be by surgery alone, irradiation alone,
or a combination of both, or irradiation alone (external Approaches
beam or brachytherapy) or preoperative chemotherapy
with uncompromised surgery and selective radiotherapy Approaches to these tumors depend on location and
(see Chapter 3 in section on survival data including can, in general, be accomplished by one of the follow-
recurrence at primary site and neck). There is little dif- ing: (1) direct intraoral; (2) mandibulotomy without
ference of opinion that metastatic cervical lymph- resection of mandible (see Fig. 15-7, which demon-
adenopathy be treated by neck dissection, either classic strates three sites); (3) resection of a portion of the
radical dissection usually preferred by the author (JML) mandible; and (4) median labiomandibular glossotomy
or selective neck dissection. The author (JML), depend- (see Fig. 15-4). For additional approaches to the base of
ing on resectability (able to resect for cure) and oper- the tongue see pages 732 to 741.
ability (whether the patient is medically suitable for
major surgery) utilizes the preoperative chemotherapy Discussion
regimen. The neck dissection is usually the classic
radical neck dissection; the suprahyoid neck dissection The direct intraoral approach facilitates resection of the
is used in selective situations, for example, in anterior anterior floor of the mouth, anterior mobile tongue,
oral cavity lesions when there is no definitive metas- buccal wall, anterior alveolar ridge, and anterior
tasis and for histologic examination and frozen section. gingiva. A mandibulotomy can be done at three sites
Remember, skipped metastasis can occur: the suprahyoid (Fig. 15-7):
ORAL CAVITY AND OROPHARYNX
ii
FIGURE15-7
I. Midline: Skin incision is midline, lower lip, be necessaryto facilitate exposure of the posterolateral
stepped to midportion of the chin or around natural and base of tongue, lateral and posterior oropharynx,
skin crease or just medial to the commissure through tonsil, superior and inferior posterior alveolar ridges,
an incisor tooth socket. It is indicated when the and palate, aswell as provide a limited gateway to the
neoplasm extends to the midline or anterior floor of inferior lateral wall of the nasopharynx and the
the mouth or originates posteriorly from the region of superior portion of the hypopharynx as well as the
the posterior or base of tongue. Otherwise avoid parapharyngeal space (see Chapter 23, Figs. 23-2 to
this approach because of the cosmetic loss of the 23-6).
incisor tooth (referred to as "mandibular swing"; see III. Region of the angle of the mandible (see Figs.
Fig. 23-7). 15-9A to F,17-3, and 22-33). Incision is made proximal
Ii. Lateral: Incision is similar to that used for the to the last molar tooth, thus facilitating exposure of
midline mandibulotomy or the area can be the base of the tongue, lateral wall of the oropharynx,
approached through elevation of a mobilized superior tonsil, palate, and parapharyngeal space.
cervical skin flap, through the socket of the first or To enhance this area of exposure, transection is
second premolar tooth, just anterior to the mental done of the stylomandibular ligament, with or without
foramen through which the mental branch of the removal of the styloid process, and other muscles
inferior alveolar nerve passes.Thus, the mental nerve attached to the styloid process-the stylopharyngeus,
may be preserved. It is sensory to the lower lip and styloglossus,and the stylohyoid. This facilitates further
chin, and its branches "communicate freely with the reflection of the transected mandible. Transection of
seventh cranial nerve" (Gray's Anatomy, 24th ed., p. the other muscles attached to the mandible, for
914). Unfortunately, transection of the lingual and example, the mylohyoid and pterygoid, may further
inferior alveolar nerve, which is the largest branch of enhance the exposure.
the mandibular division of the trigeminal nerve, may
ORAL CAVITY AND OROPHARYNX
~
Periosteum }
Cortex
•••••• '#
... .•.
t: .•.•. ~ "Mij,rrow ' .
••
.'" . >,
'. "
Cortex }
Periosteum =========::;::
~
FIGURE 15-8
b. Lateral at premolar area hard palate. This resection can reach the inferior
c. Angle of the mandible. This requires mobiliza- edge of the eustachian tube orifice. Lateral dissec-
tion of the cheek flap. The degree depends on tion of the deeper portion of the nasopharynx is
the area to be resected. hampered by the base of the pterygoid process.
4. Mandibulotomy is usually done through an extracted Actually, this may serve as a barrier to the spread
tooth socket, not between the teeth. The mylohyoid of the tumor laterally, unless it invades bone.
muscle and anterior belly of digastric are transected. However, as one resects farther posterior and supe-
5. Primary carcinoma of the oral cavity, oropharynx, rior, the base of the skull is apparent. The internal
or tongue may be attached to the cortex of the carotid artery is in jeopardy from its entrance into
mandible or arise in a tooth socket. Thus, if fixa- the parapharyngeal space as it progresses supe-
tion is present or very close to the mandible, for riorly. The internal carotid artery then leaves the
example, 1 to 2 mm, segmental resection of the operative site at the external orifice of the carotid
mandible or marginal resection (see Fig. 14-11A to canal. This artery passes then through the carotid
H) should be performed. Direct invasion is seldom canal, which is posterior to the foramen lacerum.
through the cortex. Actual cortical invasion is This is associated with a fibrocartilaginous plate. In
usually related to the site of the tooth socket. If addition, the vessel may be tortuous, making it
there is any question regarding marrow involve- more vulnerable. If there is spread into the para-
ment, the marrow at the cut ends can be smeared pharyngeal space, the dissection places the internal
on slides and reviewed as a frozen section at the carotid artery in greater jeopardy.
time of surgery. 9. When the superior portion of the pyriform sinus is
6. Resection of the entire body of the mandible included in the resection, the superior edge of the
involves resection of the following muscles from remaining portion of the pyriform sinus is sutured
anterior to posterior on the lateral border: mentalis around its edge approximately 180 degrees to any
(levator), quadratus labii inferioris (depressor of remaining tissue, thus maintaining the orifice of
the lip), and triangularis (depressor of the angle of the pyriform sinus. Any bare areas in the vicinity
the mouth). On the medial aspect of the mandible, of the pyriform sinus and inferior portion of the
the following muscles are involved: genioglossus, hypopharynx are covered with dermal graft and
geniohyoid, anterior belly of the digastricus, mylo- not a PMF. The important potential problem is bulk.
hyoid, and superior pharyngeal constrictors. Bulk can lead to a "chute" for the food into the
7. Resection of the pterygoid muscles from the ptery- larynx or hampers action of the arytenoid cartilage.
goid plate. If disease actually involves the pterygoid This same precaution must be taken when recon-
muscles, remove a portion of the pterygoid plates. struction after a lateral hypo pharyngectomy is
This would be an exposure of the parapharyngeal performed. The area more superior may be closed
space (see Chapter 23, Figs. 23-2 to 23-6). with a thin tongue flap (see Fig. 21-7) and more
8. Extent of oropharyngeal cancer into the nasopharynx inferiorly with a dermal graft. In any event, do not
can be resected by either incising or removal of the suture any flaps or graft to the arytenoid region or
soft palate and removal of a portion or all of the aryepiglottic fold.
ORAl CAVITY AND OROPHARYNX
10. Avoid ligation of the external carotid artery if 22. Tracheostomy and percutaneous endoscopic
microsurgical reconstruction is planned. At least gastrostomy (PEG) are always done.
preserve a major branch as close as possible to the 23. If at all feasible and commensurate with adequate
reconstruction. resection, preserve the 12th nerve and the superior
11. The spinal accessory nerve is sacrificed if there is laryngeal nerve. Resection of these structures is,
evidence of metastatic disease in the vicinity of the however, usually eventually compensated for.
superior internal jugular chain of lymph nodes or 24. Do not preserve the uvula when the line of resec-
if previous surgery has been performed in this tion is close to the uvula.
upper cervical area. An example is a patient who 25. Carcinoma arising in the palatine tonsil at times
has had an open biopsy of the superior internal defies identification, being very small (e.g., 5 mm
jugular nodes. and hidden in a fold of the lymphoid tissue or
12. Resect the tail of the parotid and higher if indicated follicle). Palpation is very important for diagnosis
(see Figs. 17-3 and 17-6G to I). of the larger lesions. General anesthesia may be
13. Transect or remove the posterior belly of the digas- necessary before searching for and locating the
tric, stylohyoid, styloglossus, and stylopharyngeus small lesions.
muscles with portions of the styloid process. This 26. PMF is the preferred pedicle flap for most recon-
depends on the extent of the lesion. CT and MRl may structions. The levator scapulae flap serves for addi-
be a great aid in this decision (see section on para- tional bulk in the upper cervical area or around the
pharyngeal space in Chapter 23, Figs. 23-2 to 23-6). reconstruction of the mandibular palate or Steinmann
14. When resecting a portion of the upper alveolar pin (see p. 1331 and Fig. 22-36D). When using a
ridge, remove a portion of the pterygoid plate, which PMF flap, consider removal of the medial third of
is juxtaposed to and continuous with the ridge. the clavicle (a) for extra length and (b) to close the
15. Preserve the mucous membrane on the medial dead space above the clavicle.
aspect of the whole or remaining portion of the 27. PMF can be used with a plate or Steinmann pin
mandible, commensurate with adequate resection over or under the flap. Position is based on minimal
of disease. This remaining mucous membrane serves compression of the flap.
as a suture line for a juxtaposed flap. 28. If there is any question regarding the viability of a
16. When preoperative chemotherapy is used, pretreat- PMF at the close of the operation, visualize the flap
ment tattooing is most important in cancer of the with a flexible nasolaryngoscope.
oral cavity, oropharynx, and any extension to the 29. Use the distal portion of the flap with minimal bulk
nasopharynx or hypopharynx. at the reconstructed base of the tongue.
17. At times "continuity" resection is impossible (e.g., 30. Reconstruction of the base of the tongue:
with resection of the base of the tongue, the lateral a. Retroadvance remaining tongue to the lingual
border of the tongue, and the oropharynx all in one side of the vallecula or more inferiorly if a
mass with the neck dissection separate). "Continuity" portion or all of the epiglottis is removed (see
is easier to obtain when the resection includes a Fig. 15-13D and E and Fig. 21-7). Attempt to
portion of the styloid process, the posterior belly of prevent the epiglottis or part thereof from being
the digastric, and stylohyoid and stylopharyngeus pulled too far forward. Sisson has suggested
muscles or when a segment of the mandible has suturing the tip of the epiglottis to the posterior
been removed (see Chapter 23, Figs. 23-2 to 23-6, pharyngeal wall, leaving the lateral areas open
relative to the parapharyngeal space). in an attempt to direct food laterally into the
18. The posterior facial vein offers a landmark for the pyriform sinuses. The inferior oropharynx and
ramus mandibularis of the seventh cranial nerve, oral cavity may be packed with gauze soaked in
but not always. This is of some concern when ele- antibiotic solution to control any ooze from the
vating a cheek flap below the mandible, especially tongue closure.
if the patient has been operated on previously. b. Use a PMF.
19. Incision of the lip should be stepped. 31. Parapharyngeal space dissection approach (see
20. Incision inferior to the lip can pass through the mid- Chapter 23, Figs. 23-2 to 23-6):
line or laterally on the ipsilateral side just medial to a. Use deep lobe parotid resection (see Figs. 17-3
the commissure following a natural skin crease. and 17-6).
21. Abandon the concept of planned fistula if at all b. Use oropharyngeal and nasopharyngeal resec-
possible; this rules out the forehead flap except in tion, with elevation of the cheek flap starting
situations in the section on description of forehead along the upper cervical radical neck dissection
flap (see pp. 401 and 444). A microvascular face incision to include the tail of the lateral lobe of
flap usually replaces a forehead flap on face recon- the parotid salivary gland as well as resection of
struction (see Chapter 24). the posterior facial vein with the specimen.
ORAL CAVI1Y AND OROPHARYNX
Expose and preserve the seventh cranial nerve. results. Selection is based on the extent of the
Resect the pterygoid muscles and a portion of defect and the reconstructive method that achieves
the pterygoid plate, especially if the nasophar- specific function, namely, good swallowing and
ynx is involved. reasonably good voice with no aspiration.
c. When deep resection is involved, the internal 35. Mandibulotomy is done for retropharyngeal node
carotid artery is in jeopardy: use intraoperative dissection. In the incision along the floor of the
Doppler study. mouth, care is taken not to injure the lingual nerve
d. The other approach to the parapharyngeal space or the 12th nerve. Specific care is needed when
is an extension of approach "b" to include a closing the wound so that Wharton's duct is not
total parotidectomy. This is necessary when obliterated with a suture. The other nerve to be
there is extensive disease into the space that careful of during this approach is the seventh
has been previously exposed to radiation. cranial nerve.
e. When there is evidence of extensive disease in 36. Suggest using tattoos of oral cavity and oropharynx,
the space, it is better to have proximal control hypopharynx, and nasopharynx extensions of
of the internal and external carotid arteries and tumor, even without preoperative chemotherapy, to
the internal jugular vein as well as identification help establish extent of disease at the time of sur-
of the vagus nerve in the upper cervical area. gery. At times the extent of disease can better be
L Under these conditions, arteriography or MR ascertained under general anesthesia than under
angiography is advised if there is constriction or topical anesthesia. Using both approaches may be
distortion of a vessel. necessary. The decision relative to the area of
g. It is also advised under these circumstances to resection is based on:
be prepared for temporary occlusion and recon- a. Office examination, direct visualization, palpa-
struction of the internal carotid artery for repair tion (most important). particularly at base of
or reconstruction (see Figs. 22-26E to G/22-33D). tongue
h. Walloon occlusion of the vessel done preopera- b. CT and MRI. CT can be misleading in evaluation
tively to evaluate intracranial blood flow has a of oral cavity and oropharynx (for example, see
significant risk of stroke and hence is of some Fig. 23-2 of a thyroglossal duct cyst that was
question. seen on MRI but not on CT).
l. Liberal use of frozen section is advised if margins 37. Although the pathology and these guidelines have
of disease are difficult to evaluate. been primarily related to squamous cell carcinoma,
J. Evaluate the bony external auditory canal, which the surgical principles also apply to the high-grade
may need resection and possible temporal bone salivary gland neoplasms as well as to the rarer
resection (see Figs. 23-13). adenosquamous cell carcinomas. This latter group
k. Resect seventh nerve that is encased in tumor. has been reported to occur in nasal, oral, and laryn-
Reconstruction with a sural nerve graft is feasible geal cavities as well as in the pharynx. There also
(see Fig. 3-8 and Chapter 7, p. 380). has been a question as to whether the adenosqua-
1. Resect mastoid process if disease is adherent. mous cell carcinomas of the floor of the mouth and
m. Mark any disease that is nonresectable at the lower alveolar ridge were, in fact, a result of radio-
base of the skull with titanium clips; this is an therapy. However, in the surgical management of
aid in postoperative radiotherapy. these tumors there is a significant modification and
n. Consider treatment of any residual disease at that is that a wider and more aggressive surgical
the base of the skull with a gamma knife. procedure is recommended. Although preoperative
32. Closure of large defects of the lateral oropharyn- chemotherapy has not been used in salivary gland
geal wall, for example, resection of the tonsil, can neoplasms, preoperative chemotherapy may have a
be done with PMF or a free microvascular flap; place in adenosquamous cell carcinomas for the
contiguous structures, for example, a portion of the squamous cell component. Postoperative radiotherapy
tongue, hypopharynx, and a portion of the oropha- appears to be indicated if there is any question
ryngeal wall, may be closed with advanced local regarding the adequacy of resection in either of
flaps. these carcinomas. The downside of preoperative
33. Whenever feasible without compromising adequate chemotherapy in the adenosquamous cell carcinoma
resection of a neoplasm, local mucosal flaps for may be the fact that although the squamous cell
primary closure of the primary lesion can achieve carcinoma portion may respond to the chemotherapy,
excellent reconstruction with good function, the adeno portion most likely would not and,
especially in swallowing and speech. hence, there would be a delay in the treatment of
34. Microvascular construction (see Chapter 24). At this latter component, owing to the preoperative
times, primary closure or a PMF will achieve similar chemotherapy. This, however, is speculative.
ORAL CAVITY AND OROPHARYNX
Masseter m.
FIGURE 15-9
ORAl CAVllY AND OROPHARYNX
Stylohyoid m.
Resection of Hemimandible,
lateral Oropharyngeal Wall, and B The resection of the primary lesion with radical
Portion of Soft Palate and neck dissection is shown. The lip has been split to
develop a large cheek flap. This affords excellent
Hemiglossectomy With exposure of the oropharyngeal and palatal area as well
Reconstruction Using a Forehead as exposure for mandibular disarticulation. Adequate
Flap Versus Pectoralis Major Flap resection of the contents of the parapharyngeal space
(Fig. 15-10) must be performed, especially if trismus is present (see
Chapter 23, Figs. 23-2 to 23-6).
The ideal reconstruction of the depicted defect is the The forehead flap is introduced deep to the
utilization of a bent Steinmann pin with tie wires (see zygomatic arch that has been transected in two
Figs. 14-5 and 14-6) and a PMF. This method is simple locations and left attached to the overlying skin (see
and allows for a one-stage procedure with acceptable Fig. 8-" A to J). The arrow depicts the rotation of the
cosmetic and reasonably good functional results. flap so that the raw area is faced downward.
Shown is an alternate method without mandibular
stabilization utilizing a forehead flap, which can result C The flap is sutured to the soft palate and the
in a scarred forehead. An alternative if operation time remaining oropharyngeal mucosa. The distal end of
is to be limited is to suture a cheek flap as shown in the flap is sutured to the edges of the tongue and the
Figure 14-110 to R. cheek and the remaining floor of the mouth anteriorly.
No attempt is made to reconstruct the mandible,
Highpoints because the line of resection does not cross the midline.
Care is taken to avoid making an oral cripple.
1. Refer to page 682.
2. Extreme care is taken in the dissection of the D The completed closure is shown. The dotted lines
para pharyngeal space (see Chapter 23). represent the course of the flap deep to the zygomatic
arch and cheek. In 6 to 8 weeks the forehead flap
Complications pedicle is returned to the donor site.
• Early recurrent disease with a large lesion E The preferred reconstruction of this defect is with
• Lack of mobility of reconstructed area with pooling a PMF. This can be done with a double paddle as
of saliva and food: oral cripple indicated, or a wider flap can be brought up into the
• Mandibular drift oral cavity and then at the time of placement and
• Difficulty in mastication of solid food suturing the double paddle can be developed. The
important provision for use of the double paddle is
For PMF reconstruction, see Figure 8-30. For del- that there is adequate blood supply to both paddles
topectoral flap reconstruction, see Figure 8-5. For use (see Fig. 8-30).
of bent Steinmann pin with tie wires, see Figures 14-5,
14-6, and 14-902 F The PMF is brought over the Steinmann pin, which
is used to reconstruct the mandible and is sutured as
delineated along the lateral border of the tongue and
A The tumor extends from the soft palate, the then superiorly into the defect in the oropharynx and
tonsillar region along the lateral border of the tongue, palate. The muscle delineated inferiorly is a portion of
and the floor of the mouth, with fixation to the the levator scapulae flap, which is adding bulk to the
mandible. The dotted line depicts the area resected with reconstructed area of the mandible (see Fig. 22-36).
disarticulation of the mandible. This affords excellent
exposure of the parapharyngeal space.
ORAL CAVITY AND OROPHARYNX
c D
--_._~
i
I
Ii Steinmann pin
i E I
----'---'I
I
L ..
Combined Radical Neck Dissection, 7. The following steps cover the resection of various
extensions of squamous cell carcinoma of the oral
Partial Glossectomy or
cavity and oropharynx. They are divided as following:
Hemiglossectomy, and a. A and D: Basic approach
Hemimandibulectomy Including b. B, C, F, G, H, I: Carcinoma of the tongue, floor of
Retromolar Trigone (Fig. 15-11) the mouth, and body of the mandible
c. J and K: Carcinoma of retromolar trigone
Indications d. M: Cancer of the lateral wall of the oropharynx,
upper alveolar ridge, portion of maxilla, and
These operations are performed for carcinomas of the palate
floor of the mouth and tongue that involve the 8. See section on resection of base of the tongue
mandible or for primary carcinoma of the gingiva or (pp. 732 and 733) and total glossectomy (p. 740,
the alveolar ridge of the mandible with or without Fig. Is-lsE and F).
extension to the upper alveolar ridge. Whether only the 9. Although areas overlap as described in the following
horizontal portion or both horizontal portion and three figures, three areas are specifically depicted:
ascending ramus are resected depends on the location a. Posterior third and lateral base of the tongue with
and extent of the lesion. Other applications of these floor of the mouth and juxtaposed body of the
operations are large carcinomas of the tonsil (also see mandible (see Fig. IS-lIB and C).
Fig. 15-9) with deep infiltration and carcinomas of the b. Retromolar trigone (see Fig. 15-111 and K).
base of the tongue. A portion of the palate is included c. Oropharynx and tonsil extending superiorly to
along with a portion of the upper alveolar ridge and involve upper alveolar ridge (see Fig. IS-11M).
floor of antrum and lateral wall of the nasopharynx
when the neoplasm extends superiorly. It is paramount
to extend the dissection laterally to remove as much as A The standard radical neck dissection incision is
possible of the juxtaposed parapharyngeal space soft extended upward across the lower lip. An alternate
tissue: muscle with pterygoid plates as indicated, adipose incision is along the dotted line just medial to the
tissue, and any nodes. This is an area that is prone to commissure. A tracheostomy may be performed at the
recurrence. All these patients have routine CT and/or beginning or the end of the operation. In either case,
MRI preoperatively, postoperatively, and at regular the hypopharynx is packed with gauze.
intervals for the first 3 years (e.g., every 4 months and
after that every 6 months). B Diagrammatic representation of the extent of
In malignant tumors of the tongue in which an resection for carcinoma of the tongue and the floor of
extended or hemiglossectomy is performed with the mouth involving the horizontal ramus (body) of
preservation of all or part of the mandible, closure of the mandible.
the defect is achieved by a PMF or an apron, forehead,
or deltopectoral flap (see figures in Chapter 8). Resec- C Similar lesion is viewed intraorally.
tion of the mandible is not indicated solely to facilitate
ease of closure. When mandible is not involved, the D The standard neck dissection has been carried up
approach to the posterior and base of tongue and to the level of the hyoid bone laterally. The submental
oropharynx with extension superiorly is accomplished area has been dissected, and the lower lip is split in the
with mandibulotomy (see Fig. 15-7). midline.
FIGURE 15-11
ORAL CAVITY AND OROPHARYNX
Int. pterygoid m.
Anatomy of the Tongue (Fig. 15-12) Approaches to resections of the base of the tongue are
contingent on a number of factors, namely, histology,
Sagittal section through the tongue just lateral to the whether benign or malignant, size, involvement of
midline is shown. The "cut-out area" depicts the other contiguous structures (e.g., mandible, retromolar
intrinsic tongue musculature. trigone, lateral oropharyngeal wall, lateral hypopharyn-
sup. pharyngeal
constrictor m.
Sup. longitudinal m.
Lingual aponeurosis
- ~
Palatoglossus m.
Lingual mucosa
I Palatine tonsil
Genioglossus m. I
Styloglossus m.
I.
Frenulum of tongue
Hyoglossus m.
Inf.longitudinal m.
Mylohyoid m.
FIGURE 15-12
ORAL CAVITY AND OROPHARYNX
geal wall, palate, and epiglottis), concomitant radical The type of reconstruction depends primarily on the
neck dissection, as well as the problem of preservation extent of the surgical defect, as well as the approach
of the function of the larynx, especially if the epiglottis that was utilized for the ablative surgery. For example,
must be removed. When aspiration is almost certain, and large surgical defects with segmental resection of a
both hypoglossal nerves require excision, laryngectomy portion of the mandible lend to the use of a PMF. Other
has been advocated almost as a routine procedure. somewhat lesser defects may be achieved by retroad-
Nevertheless a trial period by closure of the glottis with vancement of the tongue (see Fig. 15-130 and E). On
suture approximation of the stripped vocal cords or by somewhat smaller defects, a posterior flap can be
infolding and approximation of the aryepiglottic folds developed. This flap entails the lingual mucosa and the
has been successful. This conservation approach is lingual aponeurosis (see Figs. 15-12 and 21-7).
preferred, because a laryngectomy can then be per-
formed at a second stage if necessary. When the Approaches to Base of Tongue
epiglottis can be spared, Sisson has described suturing
the tip of the epiglottis to the posterior pharyngeal wall A number of procedures are described depicting the
to act as a "watershed," thus directing food toward the various procedures to approach and to resect the base
pyriform sinuses. of the tongue:
The alternative option is preservation of the larynx 1. Mandibulotomy (see Figs. 15-7, 15-9, and 15-14).
with a trial period of assessment regarding aspiration. 2. Segmental resection of the mandible (see Fig. 15-11).
The approach is "trial and error"-leaving the larynx in 3. Median labiomandibular glossotomy (see Fig. 15-4).
place if there is any possibility that aspiration may not 4. Transhyoid, suprahyoid, or anterior pharyngotomy
occur. This can be ascertained by the attitude and (see Fig. 21-4).
commitment of the patient, which may be by far the 5. Lateral pharyngotomy (see Figs. 15-9 and 21-5).
best yardstick. A cuffed tracheostomy tube is neces-
sary, remembering that the inflated cuff can compress The most important aspect of the approach to the base
the esophagus and thus make evaluation regarding of the tongue is adequate exposure. This is the prime
aspiration continue over a protracted period, requiring deciding factor in the use of the various approaches.
considerable patience on the part of both patient and The reconstruction of the surgical defect depends
surgeon. Removal of all or part or none of the epiglottis on the ablative approach. An approximation of the
depends entirely on the necessary extent of the ablative remaining mucosa and muscle is often adequate. If,
surgery and must not be influenced by preservation of however, this binds the remaining portion of the tongue,
structures simply to facilitate an easier reconstruction. then a transposed distant flap is utilized. The one cur-
All stages of removal or preservation of the epiglottis rently preferred is the PMF, which can aid in the
have been seen with and without any clear-cut effect closure of not only the base of the tongue but also the
on influencing swallowing or voice. lateral hypopharyngeal and oropharyngeal walls.
ORAL CAVITY AND OROPHARYNX
The alternate is the lateral mandibulotomy. D A schematic sagittal view shows the extent of
Mandibulotomy through the angle of the mandible is resection (A to A'). If the neoplasm reaches or is close
too restrictive for the entire base of the tongue. A less to the base of the vallecula, the epiglottis or a part
than 50% resection of the base of the tongue may be thereof is removed.
accomplished via the angle mandibulotomy (see
Fig. 15-9). The lip and mandible are cut in stepwise E The dorsum of the tongue is advanced, bringing A
fashion as depicted in A and AI. For additional descrip- to Al. If the epiglottis is not removed, do not suture
tion, see Figure 15-4A to C. the tongue flap to the epiglottis. Even with the
epiglottis removed, the patient can swallow without
aspiration or may encounter some coughing. With the
B The incisions are made along the floor of the epiglottis removed, it is better not to suture the
mouth away from the mandible to preserve the remaining portion of the tongue flap to the inferior
mucous membrane to facilitate closure with a future margin of the resection (see Fig. 21-7 for details of
PMF. As the posterior portion of the tongue is tongue flap). If necessary, a PMF can be utilized, but
approached, identify and attempt to preserve the unless other contiguous portions of the oropharynx
lingual and inferior alveolar nerves. They may require are resected, a flap is not usually necessary.
transection for additional exposure, however. If fea-
sible, a neurorrhaphy can be attempted at the time of
closure. The mucosal cut is outlined with electrocautery. When minimal or no bulk is needed, simple advance-
The complete resection is done either by cold knife or ment of mucosa, lingual aponeurosis, and superior longi-
by cutting cautery. The problem with using a cold tudinal muscle (see Fig. 15-12) are often feasible (see
Fig. 21-7). If larger coverage is necessary without bulk,
a microvascular flap may be used (see Chapter 24).
ORAL CAVITY AND OROPHARYNX
B c
D E
FIGURE 15-13
ORAL CAVITY AND OROPHARYNX
Midline Mandibulotomy
(Mandibular Swing) (Fig. 15-14) palate, superficial tonsillar region, and posterior third
of the tongue. This lesion is free of the mandible, and,
This is an excellent approach to the middle and posterior hence, the mandible can be spared. An incision is
portion and base of the tongue to extensive tumors of made along the floor of the mouth, leaving, if possible,
the palate with or without extension into the maxilla to a narrow rim of mucosa along the inner table of the
contiguous superficial involvement of the tonsillar mandible to facilitate placement of sutures for the
region with involvement of the mandible and pharyn- reconstruction utilizing a PMF. The lingual nerve and
gomaxillary space, and to the base of skull. If there is twelfth nerve are included in the resected specimen,
deep extension of the neoplasm in the tonsil region and which likewise includes the posterior half and base of
evidence of fixation to the periosteum of the mandible, the tongue, the lateral oropharyngeal wall, including
then a midline mandibulotomy is not done. A segmental the tonsil, the involved soft palate and hard palate,
resection of the involved mandible is performed, thus and the inferior portion of the maxilla with the lateral
affording access to section of the neoplasm and the wall and floor of the nasal cavity and septum, as
parapharyngeal space (see Fig. 15-7 showing resection required. The resection is carried superiorly to include
of segment of the mandible). If the neoplasm is adherent the lateral wall of the nasopharynx and the eustachian
only to the upper margin of the mandible, then it is tube orifice, if necessary. The pterygoid plates and a
possible to perform a marginal resection of the mandible major portion of the pterygoid muscles are included in
and a midline mandibulotomy. However, do not preserve the surgical specimen, thus reaching the base of the
a portion of the mandible if there is any evidence either skull.
by fixation or MRI regarding adherence to the perios-
teum. MRI can demonstrate adherence or extension to B The dashed line indicates the osseous resection,
within millimeters of the periosteum. including the pterygoid plates. The eustachian tube is
The periosteum can be stripped off the bone without transected within the para pharyngeal space. Extreme
any gross or even microscopic evidence of involvement care is taken not to injure the internal carotid artery
of the bone, but the margin of the specimen is either 0 and related nerves; the artery is approximately 1.5 cm
or just a few millimeters. To depend on postoperative from the posterior edge of the lateral pterygoid plate
radiotherapy to eradicate this potential source of as it enters the carotid canal and turns anteromedially.
recurrence is believed contentious. If the vessel is exposed it should be protected with a
The more anterior lesions do not require section of transposed muscle flap or a turned-in flap of prevertebral
the glossopalatine fold. In short, this approach is the fascia, which is then covered with a dermal graft.
most widely used for exposure and resection of these
lesions. It affords excellent exposure and is readily C The defect is reconstructed with a split PMF. The
combined with a radical neck dissection as indicated. technique of this split pectoralis flap is described in
Obviously, if a segment of the mandible requires resec- Figure 8-30. A prosthesis is utilized to close the palatal
tion, the midline mandibulotomy utilized for the defect. Closure of the mandibulotomy is described in
mandibular resection is not used unless the segment of Figure 15-4G.
the mandible to be resected extends to the midline.
Under such circumstances, access to the neoplasm is
When the lesion is less extensive, the resection is
via the segment of the mandible resected. easily modified to include only those structures neces-
sary for removal of the neoplasm, which emphasizes
A The mandible is transected in the midline as the versatility of this approach. The reconstruction is
described in Figure 15-13. Depicted in the accom- then modified depending on the defect. The twelfth
panying plate is an extensive neoplasm involving the nerve may be spared if a minimal portion of the tongue
is resected.
ORAL CAVlTY AND OROPHARYNX
SUBLINGUAL GLAND
12th NERVE
FORAMEN OVALE
MEDIAL
GLENOID
PTERYGOID
FOSSA
PLATE
AUDITORY TUBE
STYLOID
PROCESS
WabrUiz
FORAMEN LACERUM
B c
FIGURE 15-14
ORAL CAVITY AND OROPHARYNX
,
I
I
_L----
A
Cut portion of
peel. major
B
FIGURE 15-15
ORAL CAVIlY AND OROPHARYNX
Resection of Base of Tongue and the postoperative period to evaluate aspiration. If aspi-
Total Glossectomy (Continued) ration does, in fact, occur, then a total laryngectomy
(Fig. 15-15) would be the procedure of choice.
In total glossectomy with preservation of the larynx,
Another modification when additional muscle bulk speech may be relatively satisfactory. On the other
is needed, for example, in a total glossectomy, is tran- hand, if it is not and there is any question of aspiration,
section of the clavicular portion of the PMF from its then the procedure to do is a total laryngectomy and
insertion on the humerus. This portion requires preser- voice rehabilitation.
vation of the lateral thoracic artery. This muscle flap is A PMF has been successful in patients after total
passed underneath the main pectoralis flap that has the glossectomy. These patients have had reasonable
skin paddle. To facilitate additional length, the medial speech and ability to swallow without aspiration. In
third of the clavicle is removed. The paddle of skin is one patient, a subtotal epiglottectomy was performed.
sutured to any remnant of the mucous membrane on This amounted to a 75% removal, yet the patient is
the medial aspect of the remaining portion of the able to swallow and speak.
mandible with "slings" placed around several teeth to
take the tension off the mucous membrane closure. F This depicts the PMF reconstruction of the floor of
Portions of the flap are sutured to the oropharyngeal the mouth. The flap goes deep or medial to the
defect. The medial/posterior portion of the flap is sutured Steinmann pin, which is being used for reconstruction
to the depth of the vallecula. Unfortunately, this has a and stabilization of the mandible. Important in the
tendency to fix the epiglottis if, in fact, the epiglottis is utilization of this PMF is that as much bulk as possible
preserved. be transposed to the surgical defect. The postero-
lateral portion of the paddle is sutured to the mucosa,
forming the inferior portion of the vallecula.
D A PMFis passed under a Steinmann pin. The distal
portion of the paddle is used for reconstruction of the
base of tongue, and the proximal portion of the One author (JML) has three patients with total glos-
paddle is used to reconstruct the floor of the mouth sectomy and preservation of the larynx. Two patients
and lateral oropharyngeal wall. Advancement of local had squamous cell carcinoma treated with preoperative
mucosa of the palate is used to close the superior chemotherapy, surgery, and no radiation. The first patient
portion of the surgical defect. had no evidence of disease at 7 years and 2 months,
had intelligible speech, and was able to swallow pureed
E This is a schematic depiction of a total glossectomy foods. The second patient, in addition, had subtotal
resected in continuity with the posterior portion of the mandibulectomy with bilateral neck dissection, unin-
body of the mandible, the angle of the mandible, and telligible speech, and inability to swallow. This patient
a portion of the ascending ramus of the mandible as died 3 years after the surgery with no neoplasms evident
well as the floor of mouth. The depth of the resection at autopsy. Multiple lung abscesses were secondary, no
into the extrinsic muscles of the tongue depends on doubt, to aspiration. This patient should have had a
the extent of the disease. If at all feasible, the mylo- total laryngectomy shortly after the definitive surgery.
hyoid muscle may be preserved ifthis is commensurate The third patient had adenoid cystic carcinoma involv-
with adequate ablative surgery (see Fig. 15-12). ing the major portion of the lateral and base of tongue.
Treatment was with surgery (no chemotherapy, no
In total glossectomy, the reconstruction involves a irradiation). The patient was alive at 5 years without
major portion of bulk to reconstruct the floor of the disease at the primary site or any recurrence in the
mouth and the tongue. The best that can be hoped for neck. Speech is intelligible, and he can eat anything.
is an adequate closure. He holds meat in his hand as he chews it. Pulmonary
Although the larynx can be preserved in total glos- metastasis was detected during the past year, but his
sectomy, nevertheless, extreme care must be taken in condition is stable.
ORAl CAVI1Y AND OROPHARYNX
F
FIGURE 15-15 Continued
ORAl. CAVI1Y AND OROPHARYNX
Resection of Lesions of the Buccal Do not assume any lesion is benign until it is proved
Wall to be so. Calamities have occurred with physicians
following highly suspicious lesions (e.g., keratosis or
Buccal Wall lesions: Benign, keratosis-like), only to find squamous cell carcinoma
Premalignant, and Malignant Squamous has been smoldering. This is a tragedy because if
Cell Carcinoma untreated or if treatment is delayed then these carci-
nomas can become among the worst of all oral cavity
Predisposing Factors and oropharyngeal neoplasms. They can extend to
involve the entire oropharynx, palate, and alveolar
• Smoking ridge (superior and inferior) and into the parapharyn-
• Chewing tobacco geaI space (see Chapter 23) with or without trismus.
• Snuff There is a temptation to treat some of these benign-
• Betel nut (with slaked lime) appearing lesions with the CO2 laser. Do not use this
modality. It may destroy margins; and if vaporization is
Differential Diagnosis utilized, the entire lesion will be destroyed. No
specimen will then be available for careful histologic
I. White area on the mucous membrane can be due to: evaluation.
a. Dysplasia or atypism-so-called leukoplakia, a There are three types of buccal wall squamous cell
clinical term and not a histologic diagnosis- carcinoma:
precancerous I. Exophytic
b. Fungus infection, for example, Candida-can be 2. Ulcer, infiltrative
associated with cancer 3. Verrucous carcinoma
c. Lichen planus-can be associated with cancer
d. Scar formation, which may be due to trauma Buccal Wall: Benign Lesions (Fig. 15-16)
from biting mucous membrane or irritation by
dentures The underlying potential problem is the differentiation
e. Verrucous hyperplasia-may be premalignant between benign and malignant lesions. If reasonably
f. Keratosis certain that the lesion is benign, complete excision is
g. Pemphigus vulgaris recommended under local anesthesia. If suspicious of a
2. Reddish area on the mucous membrane can be due premalignant or outright malignant lesion, see the
to: following discussion relative to diagnosis and manage-
a. Inflammation ment. In any event, the entire lesion must be removed
b. Erythroplasia-possibly premalignant with liberal use of frozen section as indicated. The
c. Squamous cell carcinoma within areas of ery- Stensen duct orifice is preserved if feasible. If not, the
throplasia-may be clinically indistinguishable. duct is reimplanted or left free. A stent usually is not
Toluidine blue staining may be of aid. necessary. At times a benign lesion, for example, a
3. Superficial ulceration-may be associated with cavernous hemangioma and rarely a lipoma, may require
keratosis and so-called leukoplakia or erythroplakia general anesthesia because a hemangioma may extend
(which are not histologic diagnoses but clinical impres- to the edge of or around the masseter muscle. Bleeding
sions) or early carcinoma. Toluidine blue staining could be troublesome under local anesthesia. Closure
(see Chapter 3, page 91) may be of aid in selecting is usually achieved with an advanced flap of mucous
area to sample if a lesion involves virtually the entire membrane. If the defect is too large, a dermal graft is
mucosa of the buccal wall. Do not be satisfied with used. "Stealing mucous membrane" from the nasal
a random punch biopsy. It is better to excise the septum has been reported but hardly ever indicated.
entire area in question. Toluidine blue is of no use in The purpose would be to avoid a scarring complication,
inflammatory ulcerative lesions because it can give which can occur with a dermal graft.
a false-positive result.
ORAL CAVITY AND OROPHARYNX
FIGURE 15-16
A Dotted lines depict the area of resection, allowing C Cross section shows the position of the gauze
at least a 3- to 5-mm gross margin. Depth of this bolus. If necessary, an opposing second gauze bolus
resection depends on the histologic type of the lesion. can be placed over the cheek and sutured in place
Preoperative biopsy may be helpful and can be with through-and-through sutures.
selected based on positive toluidine blue staining.
Nevertheless, frozen section must be done as indi-
cated. If at all possible, a rim of mucous membrane is To quote from Hayes Martin's textbook Surgery of
preserved in the superior and inferior gingival buccal Head and Neck Thmors, "Because the tissues of the
sulci for suturing of the dermal graft. cheek are in a completely relaxed state when the mouth
is closed, split skin grafts tend to shrink and result in
B If a full-thickness graft is utilized, it is secured with the formation of localized pockets with marked restric-
a bolus of gauze soaked with antibiotic solution. The tion in the ability to open the mouth. With full-thickness
suture material preferred is nylon or Prolene. grafts, there is a greater chance of failure to 'take: but
The gauze bolus can also be used with a dermal once healed, the danger of shrinkage is much less."
graft. A significant problem postoperatively is contrac- See Highpoints under Reconstruction of Buccal Wall
ture of the dermal graft, which is worse with a split- Lesions on page 746.
thickness graft (which is not used) and less with a full-
thickness graft.
ORAL CAVITY AND OROPHARYNX
Diagnosis 1teatment
Squamous cell carcinoma, invasive but Resection of mucous membrane, buccinator muscle, and entire fat pad
limited to mucosa and submucosa with portion of masseter muscle
Squamous cell carcinoma, invasive but Resection of mucous membrane, buccinator muscle, and entire fat pad,
limited to mucosa and submucosa with plus segmental resection of the mandible (see Fig. IS-IIJ and K)
retromolar trigone involvement
Squamous cell carcinoma, widely invasive, Wide resection of primary lesion, through and through, including the skin
with deep ulcer involving skin and bone and segmental resection of the mandible
Squamous cell carcinoma, widely invasive, Wide resection of primary lesion, through and through, including the skin
with deep ulcer involving skin and bone, and segmental resection of the mandible and all areas involved with
lateral wall of the oropharynx with the dissection of the para pharyngeal space (the pterygoid muscles and
anterior and posterior pillars, palate, and plates) and the floor of the antrum. Margins should be at least 1 to
upper alveolar ridge 1.5 em where feasible.
Minor salivary gland Wide resection: 50% can be malignant
Low-grade mucoepidermoid carcinoma Wide resection
High-grade mucoepidermoid carcinoma and Wide resection of primary lesion, through and through, including the skin
adenocarcinoma and segmental resection of the mandible and all areas involved with
the dissection of the para pharyngeal space (the pterygoid muscles and
plates) and the floor of the antrum. Margins should be at least 1 to
1.5 em where feasible.
Basal cell carcinoma Local excision with 0.5- to 1.0-cm margins
Squamous cell carcinoma Wide resection, margins of at least 1 to 1.5 em: depth of resection
depends on extension of disease
Dermatofibrosarcoma protuberans involving Resection of entire skin lesion with at least l-cm margins or more and
skin of cheek buccal wall at the center of the lesion with resection of alae nasi and
lips as indicated by extension of disease: exposure of peripheral
branches of the seventh nerve; tarsorrhaphy: Stensen's duct resected
and proximal ligation (if possible. re-implant in mucous membrane).
ORAL CAVilY AND OROPHARYNX
no adherence to bone. Full segmental resection of (Gray's Anatomy). When the mandible is not
the mandible is always done with a retromolar trigone resected, the fibers attached to the oblique line of
lesion with adherence to cortex. the mandible are not transected. However, the
9. Resect buccal wall as per tattoo marks or more if fibers to the skin and subcutaneous tissue are
area is suspicious. The juxtaposed floor of the transected to mobilize the mandible.
mouth and a portion of the tongue and mandible c. If extension is anterior, transect depressor labi
and sublingual gland may be included. and the depressor angularis muscles.
10. Resect at least the mucosa extending superiorly 2. With the mandible included in the cheek flap, tran-
along the ascending ramus of the mandible; the sect muscles on the medial border of the mandible,
posterior site of mandibular transection may include mylohyoid and, if flap extends, the anterior belly of
this area. the digastric and genioglossus muscles.
11. Remove the lateral wall of the oropharynx and tonsil
if there is the slightest indication of involvement With mobilization of a cheek flap, care must be
(see Fig. 15-11). taken not to injure the nerve supply or the small mus-
12. It is usually possible to preserve the twelfth nerve; cles of expression. These nerves are via small branches
the lingual and inferior alveolar nerves may require from the various large branches of the main divisions
transection to obtain improved exposure of the of the facial nerve. They arise medially. Nevertheless, it
parapharyngeal space. is important not to elevate a flap so far anteriorly and
13. Perform a parotidectomy; the extent of resection medially that these small branches will be transected.
depends on the disease. Usually the guideline is I to 2 cm from the commissure
14. Remove the contents of the parapharyngeal space of the lips. These small nerves are involved in the
including internal and external pterygoid muscles superficial musculoaponeurotic system. In summary,
and plates if the parapharyngeal space is invaded elevation of the cheek flap is relatively safe in the
by the neoplasm. parotid area but can become dangerous in the area
15. When palate and superior alveolar ridge are anterior to the parotid gland.
involved, then these structures must be removed.
This involves removing a portion of the antrum. Reconstruction of Buccal Wall lesions
16. Do not compromise on mucosal resection; obtain
frozen sections of margins, especially when they Highpoints
look suspicious.
17. Preserve, if feasible,S to 7 mm of mandibular and 1. Reconstruct buccal wall with underlying buccinator
maxillary mucous membrane along the gingival muscle with or without fat pad:
buccal sulcus for suturing of PMF. a. Use dermal graft (possibly local mucosal flaps).
18. Separate the buccal wall from the cheek, from the b. Use radial forearm microvascular flap.
commissure of the lip to the site of the mandibular c. Use forehead flap (see Fig. 8-10).
resection posteriorly. Use tattoo marks as guide. If a. Use a full-thickness graft.
this point is more posterior, use deeper resection to 2. Reconstruct buccal wall with contiguous areas, for
include the buccinator muscle, fat pad, and portion example: oropharynx, tongue, floor of the mouth:
of the masseter muscle and portion of the oropha- a. Use a PMF.
ryngeal mucous membrane as involved up to the b. Use a microvascular flap.
premolar tooth. 3. Reconstruct entire buccal wall with overlying skin of
19. Reconstruct using a PMF and Steinmann pin with the cheek:
tie wires (see Fig. 14-5) or mandibular plate. a. Use a PMF with or without dermal graft on the
buccal wall.
Cheek Flap Mobilization b. Use a microvascular free flap, for example, an
abdominal flap for the cheek and then a dermal
1. Without the resection of the mandible, for example, graft for the buccal wall attached to the inner
use a visor flap: transect two muscles on the lateral portion of the abdominal flap. A gracilis myocuta-
border of the mandible: neous microvascular flap can be used, if indicated
a. Buccinator (see Chapter 7).
b. If flap extends posteriorly, use a portion of the c. Use a forehead flap (see Fig. 8-llA to N).
masseter muscle. The platysma muscle has some 4. When there has been a segmental resection of the
fibers inserted into the mandible below the oblique mandible:
line (lower external edge of the mandible) and a. Use a Steinmann pin with tie wires.
other fibers into the skin and subcutaneous tissue b. Use mandibular plate.
ORAL CAVI1Y AND OROPHARYNX
A
FIGURE 15-17
ORAl CAVITY AND OROPHARYNX
Resection of Carcinoma of the Although it did not occur in this patient, if the mucous
Retromolar Trigone and the Buccal Wall membrane involvement along the anterior edge of the
(Continued) (Fig. 15-17; see also Fig. 15-11 J ascending ramus of the mandible is adherent along the
and K) presenting margin, this margin of the ascending ramus
of the mandible extending up to the coronoid process
C Depicted is a separation of the buccal wall may be removed along with the overlying mucous
anteriorly extending posteriorly to the solid line (C and membrane. Portions of the temporalis and masseter
D), which includes mucosa, submucosa, and bucci- muscles are inserted on this area of the mandible. If
nator muscle from the cheek flap. This is extended resection of the margin of the mandible does not
down to the fat pad as delineated in D. When this suffice relative to adequate ablative resection, then the
separation reaches the premolar tooth (the anterior ascending ramus of the mandible is removed along
end of the transection of the end of the mandible), the with the segment involving the angle and the body.
dissection now proceeds deeper, including the entire
buccal wall and fat pad and a portion of the masseter
muscle. The mandible is transected through the tooth E Cross section is shown through the anterior area of
socket of the premolar tooth using a sagittal plane resection-the buccal wall. This includes the mucosa,
saw. At this point, the lower portion of the incision the submucosa, and the buccinator muscle.
courses down into the gingival lingual sulcus, thus
encompassing the entire mandible. El Cross section is shown through the buccal wall at
the area where there is a segmental resection of the
o This depicts the buccal wall resection starting at mandible. The resected area includes the mucosa,
the anterior commissure of the lip, extending supe- submucosa, buccinator muscle, fat pad, and a
riorly and inferiorly to the respective sulci. The solid juxtaposed portion of the masseter with the segment
vertical line corresponds to the solid line in C, which of the mandible. At the upper margin of the resection,
depicts the deeper resection posteriorly and laterally the cut edge includes:
down to the subdermal fat pad. Anterior to this line
1. Mucosa to which the edge of the PMF is sutured
the dissection extends to the fat pad. For clarity
2. The edge of the fat pad (all else is removed
purposes, the buccal wall portion of the resection is
posterior to solid line [see C and DJ)
not depicted. The vertical dotted line indicates the
3. The edge of the resected masseter muscle
mucous membrane resected along the anterior edge
of the ascending ramus of the mandible. The dashed
F The completed graft of PMF is shown. The tongue
lines indicate the segment of mandible resected. The
is not tethered-the flap is not sutured to the tongue.
entire section is done en masse including the entire
This allows free motion of the tongue. The flap
buccal wall, buccinator muscle, fat pad, and segment
inferiorly covers the Steinmann pin. This coverage of
of the mandible, with a portion of the masseter
the Steinmann pin can be either medial or lateral to
muscle. The reconstruction utilizes a bent Steinmann
the pin, depending on the location of the PMF (see
pin with tie wires and a PMF.
Figs. 14-1 OF and 15-11 Nand 0).
Continued
ORAL CAVITY AND OROPHARYNX
cut edge of
masseter m.
retromolar portion
::------..of tu mor
no.t staged)
c •
--_._~ o
facial m. of
expression masseter m.
remnant
F
FIGURE 15-17 Continued
ORAL CAVITY AND OROPHARYNX
G
FIGURE 15-17 Continued
ORAL CAVITY AND OROPHARYNX
B Horizontal mattress sutures of 4-0 and 5-0 nylon H The flap of mucosa has been rotated over the
are placed for vertical approximation. This prevents operative defect. Split-thickness skin is sewn over the
shortening of the palate. donor site. Because periosteum is present at the donor
site, the split-thickness skin is more likely to survive.
C The circular excision for a lesion of the hard palate Cotton-soaked liquid povidone-iodine or antibiotic
is outlined. ointment is again applied as a pressure dressing over
the free skin graft.
Continued
ORAL CAVI1Y AND OROPHARYNX
A B
FIGURE 15-18
ORAL CAVITY AND OROPHARYNX
,
\
\
LATERAL PTERYGOID M.
Foramen ovale
Pterygoid process
Pterygoid plates
Glenoid fossa
12th n.
Glossopharyngealn.
Jugular vein In!. carotid a.
I
I
/
/ Pterygoid plate
Foramen
spinosum Foramen
lacerum
External orifice
of carotid canal
Jugular fossa
(~
Facial n. Internal auditory canal
Levator veli
palatini m.
Medial pterygoid
Post. belly
of digastric
Occipital a.
11th n.
Pharyngeal n. branches
Int. carotid a.
Sup. cervical
sympathetic ganglion
FORAMEN OVALE
MEDIAL
PTERYGOID
PLATE
GLENOID
FOSSA
AUDITORY TUBE
L
FIGURE 15-18 Continued
ORAL CAVITY AND OROPHARYNX
Resection of Extensive Benign Minor When the patient was age 13, a benign pleomorphic
Salivary Gland Tumors of the Soft Palate adenoma was enucleated from a concavity of the hard
palate. There was no evidence of any bone destruction.
Histologically benign, locally spreading minor salivary The specimen indicated it was completely excised;
gland tumors of the oral cavity and oropharynx can margins were clear. The specimen measured 3 x 2.5 x
have superior and combined superior and inferior spread 2 em with an intact capsule.
in the parapharyngeal space (see Chapter 23), as well The patient returned at age 28 with a recurrent
as lateral extension into the space. Examples of two 2 x 2.4 em mass in exactly the same location as the
types are outlined relative to the various surgical primary tumor. CT and MRI suggested bony invasion of
approaches and structures resected. the posterior right superior alveolar ridge, pterygoid
Two initial exposures and approaches (options for plate, and hard palate. Follow-up 19 years later showed
skin incisions) include the following: no evidence of local or metastatic disease. CT and MRI
suggested bony invasion of the posterior right superior
1. Via a stepped lip and chin incision, described alveolar ridge, pterygoid plates, and hard palate.
previously (see Fig. 15-11A).
2. Visor flap (Schweitzer), which avoids the midline Minor Salivary Glands
incision and is facilitated by bilateral submandibular
skin incisions. These incisions can extend to the These tumors, although they are benign, can displace
region of the angle of the mandible and the tubercle bone, which can sometimes simulate a malignant tumor.
of the maxilla. These incisions are made sufficiently Ten to 20 percent of all salivary glands arise from sites
inferior to avoid injury to the ramus and mandibu- other than the major salivary glands: palate, tongue,
laris branch of the facial nerve. Because the nerve is lips, nasopharynx, sinuses, and larynx. Approximately
deep to the platysmal muscle, the muscle attach- half of these minor salivary gland tumors are malignant
ments to the oblique line of the mandible are not (Batsakis). However, bone erosion can occur, as well as
transected. The fibers of the muscle to the skin and soft tissue, yet these tumors are considered histologi-
subcutaneous tissue are transected; thus the muscle cally benign but simulate a malignant neoplasm.
is not elevated with the skin flap, thereby protecting An observation relative to the defect in the adjacent
the nerve although the nerve itself is not identified. bone (e.g., hard palate) is that the defect is a noninfil-
In addition, the infraorbital nerve is like-wise pre- trative compression of bone, with a bony sclerotic rim
served but it is identified. between the bone and the tumor. The tumor is still
histologically benign. This is a pressure phenomenon.
An incision is made in the inferior gingival buccal The pathogenesis is unknown.
sulcus bilaterally to further mobilize the visor flap. Five
to 7 mm of mucosa is preserved on the lateral portion Highpoints for Case 7
of the mandible to facilitate closure of the mucosa. This
incision is not necessary when a midline lip incision is 1. Tracheostomy was performed.
used, because the skin flap and the mandible are 2. Exposure and approach:
rotated together laterally. a. A visor flap (chosen by the patient for cosmetic
lWo options to expose the tumor site include: reasons) with bilateral cervical submandibular
incisions was used; the ramus mandibularis was
1. Midline or lateral mandibulotomy. avoided.
2. Midline mandibular glossotomy. This can be combined b. Bilateral incisions were made in the superior
either with the visor flap or the more preferred gingival buccal sulci (canine fossa), posterior to
midline lip incision. the region of the tubercle of the maxilla.
e. Cheek flap was elevated without platysmal mus-
cle. Ramus mandibularis is deep to this muscle.
Case 1 (Fig. 15-19A) d. Infraorbital nerve was identified and preserved.
e. Midline mandibulotomy was performed, lateral
Described is a young female patient with a recurrent retraction: incision of floor of mouth and tran-
pleomorphic adenoma in a minor salivary gland located section of mylohyoid muscle was necessary for
in the palate, which now requires a resection very similar mobilization of mandible.
to malignant minor salivary gland tumor. A pleomor- f. The lateral pterygoid plate was exposed.
phic adenoma, although histologically and morphologi- g. Exposure was enhanced by anterior traction on
cally benign, can, in fact, have significant spread and the tongue, upward traction on the maxilla, and
even invasion to contiguous structures. lateral retraction of the oropharyngeal wall with
ORAL CAVITY AND OROPHARYNX
Case I
FIGURE 15-19
the hemimandible. The visor flap exposure, how- tinus). The descending palatine artery was
ever, is not as effective as a midline lip incision. suture ligated and the stump was covered with
h. Incision through the right superior gingival buc- local soft tissue.
cal sulcus was extended and deep in exposing l. Pulsation of the internal carotid artery was felt
the two pterygoid muscles, which were transect- deep and lateral to the pterygoid muscles.
ed. No evidence of gross tumor was found. m. Frozen section of soft tissue showed margins free
Frozen section of the muscle stumps showed no of tumor.
tumor. Nevertheless, because of the CT and MRI n. The intact specimen, a portion of the hard and
findings, the pterygoid plates were transected soft palate, and a portion of superior alveolar
near their base at the pterygoid process with a ridge with the pterygoid plates were removed.
sagittal plane saw (with care not to violate the o. Frozen section of soft tissue showed margins free
internal carotid artery). of tumor: decalcified bone, no tumor.
1. Transection of the pterygoid plates with the sagit- p. Follow-up at 19 years showed no evidence of
tal plane saw was now extended across the floor local or metastatic disease.
of the antrum encompassing the superior pos-
terior alveolar ridge up to the first molar tooth, Reconstruction
which was extracted. This is the site of the
anterior cut through the alveolar ridge and forms 1. Dermal graft was used for any bone and soft tissue
the line where the hard palate is transected. regions of the resected area. This was primarily over
J. The hard palate was transected horizontally to muscle, stump, and adipose tissue.
the midline and then anteriorly to its attachment 2. Approximation of the mylohyoid and any portion of
to the soft palate. the depressor labia and anguli muscles that had
k. Included in the resection was 1.5 cm of soft been transected was done.
palate by transecting the remaining palatine 3. Palatal defect (use of obturator); a flap should not be
muscles (tensor veli palatini and the glossopala- used because it can hide early recurrent disease.
ORAL CAVITY AND OROPHARYNX
Resection of Extensive Benign Minor was extended to the mastoid process with a curved
Salivary Gland Tumors of the Soft Palate or linear incision. The cervical flap contained the
(Continued) platysma muscle with the ramus mandibularis of
the seventh nerve.
A legitimate question could be asked regarding why e. The bifurcation of the carotid artery as well as the
the resection was so extensive because the tumor was internal and external carotid arteries were exposed
benign. The answer is that with resection of a recurrent as well as the internal jugular vein.
pleomorphic adenoma, a prudent procedure is the sur- f. The cervical facial division of the facial nerve
gical resection of all suspicious tissue, soft and bone, as with the ramus mandibu\aris was identified and
delineated at the time of surgery based on the image preserved along with the greater auricular nerve.
findings. A third recurrence could be tragic, especially The skin flap with the branches of the seventh
in a young patient. nerve was left attached to the mandible and was
an advantage over the visor flap.
Case 2 (see Fig. 15-19B) g. The posterior belly to the digastric muscle and the
stylohyoid muscle were exposed. Superior to these
This patient presented with a large, smooth mass in the muscles, the parapharyngeal space was entered.
soft palate extending superiorly to the junction with Frozen section of a large lymph node indicated it
the hard palate and to the inferior tonsillar region. It was benign.
measured 5 cm vertically and 4 cm horizontally. h. The styloid process displaced by the neoplasm
was removed, which facilitated exposure into the
Surgical Technique parapharyngeal space. Neoplasm was adherent to
the medial aspect of the mandible in the region of
1. Tracheostomy was performed. the angle and extended into the cervical area.
2. Incisional biopsy sample after frozen section There was concern regarding the possible origin
showed benign pleomorphic adenoma. of the neoplasm from the deep lobe of the parotid
3. Initial evaluation of extent of tumor via transpalatine salivary gland. However, the neoplasm capsule
incision indicated neoplasm extending into the para- was not involved with the parotid gland. Pulsa-
pharyngeal, oropharyngeal, and nasopharyngeal tions of the internal carotid artery could be felt
spaces superiorly and inferiorly extending to the posterior and lateral to the neoplasm. This vessel
lower third molar tooth, adherent to the mandible and branches of the external carotid artery were
and the deeper structures of the parapharyngeal carefully protected. The twelfth nerve with the
space. The hamulus of the medial pterygoid plate ansa was identified and preserved.
was identified. i. Dissection extended superiorly into the para-
4. Exposure and approach: pharyngeal space with the internal carotid artery,
a. Midline labiomandibuloglossotomy was performed posteriorly, and laterally, with extreme care not to
with midline incision to just above the hyoid violate the capsule of the neoplasm.
bone (see Figs. 15-4A to C and 15-5). J. Neoplasm was removed intact. All margins were
b. Posterior extent of incision through the base of free of disease.
the tongue was to within 1 cm of the hyoid bone.
c. Both halves of the tongue with intact cheek flaps Reconstruction
were retracted laterally, thus affording exposure
inferiorly, medially, and laterally. The palate was reconstructed by suturing the right side
d. Additional exposure inferiorly was necessary, hence of the soft palate to the lateral oropharyngeal wall.
a combined transcervical approach was used. The Mandibulotomy was closed with the Steinmann pin
cervical incision from just above the hyoid bone and tie wires (see Fig. 15-4G).
ORAL CAVI1Y AND OROPHARYNX
Case II
FIGURE 15-19 Continued
ORAl CAVlTV AND OROPHARYNX
FIGURE 15-20
ORAL CAVI1Y AND OROPHARYNX
Excision of Ranula (Fig. 15-21) resection similar to a carcinoma of the floor of the
mouth (see Fig. 14-11A to E).
A ranula is a retention cyst or mucocele of the sublin- 8. Ligation of all blood vessels is meticulous.
gual gland or minor salivary glands located in the floor
of the mouth. These cysts may have a cervical exten- Complications
sion with submandibular swelling (so-called plunging
ranula) and represent a pseudocyst. When this occurs, • Immediate postoperative hemorrhage
the surgical approach is the same as for resection of the • Recurrence, especially if the sublingual gland is not
submandibular salivary gland (see Fig. 16-12). Another removed with the cyst
type of cyst was closely related and adherent to the • Injury to submandibular duct (Wharton's) or lingual
intrinsic muscles of the tongue with no definite nerve
connection to either the sublingual or submandibular
gland (JML). The submandibular gland and the
sublingual salivary gland were removed with the cyst. A Typical cystic swelling of the floor of the mouth is
This cyst tends to support the theory of origin from the shown. The orifice of the submandibular duct may be
first branchial cleft (see pp. 828 and 836). distorted. The dotted line represents the mucous
membrane to be excised with the cyst. It is useless to
Highpoints attempt to preserve this overlying mucous membrane.
Furthermore, the mucous membrane may be very
1. Resect entire cystic wall preferably with the sublin- adherent to the cystic wall as well as contain the up to
gual gland. 20 excretory ducts of the sublingual gland with, or
2. With recurrent ranulas, always resect the sublingual commonly without, a major duct (see Fig. 14-4E for
gland. additional anatomy).
3. Avoid injury to the lingual nerve and the submandibular
duct, and, if possible, the terminal branches of the B With an Allis clamp or small tender grip forceps,
hypoglossal nerve. the overlying mucous membrane is gently grasped.
4. If resection of the entire cyst is not possible, marsu- The dissection is begun posteriorly, identifying the
pialization can be performed by suturing the remain- lingual nerve.
ing edges of the cystic wall to the mucous membrane.
S. If the submandibular duct has been transected, the C Using first sharp and then careful blunt dissec-
proximal end is brought out through the mucous tions, the sublingual gland with the overlying cyst is
membrane closure and sutured to the mucous retracted forward. This exposes the underlying hyoglos-
membrane. sus muscle. Small terminal branches of the hypoglossal
6. Identification of the course of the submandibular nerve may be identified in this area deep to the lingual
duct may be achieved if necessary by inserting a nerve and are of little consequence, because the main
small plastic tube with the aid of a punctum dilator trunk of the nerve is beyond the surgical field. The
into the lumen. clamp is under the submandibular duct (Wharton's),
7. Warning: there is little chance of confusing a tumor which is preserved.
of the sublingual gland with a ranula because of the
difference of consistency. Virtually all tumors of the D The mucous membrane is approximated with
sublingual gland are malignant and require composite interrupted nylon sutures.
ORAL CAVITY AND OROPHARYNX
LINGUAL N.
SUBLINGUAL GLAND
A B
"
'\ HYOGLOSSUS M. ,I
,
\ Ii
\i,
C D
SUBMANDIBULAR
DUCT
',0 GENIOGLOSSUS M.
FIGURE 15-21
ORAl CAVIlY AND OROPHARYNX
FIGURE 15-22
ORAl. CAVIlY AND OROPHARYNX
1. Avoid injury to eustachian tube orifice. E A slipknot of 2-0 or 3-0 catgut is placed around the
2. Completely remove as much lymphoid tissue as clamped vessels and drawn tight with another clamp.
possible. This is the only place in surgical technique in which
such a knot is justifiable.
Complications
F The anterior pillar is retracted with a Herd
• Hemorrhage, shock retractor, and the capsule is further separated by blunt
• Aspiration of blood, especially during the postopera- dissection. Metzenbaum scissors can also be used for
tive period, which may be secondary to vomiting further dissection. The middle tonsillar vessels, if iso-
• Postoperative airway obstruction -7 respiratory lated, should be clamped, transected, and tied in a
arrest -7 cardiac arrest similar fashion.
• Septicemia (extremely rare)
• Needles of the suture ligatures may break; use heavy G When the dissection has reached the inferior pole,
needle. a snare is used to complete the removal of the tonsil.
If bleeding persists and becomes totally uncontrol- H Invariably, an inferior tonsillar pole of lymphoid
lable, perform a tracheostomy and pack the oropharynx. tissue remains. This is removed with the snare.
An endotracheal tube could be substituted for 24 to
48 hours.
ORAL CAVIlY AND OROPHARYNX
Capsule
G H
FIGURE 15-23
I The fossa is then carefully inspected, and any Point applications of a silver nitrate stick may be used
bleeding vessel is clamped and tied. Suture ligature to control areas that are oozing blood. When local
may be necessary. Deep sutures are to be avoided, anesthesia is used, the identical technique is followed,
because the internal carotid artery could be injured. except that no mouth gag is necessary.
After control of bleeding, a soft gauze sponge with Continued
string attached is placed in the fossa for a few minutes.
ORAl CAVITYAND OROPHARYNX
,---
I
•" "
I/}'
I
I
I J
FIGURE 15-24
ORAl. CAVITY AND OROPHARYNX
• Stenosis secondary to fibrous tissue of the orifice of Not all patients with this syndrome require an
Stensen's duct operation; conservative management by placing the
• Resection of buccal wall with distal portion of Stensen's infant in the prone position may suffice. If the infant is
duct for malignant neoplasm of buccal wall quiet in the resting state, an operation usually is not
necessary.
Highpoints
Indications for Operation
1. Careful evaluation is done to make sure that a
neoplasm is not the cause of the obstruction. • Moderate to severe respiratory obstruction: there is
2. Probing of Stensen's duct should first be attempted a prolapse of the tongue against the posterior pha-
to dilate the strictured area and also to ascertain the ryngeal wall and pressure on the epiglottis.
presence or absence of a calculus. • Persistent feeding problems despite the prone posi-
3. A sialogram is helpful. tion: aspiration pneumonia, failure to gain weight
• Discrepancy of 1 em or more between mandibular
The technique is an exploration of the stenotic area and maxillary arches
with its resection followed by reimplantation of the duct
into the mucosa of the buccal wall at a more proximal Highpoints
location. The duct wall is sutured to the opening in the
buccal mucosa using 6-0 nylon sutures in at least three 1. Emergency treatment: pull tongue forward with
to four locations. deeply placed suture or towel clip through tongue
and insert nasopharyngeal tube: avoid tracheostomy
Complications if at all possible.
2. Carefully plan general anesthesia: intubation can be
• The possibility of scarring and recurrence of the difficult.
stenosis 3. Tongue is attached to lower lip in a horizontal plane
(Routledge, 1960; Randall, 1964).
The technique is similar to that described for the 4. Avoid injury to Wharton's ducts.
reimplantation of the Wharton's duct, illustrated in S. Release ankyloglossia if present.
Figure IS-6EI. See Figure IS-24C and 0 for repair of a 6. Maintain fixation of tongue to lower lip for 10 to 18
laceration of Stensen's duct. months.
7. Repair cleft palate in usual fashion after the second
stage of release of tongue to lower lip is performed
Pierre Robin Syndrome (Fig. 15-25) and all danger of respiratory obstruction is past.
(After Routledge, 1960; Randall, 1964)
Complications
Characteristics
• Suture avulsion
• Micrognathia (more accurately retrognathia) • Torn tongue
• Glossoptosis • Failure of operation may require a tracheostomy,
• Respiratory obstruction in varying degrees which is associated with all the serious complica-
• Other anomalies, such as cleft palate, heart disease, tions of a tracheostomy in an infant: edema of
otologic deformities, hydrocephalus, mental retarda- trachea, plugging of the small tube, and difficulty of
tion, deformities of fingers and toes, major ocular extubation before the age of 10 to 12 months.
ORAl CAVI1Y AND OROPHARYNX
FIGURE 15-25
A, B Cross section of basic pathologic anatomy is cleft palate with the tongue locked in a posterior
shown. With the retroposition of the mandible, the position or protruding into the nasopharynx.
suspensory apparatus of the tongue musculature,
hyoid bone, and epiglottis is lacking. The tongue and C Horizontal incisions are made in the tongue and
epiglottis occlude the supraglottic air passage. B indi- lower lip.
cates the further obstruction caused by an associated Continued
ORAl CAVITYAND OROPHARYNX
FIGURE 15-25
ORAL CAV11Y AND OROPHARYNX
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