John M. Lore, Jr., M.D. 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.
Jesus E. Medina, M.D. University
Paul and Ruth Jonas Professor and Chair, Department of Otorhinolaryngology, of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, Oklahoma.
Illustrated by
Robert Wabnitz Director Emeritus
of Medical Illustration,
University of Rochester and
Medical Center, Rochester,
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
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AN ATLAS OF HEAD AND NECK SURGERY, FOURTH EDITION Copyright c 2005, Elsevier Inc. All rights reserved.
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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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CONTRIBUTORS
AHMED ABDEHALlM, M.D.
ANGELA BONTEMPO,
Clinical Assistant Professor of Diagnostic Radiology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Neuroradiologist, Roswell Park Cancer Institute; Neuroradiologist, Women and Children's Hospital of Buffalo (Kaleida Health System), Buffalo, New York Advanced Techniques for CT in the Head and Neck (Chapter 1)
President and CEO, Saint Vincent Health System, Erie, Pennsylvania A Comprehensive, Interdisciplinary Head and Neck Service (Chapter 3)
F.A.C.H.E.
DANIEL BRODERICK, M.D. Assistant Professor of Radiology, Mayo Clinic, Jacksonville, Florida Bone Imaging and Pathology (Chapter 3)
RONALD A. ALBERICO, M.D.
DANiEl SETTE CAMARA, M.D.
Associate Professor of Radiology and Assistant Clinical Professor of Neurosurgery, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Director of Neuroradiology and Head and Neck Imaging, Roswell Park Cancer Institute; Director of Pediatric Neuroradiology, Women and Children's Hospital of Buffalo (Kaleida Health System), Buffalo, New York Advanced Techniques for CT in the Head and Neck (Chapter 1)
Clinical Associate Professor of Medicine, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Gastroenterology Service, Sisters of Charity Hospital, Buffalo, New York Percutaneous Endoscopic Gastrostomy (Chapter 21)
JOSEPH M. ANAIN, M.D. Assistant Clinical Professor, Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Chief, Division of Vascular Surgery, Sisters of Charity Hospital, Buffalo, New York Vascular Procedures (Chapter 22)
DAVID M. CASEY, D.D.S., M.S. Clinical Professor, Department of Restorative Dentistry, State University of New York at Buffalo School of Dental Medicine; Head, Maxillofacial Prosthetic Section, John M. Lore, Jr., M.D. Head and Neck Center, Sisters of Charity Hospital; Maxillofacial Prosthodontist, Department of Dentistry, Maxillofacial Prosthetics, Roswell Park Cancer Institute, Buffalo, New York Dental and Prosthetic Considerations in Head and Neck Surgery (Chapter 3); Maxillofacial Prostheses (Chapter 3)
SHIRLEY A. ANAIN, M.D. Assistant Clinical Professor, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York Facial Paralysis (Chapter 7)
GREGORY J. CASTIGLIA, M.D. Neurosurgeon, Buffalo Neurosurgical Group, Amherst, New York Supraorbital Approach to the Orbit and Paranasal Sinuses (Chapter 23)
JOHN E. ASIRWATHAM, M.D. Clinical Associate Professor of Pathology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Department of Pathology, Sisters of Charity Hospital, Buffalo, New York Bone Imaging and Pathology (Chapter 3); Pathology of the Parathyroid Glands (Chapter 18)
v
CONTRIBUTORS
NIEVA B. CASTILLO, M.D. Assistant Clinical Professor of Pathology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Associate Chief of Pathology, Department of Pathology, Sisters of Charity Hospital, Buffalo, New York Malignant Mixed Tumor (Chapter 17); Endocrine Surgery (Chapter 18); Vascular Procedures (Chapter 22) KANDALA CHARY, M.D. Medical Oncology, Sisters of Charity Hospital, Buffalo, New York Preoperative Chemotherapy, Uncompromised Surgery, and Selective Radiotherapy in the Management of Advanced Squamous Cell Carcinoma of the Head and Neck (Chapter 3) SCOTT CHOLEWINSKI, M.D. Director, Department of Magnetic Resonance Imaging, Sisters of Charity Hospital, Buffalo, New York CT and MRI (Chapter 1); Bone Imaging and Pathology (Chapter 3) KEITH F. CLARK, M.D., Ph.D. Clinical Professor, Department of Otorhinolaryngology, University of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, Oklahoma Endoscopic Sinus Surgery (Chapter 5) ERNESTO A. DIAZ-ORDAZ, M.D. Assistant Professor of Otolaryngology and Assistant Professor of Communicative and Speech Disorders, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Acting Chair, Department of Otolaryngology, Sisters of Charity Hospital, Buffalo, New York Infratemporal Approach to the Skull Base (Chapter 23) ROBERT W. DOLAN, M.D. Surgeon, Department of Otolaryngology, Head and Neck Surgery, Lahey Clinic, Burlington, Massachusetts Microvascular Surgery (Chapter 24) MEGAN FARRELL,M.D. Endocrinologist, John M. Lore, Jr., M.D. Head and Neck Center, Sisters of Charity Hospital, Buffalo, New York Endocrine Surgery (Chapter 18)
DAVID F. HAYES, M.D. Assistant Clinical Professor of Radiology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Chair, Department of Diagnostic Imaging, Sisters of Charity Hospital, Buffalo, New York CT and MRI (Chapter 1); Ultrasound (Chapter 1) l. NELSON HOPKINS, M.D. Chief of Neurosurgery, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York Vascular Procedures (Chapter 22) R. LEE JENNINGS, M.D. Assistant Clinical Professor of Surgery, University of Colorado Health Sciences Center School of Medicine; Colorado Surgical Oncology Associates, Denver, Colorado Preoperative and Postoperative Care (Chapter 3) CONSTANTINE P. KARAKOUSIS, M.D., PH.D. Professor of Surgery, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Millard Fillmore Hospital (Kaleida Health System), Buffalo, New York Malignant Melanoma (Chapter 3); Soft Tissue Sarcoma (Chapter 3) SOL KAUFMAN, Ph.D. Research Assistant Professor of Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Consultant, Biostatistics, Buffalo, New York Preoperative Chemotherapy, Uncompromised Surgery, and Selective Radiotherapy in the Management of Advanced Squamous Cell Carcinoma of the Head and Neck (Chapter 3) DOUGLAS W. KLOTCH, M.D. Surgeon in Private Practice, Tampa, Florida Fractures of Facial Bones (Chapter 13) ASHOK KOUL, M.D. Clinical Assistant Professor of Pathology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Director of Pathology and Laboratory Medicine, Sisters of Charity Hospital, Buffalo, New York Commonly Used Terminology for Squamous Epithelium (Chapter 3)
CONTRIBUTORS
JOHN LAURIA, M.D.
DOUGLAS B. MORELAND, M.D.
Professor and Chair Emeritus, Department of Anesthesiology, State University of New York at Buffalo School of Medicine and Biomedical Sciences and Sisters of Charity Hospital, Buffalo, New York Venous Air Embolism (Chapter 2); Malignant Hyperthermia (Chapter 2)
Director, Buffalo Neurosurgery Group; Chief of Neurosurgery, Sisters of Charity Hospital; Co-Director, Gamma Knife Center, Roswell Park Cancer Institute, Buffalo, New York Endoscopic Endonasal Transsphenoidal Approach to the Pituitary Gland (Chapter 23)
WILLIAM M. MORRIS, M.D. KEUN Y. LEE, M.D. Assistant Clinical Professor, Department of Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Attending in Otolaryngology-Head and Neck Surgery, Sisters of Charity Hospital; Buffalo Otolaryngology Group, Buffalo, New York Posterior Neck Dissection (Chapter 16)
Buffalo, New York Cardiopulmonary Resuscitation (Chapter2)
WILLIAM R. NElSON,
M.D.
Clinical Professor Emeritus of Surgery, University of Colorado Health Sciences Center School of Medicine, Denver, Colorado Preoperative and Postoperative Care (Chapter 3)
JOHN S. LEWIS, M.D.
ROBERT J. PERRY, M.D.
Associate Clinical Professor Emeritus of Otolaryngology, Columbia University College of Physicians and Surgeons, New York, New York Temporal Bone Resection (Chapter 23)
Clinical Associate Professor of Surgery (Plastic), State University of New York at Buffalo School of Medicine and Biomedical Sciences; Chief, Division of Plastic Surgery, Women and Children's Hospital of Buffalo (Kaleida Health System), Buffalo, New York Cleft Lip and Palate (Chapter 10)
THOM R. LOREE, M.D. Chief, Department of Head and Neck Surgery, Roswell Park Cancer Institute, Buffalo, New York Management of Salivary Gland Tumors (Chapter 17)
JOACHIM PREIN, M.D., D.M.D.
Senior Vice President, Medical Affairs, Sisters Healthcare System, Buffalo, New York A Comprehensive, Interdisciplinary Head and Neck Service (Chapter 3)
Professor of Maxillofacial Surgery and Chair, Clinic for Reconstructive Surgery, Unit for Maxillofacial Surgery, University Clinics of Basel; Chair, European Maxillofacial Education Committee, Basel, Switzerland Compression Plating for Ireatment of Mandibular Fractures (Chapter 13)
JESUS E. MEDINA, M.D.
ALLEN M. RICHMOND,
Paul and Ruth Jonas Professor and Chair, Department of Otorhinolaryngology, University of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, Oklahoma The Neck (Chapter 16)
Clinical Instructor, Department of Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; John M. Lore, Jr., M.D. Head and Neck Center, Sisters of Charity Hospital; Staff, Buffalo Hearing and Speech Center, Inc., Buffalo, New York Voice, Speech, and Swallowing Rehabilitation of the Head and Neck Patient (Chapter 3)
A. CHARLES MASSARO, M.D.
ROBERT S. MILETICH, M.D., Ph.D. Associate Professor of Clinical Nuclear Medicine, Department of Nuclear Medicine, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Staff Physician, Veterans Affairs Western New York Healthcare System, Buffalo, New York; Staff Physician, Dent Neurologic Institute, Amherst, New York Positron Emission Tomography (Chapter 1)
PH.D.
ARTHUR J. SCHAEFER, M.D.t Clinical Professor of Ophthalmology and Clinical Assistant Professor of Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York Blindness and Ophthalmic Complications of Surgery of the Head and Neck (Chapter 2) t Deceased.
CONTRIBUTORS
DANIEL P. SCHAEFER, M.D.
MONICA B. SPAULDING,
Director of Oculoplastic, Facial, Orbital, and Reconstructive Surgery; Clinical Professor of Ophthalmology; Clinical Assistant Professor of Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York Blindness and Ophthalmic Complications of Surgery of the Head and Neck (Chapter 2); Thyroid-Related Orbitopathy (Chapter 3); Supraorbital Approach to the Orbit and Paranasal Sinuses (Chapter 23)
Associate Professor of Medicine and Otolaryngology, State University of New York at Buffalo School of Medicine and Biomedical Sciences; Chief, Oncology Section, Veterans Affairs Western New York Healthcare System, Buffalo, New York The Place for Chemotherapy in Management of Squamous Cell Carcinoma of the Head and Neck (Chapter 3)
DHIREN K. SHAH, M.D. Medical Director, Cancer Treatment Services; Assistant Clinical Professor, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York Radiation Therapy for Laryngeal Cancer (Chapter 20)
DONALD P. SHEDD, M.D. Professor Emeritus, Department of Head and Neck Surgery, Roswell Park Cancer Institute, Buffalo, New York Common Departures from Sound Management (Chapter 3)
M.D.
MAUREEN SULLIVAN, D.D.S. Chief, Department of Dentistry and Maxillofacial Prosthetics, Roswell Park Cancer Institute, Buffalo, New York Osseointegrated Implants in Head and Neck Reconstruction (Chapter 3)
NAN SUNDQUIST,
R.N.
Formerly Chief Nurse, Department of Otolaryngology, State University of New YQrk at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York Preoperative Chemotherapy, Uncompromised Surgery, and Selective Radiotherapy in the Management of Advanced Squamous Cell Carcinoma of the Head and Neck (Chapter 3)
IN
MEMORIAM
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 contributions 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. Thom R. Loree, M.D.
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 JOHN M. LORE, M.D., F.A.C.S.
1892-1950 whose energy and devotion both in his chosen field in medicine-otolaryngologyand in his dedicated aim in medical education-a new medical center for his medical school, New York University-were and still are an inspiration. His desire for cooperation in and plans for a consolidated surgical training program in the field of head and neck surgery provided the impetus for this Atlas.
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 first edition of An Atlas of Head and Neck Surgery, including three English editions and one Spanish edition. This Fourth Edition has further broadened its background-an increased scope of each chapter with an additional number of contributors. Jesus E. Medina, M.D., is welcomed as an associate editor to this Fourth Edition. He has been instrumental in a number of facets, namely in obtaining Robert W. Dolan, M.D., Department of Otolaryngology, Head and Neck Surgery, Lahey Clinic, to author the new chapter on Microvascular Surgery, and Keith F. Clark, M.D., Ph.D., for the addition of Endoscopic Sinus Surgery to Chapter 5. Dr. Medina also has contributed to a number of other areas. The additions, it is believed, cover items that hit the highlights of a number of aspects of head and neck surgery, which are available to the surgeon as up-tothe-minute help. It is not a cookbook of surgery, however. This could be an inherent danger in an atlas. The surgeon must be experienced with the various procedures and modifications thereof. No dabblers.! The choice of the surgical procedure must not be based on the easiest and quickest minimum resection but rather must be aggressive'> There is a danger of preserving soft tissue and bone with disease-free minimum margins and even no margins. Reference is made to Dr. Murray F. Brennan's presidential address to the Society of Surgical Oncologists in 1996.3 There should be no such attitude as "leave disease right up to the line of resection." It appears that widespread use of radiotherapy as a routine postoperative modality is fraught with the misconception for the surgeon that if a little tumor is left behind it is really no worry since routine radiotherapy is the catchall. Margins in this methodology mean little since ionizing radiation will handle all that the surgeon neglects. Radiotherapy, as well as chemotherapy, plays an important part in the management of head and neck squamous cell carcinoma, Stage III and Stage IV, but is not meant to give a false sense of security to the surgeon. Hence, it is believed that radiotherapy should not be routinely used postoperatively but rather selectively. This spares the patient of the side effects of radiotherapy, as well as making radiotherapy available during the entire
follow-up period if indicated. With the use of chemotherapy, the surgeon must not compromise the scope of surgical resection when there is a favorable response to the chemotherapy. Please confer preoperative chemotherapy in Chapter 3. As more tissue and bone are removed, the reconstructive measures must be further improved and expanded from a cosmetic and a functional point. A caveat that must be emphasized is that wherever possible or practical the reconstructive measures should not mask early or late recurrence of disease. At times this is not possible. As an expansion of the reference to microvascular surgery in the preface of the Third Edition, a new Chapter 24 has been added. The indication for microvascular surgery has broadened and has served well in a number of reconstructive problems, especially free skin flaps for major skin defects of the cheek, as well as muscle and bone transfers. This new chapter by Dr. Dolan serves two purposes: (1) to demonstrate to the head and neck oncologic surgeon what can be achieved by microvascular surgery and (2) to present the techniques involved. These techniques are not for the dabblers-only for experienced microvascular surgeons. Take time to evaluate and record the extent of disease utilizing tattoo, when possible, prior to any management plan. Do not depend on the site evaluation at the time of the initial surgical procedure. This admonition is an absolute with the use of preoperative chemotherapy or, for that matter, radiotherapy, especially if salvage surgery becomes necessary following any recurrence after the radiotherapy. Regular careful and thorough follow-up of patients must be carried out to the best possible degree. Followup must be done by the surgeon and by those expert in the field of head and neck examination and knowledge of the natural history of the disease. The primary responsibility is the surgeon's and not the primary care physician's. Keep records, which will be valuable as an evaluation of outcome-not only the physical examination, but also the quality of life. When evaluating the quality of life, take into account the family support or lack of support. It may be worthwhile at different times to have different physicians in other allied disciplines involved in the search for early recurrence. For example, the XIII
PREFACE
reconstructive surgeon, the prosthodontist, the radiation oncologist and the medical oncologist, and the specially trained nurse clinicians all should be involved in evaluation. This approach is time consuming both for the medical professionals as well as the patient, and sometimes it's shattering for the HMOs. These follow-up examinations should be based on a regular schedule-usually one time per month for the first year and then every two months for the second year and so on up to five years. They continue every 5 to 6 months, as enumerated later. There is some indication or recurrence following preoperative chemotherapy. New primaries may appear between the seventh and the tenth year. Follow-up should not be more than every 5 to 6 months; sooner if there appears to be a predisposing factor to squamous cell carcinoma. Follow-up is for life. A patient who continues to smoke or who has an indication of field carcinogenesis is an example. Frequencies may be increased or decreased, depending on the anticipated natural history of the disease. This is time consuming yet most important. Review all images-not just reports. CT, MRl, MRA, angiograms, and PET scans, when appropriate, must be reviewed by the surgeon. It is not unusual to spend upwards of one hour in this type of preoperative evaluation. Postoperative examination, especially long-term, likewise involves considerable time and effort. This is another problem for those from the HMOs to comprehend even though they may be physician consultants. One HMO recognized this "unique specialty practice" involving training in both otolaryngology and general surgery. All this is a significant and tremendous responsibility for the surgeon and all those concerned. In the Preface of the Third Edition, the concept of centers of excellence was introduced in the management of neoplasms of the head and neck. In 1993, this concept was initiated at Sisters of Charity Hospital in Buffalo, NY. The following is a description of such a center. It has flourished well and its weekly tumor conferences with surgery, medical oncology, radiation oncology, and endocrinology, as well as with its specialized nurses and support personnel, has attracted local physicians from other hospitals in the Buffalo area. Since its inception, it has trained fellows with backgrounds in otolaryngology, general surgery, and plastic surgery. The center supports the concept of excellence in patient care plus the important addition of academia and ecumenism. The academia in itself is desirable, and when joined in a single service including all of the disciplines involved becomes a sine qua non in the management of head and neck neoplasms, including thyroid diseases. A dedicated interest in academia produces interest in newer concepts-for example, molecular biology with gene therapy-which may well become the basis of future treatment of head and neck squamous cell carcinoma.
Description of Head and Neck Services at Sisters Hospital4 Over the years, management of neoplastic disease as well as other diseases has crossed time-honored established disciplines. In head and neck neoplasia, including thyroid malignancy; surgical, medical, and radiation oncology; and endocrinology, other supportive disciplines and services are involved. The input from these disciplines is usually achieved by multidisciplinary conferences. To further develop this ecumenical approach, to avoid "turf battles," and to further enhance cooperative and close exchange of ideas regarding diagnosis and management of head and neck neoplasia, a Head and Neck Oncology Service within the John M. Lore, Jr., M.D., Head and Neck Center at Sisters Hospital, Buffalo, NY, was established 8 years ago. This service encompasses the aforementioned disciplines plus all other germane disciplines and services, including General Otolaryngology, Reconstructive Surgery, Vascular Surgery, Microvascular Surgery, Neuro-otology, Skull Base Surgery, Oncologic Ophthalmology, Diagnostic Imaging, Head and Neck Pathology, Nuclear Medicine, Psychiatry, Maxillofacial Prosthetics, Dental Pathology, Swallowing and Speech Pathology, Nutrition and Biostatistics. The main purpose is to render the best possible patient care, to attract the best qualified physicians and other professionals (thus sifting out the dabblers), and to promote an academic atmosphere. This oncology service functions as an autonomous service with the cooperation and support of the Chairman of the Department of Surgery and the Chairman of the Department of Internal Medicine. The Service is responsible for its own quality review data, which is supplied to the Quality Review hospital committee. Outpatient; inpatient; speech and swallowing professionals with laboratory staff, physicians, fellows, and nurse clinicians; as well as oncologic dentistry, conference rooms, library and nutritional offices are all contiguous and on the same floor of the hospital. On the same floor is the Pathology Department and up one flight are the OR and ICU. Down one flight is Diagnostic Imaging and Nuclear Medicine. On another floor is the Microsurgical Laboratory. It appears that this approach to head and neck neoplasia, including thyroid and parathyroid tumors, truly improves patient care without the stigma of "treatment by committee." We may agree or disagree yet each individual is free to treat the patient as he or she sees fit. This type of service avoids the wasted time involved in turf conflicts. The Head and Neck Oncology Service is a complete system where the sum of all the components is much better for patient care than any independent part. At the very beginning of this project was and still is Robert E. Rich, the founder of Rich Products, who
PREFACE
gave me the impetus to go ahead with this idea. He produced the wherewithal to start basically a "onestep" facility, which minimizes "wasted time" in the diagnosis and management of head and neck neoplastic disease. There are four team players who helped in the inauguration of this multiple discipline service: Kenneth Eckhert, M.D., Chief of Surgery; Nelson Torre, M.D., Chief of Medicine; Sister Angela Bontempo, Administrator at Sisters of Charity Hospital; and Charles Massaro, M.D., Vice President of Medical Affairs at Sisters of Charity Hospital. Without the cooperation of these individuals this service could never have been developed. It had previously been proposed when I was Chairman of the Department of Otolaryngology at the State University of New York at Buffalo to the dean, and twice he turned this concept down saying, "We are not ready for anything like that just yet." Hence, the medical school was bypassed in this endeavor. The amalgamation of the Society of Head and Neck Surgeons, founded by Hayes Martin and Grant Ward in 1954, and the American Society for Head and Neck Surgeons, established in 1958 by the hard work of George Sisson, M.D., along with other dedicated head and neck surgeons, was a great step forward. Among the other dedicated surgeons as founders of the American Society for Head and Neck Surgery was Edwin W Cocke, M.D., John S. Lewis, M.D., W. Franklin Keim, M.D., William M. Trible, M.D., and John M. Lore, Jr., M.D. This amalgamation in 1999 united the two societies into one society, now known as The American Head and Neck Society. This joined the disciplines of otolaryngology, general surgery, and plastic surgery into one endeavor. There are many benefits to this amalgamation, not the least of which, of course, is improvement of patient care by the sharing of various ideas among the various disciplines all present at the same meeting. The main downside as I see it is the fact that the larger the society is, the less discussion there is from the floor and membership. I would strongly suggest that adequate time be allowed in meetings for this type of discussion, because this enhances the exchange of different ideas and different methodologies of treatment. There is an interesting and laudable result of this amalgamation in that it should and will eliminate the striving of one society to have more members than the other. This inherent danger, which previously existed, should be eliminated once and for all. This attempt at getting more members led to the admission of surgeons regardless of background who were not fully qualified in the field of head and neck oncology. There is no need for an unlimited supply of head and neck surgeons since, to quote from the Third Edition, "There are only about 50,000 new patients each year with head and neck cancer, and only approximately 35 to 75 new, well-trained head and neck oncologic surgeons are necessary each
year to maintain an adequate workforce of some 400 to 1,000 head and neck oncologic surgeons to manage this number of patients. Thus, we must minimize the number of 'dabblers.'] There is simply no reason to accept physicians who are not well-trained in this field. Quality and not quantity is the objective. There is no doubt that, except in the rare case, the residents interested in this field must be dedicated to it and spend extra time in a fellowship, preferably approved by the American Head and Neck Society. This would help them reach near perfection in their chosen field as best as possible. This concept in medicine has been useful in the training of hand surgeons, since it involves the disciplines of general surgery, orthopedic surgery, and plastic surgery. In hand surgery, this has been recognized by the three boards as an important facet in the training of a hand surgeon. Unfortunately, in head and neck surgery, the three boards involved, namely, otolaryngology, general surgery, and plastic surgery, have not seen fit to endorse this concept. Unless the individual is a genius, there is simply no way to adequately train a resident in the various facets of head and neck oncology and endocrinology in a residency training program, since the training in that particular specialty involves a number of other aspects over and above head and neck oncology. As Harvey Baker, M.A.,s discussed in his presidential address to the Society of Head and Neck Surgeons entitled Head and Neck Surgery: The Pursuit of Excellence in 1971 and pointed out that to be active, for example in general otolaryngology, simply does not afford the time and effort needed to become a welltrained and practicing and active head and neck oncologic surgeon. Logical conclusion to these standards is the active participation in one of the approved fellowships. Having been the originator of this additional fellowship training plus having the position of president of both head and neck societies, I have had, and I say this with humility, experience in the endeavor. Changes in the fellowship curriculum were made from time to time and rightly so. The latest one of admitting graduates of well-trained foreign programs is strongly commended. Remember, American surgeons at the time of the late 1800s and early 1900s were afforded the benefits of learning from their European counterparts. We have the same obligation and advantage today to share all our ideas and techniques with our European colleagues. We learn from one another. Some flexibility is worthy of implementation, namely, possibly one or two types of fellowships. The one-year fellowship would primarily focus on the clinical aspects of head and neck oncology but would also include a reasonable amount of clinical research. The two-year fellowship would involve basic research along with clinical exposure in a suitable institution where the candidate's desires can be realized. Selected arrange-
PREFACE
ments for rotation of fellows from one parent institution to one or two other institutions-for one monthwould afford the fellow an excellent exposure to other methodologies in the overall management of head and neck neoplasia. Again, it is my strong admonition that two years of basic surgical training in an approved general surgical training program is highly recommended for those who wish to pursue a head and neck oncologic fellowship. The exposure to basic surgical principles cannot be achieved, I believe, in a single discipline-oriented program. I can attest to this again by personal experience, having completed the approved residency in the American Board of Otolaryngology and the American Board of Surgery. I am not inferring that double boards are necessary. But otolaryngology residents would certainly benefit from two years of general surgery. The reverse, namely, dedicated training in otolaryngology, is also true for the general surgery and plastic surgery residents. Ideally, another year of plastic surgery would be fortuitous. The next step in the joint venture of all three disciplines, namely, general surgery, otolaryngology, and plastic surgery, would be the recognition by the three boards concerned relative to an approval of this fellowship. To attempt to achieve this objective, plans were modeled after the three boards of general surgery, plastic surgery, and orthopedic surgery, agreeing on a postresidency hand training program. Dr. George Omer, from Albuquerque, New Mexico, was the driving force in this venture. It appears that they have succeeded with the cooperation of the three boards recognizing an acceptable fellowship in hand surgery. Following this concept that was developed in hand surgery, an attempt was made to achieve the same type of recognition by the three boards involved in training of head and neck oncologic surgeons. The initial datagathering trip was made by Dr. William Nelson and me going to Albuquerque to review with Dr. George Omer how he achieved the cooperation of the three boards. Following his ideas, Dr. Elliott Strong and I developed a similar concept for the recognition of head and neck oncologic surgery by the American Boards of Otolaryngology, Surgery, and Plastic Surgery as "added qualifications." Unfortunately, we failed despite our efforts at the board level and at the American College of Surgeons level and it was then that we simply gave up the endeavor. I decided then to take the next step and that was to develop a center of excellence in our particular field and, hence, the development of the Head and Neck Oncologic Service at Sisters of Charity Hospital. Another aspect that is most important in the development of our field is the realization that we are a profession and not a business. This is aptly referred to in Dr. Robert M. Beyers's presidential address to the Society of Head and Neck Surgeons in 1996 entitled, Barberpoles,
and Wounds that Will Not Heal.6 I quote him as follows: "If we act like a trade or business rather than a profession, we shouldn't complain about words used to describe us such as healthcare providers and our patients as clients." Dr. Beyers goes on to quote Simon H. Rifkind, a lawyer, who expressed his views about how a profession loses its professionalism. It is recommended that Dr. Beyers's presidential address be read in its entirety.
Battlefields,
And Now a Few Caveats Insecurity is the main stumbling block for a joint venture. For management with the best overall survival for advanced squamous cell carcinoma of the head and neck, aggressive surgery is the mainstay.2 Radiation Oncology and Medical Oncology are ancillary and required fine-tuning. Molecular Biology may alter this sequence in years ahead. For organ preservation in advanced squamous cell carcinoma of the head and neck, chemotherapy and radiotherapy are the primary modalities with salvage surgery for failures and backup. Patients must be aware of the complications and effect on survival and quality of life, specifically the significant complications of salvage surgery. These complications were experienced some 40 to 50 years ago when radiation was the first treatment modality followed by surgery. Because of these complications, the sequence of treatment was changed to surgery followed by radiotherapy. Physicians must be the real leaders in medicine. Unfortunately, from time to time, physicians have abrogated this responsibility and opportunity. Do not admit physicians into the American Head and Neck Society who are not adequately and completely trained. Quality and not quantity is the objective. Our prime objective is the best of care, the highest quality for patients, regardless of the pressures of paperwork and other limitations by insurance companies and government. Closely related to the prime objective is evaluation of each and every service's end results, performance data, and quality of life- "evaluate your track record." Just because a procedure can be done, that is not the reason to do it. Develop the atmosphere of academia, which stimulates intellectual curiosity and improves quality of patient care. Randomization-Is this always necessary? Does it make any and every presentation valid? Review the pros and cons of randomized study techniques when you report your end results.8 (Suggest review of this reference by Drs. Fung and Lore.) There are shadows that surround us. Namely, the insurance companies, the paperwork, and the loss of valuable time in the encountering and fighting of these obstacles. In any event, we must not be complacent and discouraged. We must not lose the main objective
PREFACE
of our calling in life. We must not be dabblers. I We must assume our responsibilities.? We must return to the philosophy of the founding fathers of our country and Constitution when they saw fit to engrave on our coins In God We Trust. Recommendations It is recommended that the head and neck surgeon, especially the younger ones who are not aware of the background of this entire field, review a number of excellent resumes and books. They are as follows: The Head and Neck Story, by George A. Sisson, M.D., 1983, published by the American Society for Head and Neck Surgery, produced by Kascot Media, Chicago, IL. The Making of a Specialty, Hayes Martin Lecture, by Jatin P. Shah, M.D., American Journal of Surgery, Vol. 176, Nov. 1998, pp 398-403. History of Head and Neck Surgery,by Jerome C. Goldstein, M.D., and George A. Sisson, M.D., Otolaryngology Head and Neck Surgery, Vol. 1, US, #5, 1996.
Donald P. Shedd, Historical Landmarks in Head and Neck Cancer Surgery, 2000, American Head and Neck. Society. REFERENCES 1. Lore, JM, Jr: Dabbling in head and neck oncology (a plea for added qualifications). Arch Otolaryngology Head Neck Surg 1987; 113:1165-1168 2. Forastiere, A, Koch, W, Trotti, A, Sidransky, D: Head and neck cancer. N Engl J Med 2001; 345:1890-1900. 3. Brennan. MF: The enigma of local recurrence. Ann Surg Oncol 1997; 4:1-12. 4. Lore, JM, Jr., Massaro, M: Description of Head and Neck Services at Sisters Hospital Abstract submitted. 5. Baker, HW: Head and neck surgery: The pursuit of excellence. Am J Surg 1971; 122:433-436. 6. Beyers. RM: Barber poles. battlefields and wounds that will not heal. Am J Surg 1996; 172:613-617. 7. Lore. JM, Jr: Bill of responsibility. The Hayes Martin Lecture. Am J Surg 1992; 164:556-562. 8. Fung E, Lore, JM, Jr: Randomized control studies for evaluating surgical questions. Accepted for publication Arch Otolaryngol In press.
ACKNOWLEDGEMENTS
First, I wish to once again thank my wife, Chalis, for all the ancillary work she did as well as her quiet support despite the mess of "paper" that I managed to disperse throughout our home during these more than five years of work on this Fourth Edition. Shortly after deciding to go ahead with the Fourth Edition, Robert Wabnitz, our master illustrator, suffered a stroke, which to everyone, especially his wife, Sue, was a terrible shock. He could no longer continue on with this venture. Fortunately, he had taught medical illustration at the University of Rochester Medical Center. Margaret Pence, one of his students, took over for Robert. She uses the same style that her teacher taught her, and she has done an excellent and professional job. Not only for her expertise as an illustrator are we all grateful, but also her pleasant cooperation in anything and everything we asked of her in her chosen field. She is a superb Medical Illustrator. I wish to also thank Jesus E. Medina, our associate editor, and all of our contributors-in the previous editions and in this edition-for their time, interest, and expertise. They are all detailed in the list of contributors. Many, many thanks. The extent of their contributions is noted in the various chapters. These included contributions for an entire chapter, for example, Chapter 24, to major portions, inserts, and commentaries. To a very grateful patient, supporter, and sponsor of the John M. Lore, Jr., M.D., Head and Neck Center at Sisters Hospital-Robert E. Rich. He recognized the importance of an ecumenical approach in the development of a medical and surgical service to achieve quality of patient care. The center is a byproduct of this atlas, and I am deeply appreciative of Bob's involvement and support. The next expression of gratitude goes to the two transcriptionists: Lauri L. Hess, of Dr. Medina's office, who, in dedicated fashion, transcribed my illegible inserts onto the disks, and Leslie Berry, a freelance transcriber par excellence, who, under considerable pressure, completed the final draft. Dottie Kane, who did most of the transcribing for the Third Edition, helped us with initial note-taking relative to this Edition of An
Atlas of Head and Neck Surgery.
Other acknowledgements go to the staff of our Head and Neck Service at Sisters of Charity Hospital in Buffalo, NY: Karen Stawiasz, MS, RN, NP, OCN (Oncology Certified Nurse), an incredible person who is Jill-of-alltrades and master of all and, specifically, our Oncology Clinical Nurse Specialist and Nurse Practitioner. To all our specially trained head nurses, who tolerated my idiosyncrasies during this protracted period, to complete this edition: Joyce Clemons, our patient coordinator, Jennifer Feltz, Maureen Heatley and Nancy Wojtulski, Kathleen Killion, RN, OCN, Tracy Trifilo, RN, Jean Errington, RN, Elizabeth Gryzybowski, RN, and James Sped ding, a key helper and patient. Thanks to Barbara Lowe, MS, RD, our nutritionist. Thanks goes to a number of other transcribers: Becky Lonczak, Sandra Ochs, and Linda Eick. To the office secretaries and administrative assistants over the years, I'm indebted to Dottie, and Linda Runfola. My deepest appreciation goes to Sharon Eagles who bridged the gap from one Hospital to another, Sisters of Charity Hospital to Roswell Park Cancer Institute. Many thanks to Elsevier Saunders, especially to Rebecca Schmidt Gaertner, Stephanie Smith-Donley, Christian Elton, and Arlene Chappelle, who were of exceptional help in manuscript review, as well as all the previous medical editors and associates, for without them this publication could not have existed. Among these are John Dusseau, Robert Rowan, and Sam Mink. My condolences to the families of William Bukowski and Paul Milley-both contributors who have passed away since the Third Edition. Their contributions were valued. Bill was my personal primary care physician. Paul was an excellent head and neck pathologist. (I remember when he examined 137 sections of a thyroid gland for the primary tumor in a patient who had an incidental finding of metastatic papillary carcinoma of the thyroid in a radical neck dissection, which was done for squamous cell carcinoma.) Many thanks to all and to all Ave atque Vale. JOHN M. LORE,JR.
XIX
PREFACE TO THE THIRD EDITION
Twenty-six years have elapsed since the first edition of this atlas, and 15 years since the second edition. This third edition has in some respects departed from the original concept of being simply an atlas. It contains much more information, with background material in a number of subjects, such as endocrine surgery of the head and neck and chemotherapy. This background material is most important if the surgeon is not to be relegated to the position of being solely a technician, which, sad to say, is occurring in a number of surgical disciplines. This is not to say that diagnosis and management of problems such as endocrine diseases involving the head and neck are to be performed solely and independently by the head and neck surgeon. The endocrinologist, specialists in nuclear medicine, and imaging and surgical pathologists are all necessary, integral members of the management team. It does mean, however, that the surgeon operating on, for example, the thyroid gland and parathyroid glands must have more than just a superficial knowledge of these endocrine organs. The third edition has been expanded in a number of facets. The number of chapters has been increased from 21 to 23 with the addition and further clarification of Emergency Procedures (Chapter 2) and Base of the Skull Surgery (Chapter 23). Although both these new chapters include some procedures that were covered in the previous editions, this material has now been significantly revised and relegated to these two new chapters. Virtually every chapter has been enlarged with new and other time-proven procedures, encompassing additional text and plates. The reader has simply to refer to the table of contents to see the increased amount of material. To emphasize these additions, examples include the following: expanded listing of complications following most procedures along with air embolism and blindness and pitfalls; adjuvant chemotherapy; carbon dioxide laser surgery; myocutaneous and myomucosal flaps; updated management of cleft lip and palate; compression plates in the management of facial fractures; various types of neck dissections and their applications; expansion of thyroid and parathyroid surgery; rehabilitation following laryngectomy; expansion of various reconstructive procedures related to the pharynx and esophagus; and updated vascular procedures and
tissue expanders that lead to interesting possibilities for reconstruction. The number of contributors has also increased. The anatomic sectional x-ray plates in Chapter 1 have been related to the newer techniques of imaging. These reproductions can be of great aid in the correlation with both CT scans and MRI. The comments in the preface of the previous editions are still valid for the most part. Progress has been made in the training of head and neck oncologic surgeons by the formation by the American Society for Head and Neck Surgery and the Society of Head and Neck Surgeons of a Joint Council for Approval of Advanced Training in Head and Neck Oncologic Surgery. This was accomplished during 1976 to 1977 with the result being the formation of a carefully structured fellowship following the completion of a residency in otolaryngology, general surgery, or plastic surgery. This fellowship is the only one of its kind in head and neck surgery having a carefully structured evaluation system, site visits, and review by the executive councils of both head and neck surgical societies. A diploma is awarded by these two societies to those candidates who follow the rigid criteria and successfully complete the fellowship. The fellowship encompasses three phases: Phase [-basic surgical training involving 1 or 2 years; Phase II-residency in one of the aforementioned disciplines; and Phase [[[the fellowship portion of 1 or 2 yeats. Details of this fellowship have been previously reported (Lore, J.M., Jr.: Head and neck oncologic training: Where we have been and where we are going. Am. J. Surg. 142:504-505, 1981). Sixteen programs are now approved for this type of training-IS in the United States and one in Canada. The term head and neck oncology might be the better term applied to this fellowship, since it involves not only surgical training but also a knowledge of radiotherapy, chemotherapy, and, where applicable, the future of immunotherapy. This facet of head and neck oncology is only one of five categories involved in head and neck surgery, with the others being congenitallesions, cosmetic surgery, and infectious disease. Likewise involved in head and neck surgery is reconstructive surgery, which relates to both head and neck oncologic surgery and cosmetic surgery.
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Head and Neck Oncologic Surgery The concept of regional surgery appears to be well established. Stumbling blocks still remain, one of them being the cliche "fragmentation" of the parent disciplines. Interestingly enough, it all depends on one's biases as to whether the changes of a specific aspect of a major discipline are termed "fragmentation" or "specialization." Regardless, it is the marketplace that sets the pace-specifically, the number of patients available. To borrow the words of James Humphreys, M.D., "surgery was fragmented when the surgeon left the barber shop." The bottom line, however, is the search for excellence in patient care and physician training. These two aspects must not be compromised. The thrust of head and neck oncologic surgery is a cooperative and joint venture encompassing all disciplines that can and should contribute to this endeavor. The initial step has been made with the two head and neck surgical societies setting up the guidelines, site evaluations, approval, and awarding of a diploma. The next step is the formal implementation and recognition of these postresidency fellowships by the residency review committees and the specialty boards involved, an examination, and board recognition. Currently, it appears that this recognition could be achieved by "added qualifications" in head and neck oncology by the boards. These "added qualifications" could then be affixed to the existing certificate of each board. It is hoped that this would be accomplished by the three boards jointly agreeing on the same guidelines and examination. An excellent example of this type of joint venture is the solution of education in hand surgery, which has been worked out by the two hand societies and the three boards of orthopedics, general surgery, and plastic surgery. George Omer, after many years of dedicated work developing articles of agreement, is to be congratulated on its fruition. I hope that a similar modus operandi will be achieved in head and neck oncology. To date, this concept of added qualifications has been stalled by the concern of the three boards and the three residency review committees as well as a number of practicing surgeons in the three disciplines. Their fears surround the worry of fragmentation of their disciplines as well as the misgivings that such added qualifications will lead to "a special club" of head and neck oncologic surgeons and thus restrict their practice. It must be remembered that there are only about 50,000 new patients each year with head and neck cancer and that only approximately 35 to 75 new welltrained head and neck oncologic surgeons are necessary each year to maintain an adequate work force of some 400 to 1000 head and neck oncologic surgeons to manage this number of patients. Thus, we must minimize the number of "dabblers." No one who requires coronary artery bypass surgery would seek treatment
by a surgeon and team who perform only a few such procedures a year. We as surgeons must seek the solution, rather than have nonmedical forces outline the solution for us. Yet with all this protectionism, general surgery has in fact been fragmented. Otolaryngologists are going down the same course with the fear of fragmentation. Hence, it appears that this concern only enhances fragmentation rather than alleviating it. The basic problem is that the profession of medicine and its physicians and specialty societies react to obvious changes that are in the making, rather than acting. Physicians must be the leaders in this change, rather than the followers. They must shape these changes, since they are the ones who know the problem and can best suggest and initiate the changes best suited to excellency in patient care and physician training. Unless this is achieved, a number of legitimate concerns that exist will become aggravated. Following is a list of such concerns (from Lore, J.M., Jr.: Issues in community hospital or cancer center care of head and neck cancer patients. In Myers, E. N., Barofsky, I., and Yates, J. W. [eds.]: Rehabilitation and Treatment of Head and Neck Cancer. Washington, D.C., U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health [NIH Publication No. 86-2762], 1986, pp. 155-165).
1. The occasional patient manager or "dabbler." 2. Loss of expertise and proficiency for even the welltrained physician. 3. Marginal and then inadequate treatment for head and neck cancer patients. 4. Loss of concentration of training clinical material. 5. Loss of any significant number of patients for evaluation as to treatment methods, old and new. 6. Increased morbidity, mortality, and cost of medical care. To achieve the solution to these problems, it appears that the three boards and the three residency review committees should pursue the concept of added qualifications and recognize the additional training beyond the residency years so necessary to achieve the desired excellency. In other words, support the fellowship concept and officially recognize the fellowship concept. To aid in the solution to these problems in a recognized manner, several additional steps are suggested. Training
1. The American Board of Surgery should develop recognized training in basic surgery that might encompass 2 years, with examination and certification for the trainee. 2. The trainee then completes the standard residency in general surgery, otolaryngology, or plastic surgery.
PREFACETO THE THIRD EDITION
3. The trainee enrolls in a fellowship approved by the three boards. An alternate route could be a similarly approved preceptorship. Centers of Excellence
Centers of excellence in head and neck oncology can either be achieved in a university or community hospital center with adequate patient load, professional personnel, and support staff. The interested reader is referred to the aforementioned NIH publication as well as the author's Presidential Address at the annual meeting of the American Society for Head and Neck Surgery (Dabbling in head and neck oncology-A plea for added qualifications. Arch. Otolaryngol. 113:1165-1168, 1987).
Controversial
Items
There are a number of controversial items quite apart from the preceding that this author wishes to enumerate. Correct and Exact Terminology
In the evaluation of statistics relative to survival with or without disease, a distinction should be made at the onset of treatment as to whether a patient is "operable" and whether the lesion is "resectable" for cure or palliation. Operability refers to whether the patient can safely undergo a major surgical procedure, whereas resectability refers to whether a neoplasm can in fact be totally removed by the surgeon. Nonresectability distinctly implies advanced disease and actually further implies a stage beyond stage IV, namely a stage V disease. This concept has been previously suggested in a publication entitled Head and Neck Cancer; Proceedings of the First International Conference, The Society of Head and Neck Surgeons (Chretien et aI., St. Louis, C.V. Mosby, 1985, p. 434). Another point of contention are the words partial, subtotal, near total, and total in regard to the various surgical procedures, especially thyroidectomy. Granted, there are fine lines that separate these terms and defy total exactness, but regardless a more accurate designation of the surgical procedure is warranted as well as a close adherence to the exact implication of these terms. The same goes for the terms referring to the various types of neck dissections, e.g., radical neck dissection, classical neck dissection, modified radical neck dissection, functional neck dissection, and conservation neck dissection. Indications for Surgical Procedure
As for indications for surgery, my bone of contention is a fundamental philosophical and, for that matter,
practical problem, which can best be summarized as follows: Just because a procedure can be technically performed, that is not the indication to perform the procedure. Advances in medicine and surgery require the development and trial elfnew procedures. Nevertheless, these trials must be tempered to a certain degree by past as well as present experience. Again, there is the "gray zone." Specifically, a number of techniques and procedures come to mind, for example, microvascular surgery. These procedures have a selected place in head and neck surgery relative to the following surgical problems: 1. Augmentation of soft tissue with microvascular anastomosis, e.g., involving massive defects of the top of the scalp that cannot easily be reached by a myocutaneous flap (tissue expanders may have a significant application in closing such defects). 2. Certain congenital lesions in which a transposed flap or myocutaneous flap is not indicated. On the other hand, microvascular techniques do not appear routinely warranted in, for example, the following: 1. Reconstruction of the mandible (associated with ablative surgery) with an iliac bone graft and overlying skin. The added time necessary to accomplish these procedures must be taken into account when ablative surgery has already consumed a significant number of hours of operating time. These microvascular techniques on the other hand are applicable to massive defects resulting from trauma. 2. Reconstruction of the laryngopharynx with a free jejunal graft or gastric pull-up. The latter procedure or colon interposition is definitely indicated when a total esophagectomy is necessary. Often, a much simpler reconstructive procedure does in fact achieve the same end results related to the reconstructive surgery. For example: 1. Mandibular resection that is reconstructed with the simple use of a bent Kirschner wire with tie wires. 2. Total laryngectomy with total hypopharyngeal, oropharyngeal, and partial nasopharyngeal resection reconstructed with a myomucosal tongue flap with dermal graft or pectoralis major flap with dermal graft. These simpler forms of reconstructive surgery make total hypopharyngectomy a very feasible and relatively easy procedure. These techniques are believed to afford a much better chance of resecting the entire structure, thus leading to improved survival rates. Preserving a narrow strip of posterior hypopharyngeal mucosa for reconstruction of the gullet hardly seems justified.
PREFACETO THE THIRD EDITION
Other Suggestions 1. TNM classification. It is suggested that in the initial evaluation of the patient basic information should be tabulated along with the appropriate drawings, and, if possible, photographs, which at any time can then be transferred into virtually any TNM classification that may be developed in the future (Kaufman, S., and Lore, J.M. Jr.: TNM classification and disease description in head and neck cancer. Am. J. Surg. 136:469-473, 1978).
2. Prevention and treatment of premalignant lesions. Head and neck oncologic surgeons must face the fact that to help achieve improved survival rates for patients with head and neck cancer they should be actively involved and cognizant of the premalignant lesion as well as the management of "condemned mucosa." This concept applies to the high-risk patients and those with mucosal atypism and dysplasia. Obviously, the avoidance of tobacco and exposure to carcinogens is foremost. Next in line is the use of the retinoic acids-vitamin A-as a dietary supplement, recognizing, of course, the possible toxic side effects, particularly of overdosage of vitamin A. This leads to the establishment of, or at least involvement by, head and neck surgeons in basic research. 3. Adjuvant chemotherapy. Another consideration is the admonition that adjuvant chemotherapy be relegated to organized protocols rather than the haphazard use of chemotherapeutic agents in the management of head and neck cancer. 4. Violation of the "Virgin Neck." Many years ago Hayes Martin emphasized that limited surgical procedures should be avoided in the unoperated neck, since this could very well mask future metastatic disease. This admonition is still true for the most part. For exam-
pIe, I shudder when I see and hear about the use of the sternocleidomastoid muscle for solely a reconstructive procedure in a patient with a surgical defect following ablative surgery for intraoral cancer. 5. Randomized studies evaluating treatment and end results. Although randomized protocols certainly have definite advantages, there are a number of drawbacks. When multiple institutions are included, variations in technique among the surgeons involved cause inevitable problems. In addition, these studies may not be as valid as they are supposed to be if the number of patients is small or if a study lacks adequate stratification of the various factors involved. In one recent study (Corey, J.P., et al.: Surgical complications in patients with head and neck cancer receiving chemotherapy. Arch. Otolaryngol. 112: 437-439, 1986) evaluating surgical complications in patients receiving chemotherapy, the patients were, I believe, incorrectly stratified as follows: Patients
Stage II Stage 1Il Stage IV
Control 5 8 6
Chemotherapy 1 12 10
The control group is overweighted with stage II disease, and underweighted for stage 1Iland IV disease, a form of incorrect stratification that places the chemotherapy group at a disadvantage. In short, when a trial is randomized, care should be taken regarding possible imbalance of results. In summary, it is hoped that the preceding philosophical comments and suggestions as well as the expansion of this third edition will be of interest to the head and neck surgeon. JOHNM. LORE,JR.
ACKNOWLEDGEMENTS IN THE THIRD EDITION
During the years taken to expand this atlas many friends have contributed-some as formal contributors, others in ways and at times unknown to them either in the sharing or exchanging of knowledge, others in technical help, and still others in the various phases of patient care, which in effect has had significant bearing on this revision and expansion. My wife, Chalis, has tolerated this third episode with exceptional calm and has also helped in selective typing. For the third time, Bob Wabnitz has joined me as the one and only medical artist and illustrator of all the editions of this atlas, demonstrating his skill par excellence. Working with Bob is actually a pleasure. His skill in his chosen profession as well as his knowledge of anatomy and surgical procedures is only surpassed by his humor and cooperative attitude. I repeat, "without him, the atlas would not be." For the bulk of the stenographic labor, I am deeply indebted to Dottie Kane, who like Bob Wabnitz simply smiled when I asked that more had to be done, and of course, done yesterday. In the patient care arena, which is so important to a surgeon and the success of patient management, I extend gratitude in a special way to those primarily associated with the Sisters of Charity Hospital of Buffalo. This includes in administration Sister Mary Charles and Sister Eileen, and more recently, Sister Angela and her staff; in the operating room, Sister Thomasine, and after her, Pat Archambault, R.N., and on the special head and neck nursing unit, the head nurse, Diane Smeeding, R.N., and her staff of devoted and skilled nurses, practical nurses, aides and our floor secretary, Beth Powalski. Along with patient care and many of the facets related to this endeavor, I am grateful to my office staff, especially Nan Sundquist, R.N. and Debbie Foschio, and also to Joan Bilger, R.N., who is our nurse clinician at the Erie County Medical Center. I have picked the brains of many physicians, especially my former associate, Duck Kim, M.D., and my current associate in practice, Keun Lee, M.D. They filled in for me while I struggled along with this revision. Also in this aspect I am grateful to the Pathology Department of Sisters Hospital. To Paul Milley, M.D., I am deeply grateful for his contributions both in his section and in the chapter on endocrine surgery and for
his time, which he afforded me in the numerous problems associated with surgical pathology. John Sheffer, M.D., and Ashok Koul, M.D., likewise were helpful in this phase of surgical pathology, which is reflected in hidden ways in many of the surgical procedures. These three surgical pathologists are placed among the best in the field of head and neck surgical pathology, especially related to frozen section, cytology, and recuts and searching through many surgical specimens. This is specifically applicable not only to carcinoma hidden in those specimens that had a complete clinical response to chemotherapy but also in thyroid specimens where there has been a search for primary tumors as well as C-cell hyperplasia. I am indebted to Martha Schmidt, M.D., the expert in nuclear medicine, especially that related to thyroid scanning, as well as to Joseph Prezio, M.D., who is chairman of the Department of Nuclear Medicine at the School of Medicine, State University of New York at Buffalo and Kwang Joo, M.D., who covers Sisters Hospital. Gratitude is also extended to their technicians, who are most important in this particular phase of diagnostic imaging. In a similar vein, Monica Spaulding, M.D., and Kandala Chary, M.D., our medical oncologists are a great help in the management of patients with advanced neoplastic disease. Included on our team is William Bukowski, M.D., our internist, and David Casey, D.D.S., our maxillofacial prosthodontist, who have contributed significantly to the team approach in the management of our patients. Without the expert contribution of the Department of Diagnostic Radiology and Imaging under the direction of David Rowland, M.D., and the person who I pester the most, David Hayes, M.D., many of the surgical procedures would not have been brought to a successful conclusion. When speaking of "brain picking," the participants in our endocrine conferences contributed much to my understanding of thyroid and parathyroid disease. The "regulars," Robert LaMantia, M.D., Donald Rachow, M.D., Jack Cukierman, M.D., and James Kanski, M.D., are the stalwarts. However, I must say if there are differences of opinion in the endocrine chapter, these are my responsibility, not theirs. Contributing in this
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ACKNOWLEDGEMENTS
IN THE THIRD EDITION
same fashion is Richard Blanchard, M.D., who would come to my office and spend hours reviewing cases of patients with thyroid and parathyroid disease, thus affording me a learning experience seldom available to a surgeon. I am deeply indebted to Paul J. Davis, M.D., Professor of Medicine and Chief of Endocrinology at the State University of New York at Buffalo, for his review, suggestions and additions to the endocrinological aspects of the chapter on Endocrine Surgery. His help was most important. Part of the learning experience is exemplified by many of my residents and fellows who were involved in the exchange of knowledge and ideas-so well stated by John Henry Cardinal Newman in his treatise "The Idea of a University." Several general surgeons have been significant contributors to this endeavor in many facets. Frank Marchetta, M.D., a head and neck surgeon par excellence, is responsible for many original contributions to head and neck surgery, as is Alfred Luhr, M.D., who operated with me on some two-team procedures. Joseph Anain, M.D., a certified general vascular surgeon and co-author of Chapter 22, was and is a significant collaborator in our head and neck vascular procedures. He is not only
involved in the operating room but also in the work-up of patients who are suspected of having vascular probems associated particularly with neoplasia. In all of this, a chairman of a department at a medical school needs the support of his chief, viz. Dean John Naughton, M.D., who is also Vice President of Clinical Affairs. This support is afforded in many ways-some not immediately recognized, but always appreciated. In the publishing of a medical book with all its applications, decision making, changes, and additions, the staff of the W.B. Saunders Company has been understanding, helpful, and cooperative. When I try to remember all who have been an inspiration and at the same time contributed much to head and neck surgery, George Sisson, M.D., Chairman, Department of Otolaryngology, Northwestern Medical School, comes often to my mind. Many thanks George. Although my mother has passed away during the period between the second and third edition, she was and still is an inspiration, and once again I dedicated this atlas to my Dad, who was the inspiration behind this entire endeavor. JOHN M. LORE,JR.
PREFACE TO THE SECOND EDITION
Eleven years have passed since the publication of the first edition of this atlas. The convictions expressed in the preface of the first edition are reiterated here and, in addition to them, the grave importance of the cooperation of the various disciplines involved in surgery of the head and neck-both in the management of patients and in the training of residents-is emphasized. The combined efforts, contributions, cooperation and sharing of patient problems and management must be part of every aim in medicine and surgery, especially in head and neck surgery in which there is so much overlap among the various disciplines. Fortunately, during the past five years, a definite cooperative trend among the prime disciplines of general surgery, otolaryngology, plastic and reconstructive surgery and oral surgery has been developing. A number of various types of combined head and neck services at universities known to the author are participants in this trend-the State University of New York at Buffalo, Northwestern University, the University of Virginia and Yale University-and others are surely in existence. However, even more important than these services is the emergence of a spirit of cooperation which has been spread as seeds throughout the surgical community. Unfortunately, among the fruitful seeds are still the weeds which attempt to choke out the wheat because of inherent parochialism, insecurity, jealousy and greed of power or whatever. Regardless of the type of arrangement of a combined venture, its success or failure depends not so much on signed documents as on a spirit of equal cooperation, understanding and trustworthiness. To insist that a combined head and neck service lies solely within one discipline or is a subspecialty of general surgery is to lead the entire endeavor to certain doom. Flexibility should be tolerated. For example, if need be, a multidiscipline head and neck service could be established within one department and thus achieve an objective similar to that of a head and neck service which involves more than one department. It is interesting to note that during the past decade otolaryngology has made significant strides and at present is believed by many to be the prime discipline in the complete training of the head and neck surgeon. The problem does not appear to lie among the various head and neck surgeons of different backgrounds but
rather with certain autocratic and political forces who attempt to control a major portion of surgery-the socalled "umbrella of general surgery," an antiquated and obsolete concept. However, it is the conviction that general surgery serves as the foundation and the specialties as the superstructure. Therefore it appears that the concept of regional surgery of the head and neck will be the end-result. It was not so long ago that mutual scorn and distrust between several disciplines were so intense that any exchange of ideas was tantamount to proclaimed heresy. Now, it is changing toward a mood of basic ecumenicalism. The two head and neck societies, the Society of Head and Neck Surgeons and the American Society for Head and Neck Surgery, have had a joint meeting in 1973-an event which might well have been unthinkable a few years ago. Both societies have opened their memberships to capable surgeons in the various disciplines with similar standards and requirements. It is believed that this cooperation is leading to a more complete exchange of ideas and that this can be achieved without the destruction of some of the good points of a competitive climate. As we proceed along the common pathway, a number of questions are encountered. For example: I. What does the field of head and neck surgery encompass? 2. What is the need in quality and quantity of surgeons well trained in this field? 3. Should all residents in general surgery, otolaryngology and plastic and reconstructive surgery be trained as head and neck surgeons? 4. What should this training entail? 5. Should there be a cooperative effort among the various disciplines or boards, and if so, how best is this objective achieved? 6. Should there be a certificate of competency issued by the various boards involved? 7. Is some type of basic framework for residency training desirable, or rather, should there be an individual solution to the training problem at the various large centers? These queries cannot be answered or solved overnight, and yet a few responses are possible at present.
xxvii
PREFACETO THE SECOND EDITION
The field and training in head and neck surgery should have a broad base and be flexible. Individual surgeons and groups of surgeons may have their own specific interests; there is no criticism of this action. Nevertheless, it is important that the trainee develop a versatility in the changing world of medicine and surgery, and hence it is believed that to have a lasting and firm foundation head and neck surgery should encompass four categories. 1. 2. 3. 4.
Malignant and benign tumors. Reconstructive surgery. Congenital lesions. Infectious surgical diseases.
Thus it is quite obvious that such training crosses and encompasses a number of specialties as we know them today. The old boundaries are no longer valid nor . practical, and the new boundaries are far more flexible. It must be emphasized that the various surgical specialties, as well as general surgery, are not in existence for their own benefit but rather for the promotion of ultimate excellence in patient care. Another point appears quite clear. There is not a need for a large number of head and neck surgeons, but rather a need for a moderate number (how many??) of well trained head and neck surgeons. For example, many of the procedures outlined in this atlas are not intended for the occasional operator with limited background, but are intended as a reminder or review for those well educated in the overall field of head and neck surgery. For the latter audience, this atlas may be a source of material in the ever-continuing field of medical education. During the past six years as a program director, the author has realized a number of problems. First of all, not all residents in either otolaryngology, general surgery or plastic surgery need be, nor should be, trained as head and neck surgeons per se. Secondly, a solid block of time in general surgery (two to four years) followed by a solid block of time in otolaryngology (three years) has certain drawbacks. There is a psychological problem of a candidate being a senior resident in general surgery and then starting at the bottom in otolaryngology. This is no small matter. Another problem is that of graded training in both fields. It would seem much easier to train a resident in physical diagnosis in both specialties at an early stage in his career. The same comparison goes for the senior levels in which major surgery will be performed. It is at this stage of one's training that senior responsibility in both specialties should be achieved, almost side by side, and certainly not separated by several years, as is the case in the solid block concepts. At any rate, it appears worthwhile to outline an integrated step-wise plan for head and neck surgical train-
ing, which recently has been passed by both the American Board of Otolaryngology and the Conference Committee on Graduate Education in Surgery, representing the American Board of Surgery, the American College of Surgeons and the Council of Medical Education of the American Medical Association. This experimental program, applicable to certain selected candidates with approval on an individual basis, exists at the State University of New York at Buffalo with instruction in otolaryngology, general surgery and plastic surgery. This concept was originally planned with the cooperation of John R. Paine, then Chairman of Department of Surgery. Glenn Leak played an integral part in the original outline. With the untimely passing of both of these friends, G. Worthington Schenk, Jr., now Chairman of the Department of Surgery, gave his support and effort to achieve the final approval of this plan. The program entails a five-year residency which, in stepwise fashion, integrates in graded responsibility the basic aspects of otolaryngology and general surgery and the principles of plastic surgery. The years in training would alternate between general surgery and otolaryngology, with plastic surgery training incorporated within general surgery, and additional reconstructive surgery within otolaryngology. Senior resident levels in both general surgery and otolaryngology would be reached in the final two years. Not all residents in either of these two fields would be included in the program-only one or two at the most in anyone year. Nor is this program intended to be the only avenue of training in head and neck surgery. In summary, the second edition of this atlas is directed to the ecumenical approach in both patient care and resident training in the field of head and neck surgery. REFERENCES Baker. H. w.: Head and neck Amer. J. Surg., 122:433-436, Beahrs, O.H.: The next plateau. Bordley, J.E.: Problems facing
surgery: The pursuit of excellence. 1971.
Amer. J. Surg. 114:483-485, 1967. otolaryngology today. Ann. Otol.,
80:783,1971. Chase, R.A.: I'm against a rigid core curriculum prior to specialty training in plastic surgery. Plast. Reconslr. Surg., 46:384-388, 1970.
Chase, R.A.: The "core knowledge" principle and erosion of specialty barriers in surgical training. Ann. Surg., 171:987-990, 1970. Eckert, C. (panel member): Panel discussion: Head and neck surgical training. Medical
Society
of the State of New York Convention,
February 1972. Fitz-Hugh, G.S. (panel member): Panel discussion: Head and neck surgical training. Medical Society of the State of New York Convention, February 1972. James A.G.: Board to Death. Amer. J. Surg., 116:477-481, 1968. Klopp, C.T.: Presidential address. Tenth annual meeting of Society of Head and Neck Surgeons. Amer. J. Surg., 108:451-455, 1964. Lore J.M., Jr.: Editorial. Head and neck surgery. Surg. Gynec. Obstet. 118:117-118, 1964.
PREFACE TO THE SECOND
Lore, J.M., Jr.: Future of head and neck surgery. A combined head and neck service: An ecumenical approach. Arch. Otolaryng. 87:659-664, 1968. Lore, J.M., Jr.: Head and neck surgery: 78.842-843, 1963. Lore, J.M., training MacComb, J. Surg., McCormack, surgical
The problem.
Arch Otolaryng.
Jr.: Head and neck surgery: Proposed head and neck program. Arch. Otolaryng. 79:112-113, 1964. WS.: Future of the head and neck cancer surgeon. Amer. 118:651-653, 1969. R.M. (panel member): Panel discussion: Head and neck training. Medical Society of the State of New York Convention, February 1972.
EDITION
Sisson, G.A.: Otolaryngology, maxillofacial surgery embark on challenging course. From the Department of Otolaryngology and Maxillofacial Surgery, Northwestern University, Evanstown, Illinois. Southwick, H.W: Presidential address. Eleventh annual meeting of the Society of Head and Neck Surgeons. Amer. J. Surg. 110:499-501, 1965. Wullstein, H.L.: A concept for the future Ann. 0101., 77:805-814, 1968.
of otorhinolaryngology.
ACKNOWLEDGEMENTS IN THE SECOND EDITION
As with the first edition, my prime indebtedness is to my wife Chalis, who single-handedly transcribed the changes in the first edition and all the new text for this expanded second edition. In addition to the manuscript, she typed the bibliography with some help in classification from my daughters Margaret and Joan. The medical artist and illustrator is the same skilled and dedicated one-Robert Wabnitz. Without him, this atlas simply would not be. His persistence in accuracy and consistent drive for detail is obvious in the artwork. To him, also, am I deeply indebted. Again, I am thankful to my mother for her encouragement and prayers. For his revisions and statistics relative to temporal bone resection, I am thankful to John S. Lewis, M.D. I wish to thank William R. Nelson, M.D., who has contributed a new section on pre- and postoperative care. He has been kind enough to condense a much larger treatise of this aspect of head and neck surgery, which he originally produced in booklet form. Gratitude is extended to James Upson, M.D., for his review of the section on surgery of degenerative vascular lesions and to John Bozer, M.D., as a consultant internist. I also wish to thank a number of photographers at the various hospitals affiliated with the Medical School at the State University of New York at Buffalo. They are Sheldon Dukoff and Charles Jackson, of the Edward J. Meyer Memorial Hospital; Joseph A. Dommer and Dough Hanes, of Buffalo General Hospital; and Harold C. Baitz, Theodore A. Scott and their secretary, Mrs.
Alfred Davis, of the Medical Illustration Service of the Veterans Administration Hospital, Buffalo, New York. Although many of their photographs do not appear in the atlas, they served as a guide for the artwork and the text. Thanks also go to Joan R. Bilger, R.N., of the Edward J. Meyer Memorial Hospital, for help in preparing some of the photographic arrangements and supplying other technical data; and to Bette Stinchfield, my secretary at the Buffalo General Hospital, for aid in obtaining some of the reference material. During the time between editions, many new techniques and modifications have reached the surgical arena, a significant number of changes have occurred and friends have lent their ideas and methods; however, one bit of philosophical admonition comes to mind-primum non nocere-first, do no harm. I know not the originator of this phrase, but to Julius Pomerantz, a senior fellow physician from Good Samaritan Hospital, Suffern, New York, I am indebted. It is to my residents who have also contributed unwittingly to this endeavor that I often pass on this thought in management of our patients. A great debt of gratitude is due the entire staff of the W.B. Saunders Company for their unparalleled aid in publishing this atlas. Their continuing help both as publisher and personal friends makes an otherwise burdensome task possible; their skill in the art of publication makes it all worthwhile. JOHN M. LORE,JR.
xxxi
PREFACE TO THE FIRST EDITION
The purpose and intent of this atlas is to encompass in one volume related regional procedures of the head and neck. It is actually a plea for a broader training program to reunite with basic general surgery the many surgical specialties and subspecialies concerned in this area. Surely, there will always be a need for such specialty groups alone but there is an even greater need for the amalgamation and dissemination of their skills in the total treatment of problems of the head and neck. The foundation upon which this concept is built is the basic principle that general surgery is the mother and nurturer of all major surgery. The specialties are the fruits. Hence, general surgery as well as the specialties of otolaryngology, plastic and reconstructive surgery, maxillofacial surgery, neurosurgery, oral surgery and thoracic surgery are involved. Disease knows not the man-made barriers that have been set up. Each field can contribute to the others. One has only to reflect on the importance of mirror laryngoscopy before and after thyroid surgery. Adequate examination of the larynx is felt to be a sine qua non for any surgeon who performs a thyroidectomy just as a sigmoidoscopy should be performed by the surgeon who performs the abdominoperineal resection. For anyone who does major surgery in the neck, extension of resectability must not be hampered by a lack of familiarity with thoracic surgery when the disease has extended below the clavicles. This principle holds true for both malignant disease and trauma. Major surgery on the larynx sooner or later will involve the cervical esophagus and basic knowledge of bowel surgery will enhance the armamentarium of the surgeon and aid in his decision when selecting the most suitable type of esophageal reconstruction. Procedures on the nose, except the very simplest, can be refined and well selected only when the surgeon borrows from the orolaryngologist, the plastic and reconstructive surgeon and the general tumor surgeon. The skills and tricks of one field are often applicable to another field. In the definitive treatment of malignant tumors the details of an elaborate reconstruction procedure are of little avail unless the primary disease has been handled correctly with full knowledge of the natural history of the disease. By the same token, radical surgical treatment is incomplete if a suitable and adaptable
reconstructive procedure or prosthesis has been omitted purely through a lack of versatility. Obstructive vascular disease affecting the intracranial circulation amenable to surgical correction may have its center of trouble located either in the chest or neck or in both regions. The selection of the best-suited vascular procedure is enhanced by a working knowledge of general vascular surgery. With anticipation of the criticism that such a concept would lead to a Jack-of-all-trades, master of none, one need but read the history of surgery. Many of the great surgeons of yesterday were first primarily general surgeons; with this basic knowledge they contributed lasting ideas both in the specialty fields and in general surgery. Billroth was the master of gastrectomy and at the same time contributed to cleft palate repair by fracturing the hamulus of the pterygoid process, thus releasing the tensor veli palatini muscle. King, a general surgeon, made a significant contribution in the treatment of bilateral abductor cord paralysis of the larynx. Such examples are not intended to detract from the innumerable contributions by the surgical specialists which in their own fields outnumber these examples. Nor is the concept that is portrayed in this atlas intended to lessen or minimize in any way the need for the specialist. Actually it supports the specialist and reemphasizes the natural evolution of surgery. John Henry Cardinal Newman in his classic The ldea of a University advocated a liberal education which would serve as the background for future endeavors. He pointed out that any student able "to think and to reason and to compare and to discriminate and to analyze, who has refined his taste, and formed his judgment will not indeed at once be a lawyer, or a pleader, or an orator, or a statesman or a physician ... but he will be placed in that state of intellect in which he can take up anyone of the sciences or callings ... with an ease, a grade, a versatility, and a success to which another is a stranger." So in the art and science of surgery, a liberal basic foundation is necessary. From such a foundation and broad outlook, the field of head and neck surgery seems to have drifted. Reunification of all groups interested in the field of surgical problems related to the head and neck is the intention, hope and aim of this Atlas of surgical techniques. JOHN M. LORE, JR.
xxxiii
ACKNOWLEDGEMENTS IN THE' FIRST EDITION .-,.-
I am deeply grateful to my wife, Chalis, for her sacrifice, patience and able skill as an executive secretary. She has typed and retyped the manuscript under considerable duress. My children, John III, Peter, Margaret and Joan, have all felt the pressures and sacrifices resulting from the loss of many happy hours together which have been missed because of the time consumed in the preparation of this work. I am indebted to my mother for her encouragement and prayers. Professionally, my indebtedness extends from books, journals and other collections of the surgical literature, through various opinions voiced at surgical meetings (the authors of which I regret to say have slipped my memory), to my recent and past teachers and associates. All education is a compendium, and even more so surgical education. Hence many of the steps in this atlas are the ideas, thoughts and work of surgeons under whom I have trained or worked. I owe much to my father and to John J. Conley who were my early teachers. A great many of the surgical procedures and techniques concerned with the treatment of tumors of the head and neck either originated with or were developed by Hayes Martin and other surgeons on the Head and Neck Service of Memorial Hospital. In the basic background of general surgery which forms an integral part of this atlas, I owe a debt of great magnitude to John L. Madden, Director of Surgery at Saint Clare's Hospital. To make the decision after my father's death to continue surgical training in general surgery after completion of the first phase in otolaryngology presented a crisis. Two men convinced me and gave me advice of immeasurable value. They are Michael Deddish, M.D., and Alexander Conte, M.D. Without them I never would have completed my surgical training and never would have come to realize the benefits of a multifaceted surgical background. John S. Lewis, M.D., who is mainly responsible for the present technique of temporal bone resection in cancer of the middle ear, has kindly contributed to that section of the atlas. Edward Scanlon, M.D., has been kind in lending his original experiences and thoughts in colon transplants for reconstruction of the esophagus. These ideas have
been of considerable aid and have been a guide to personal experiences in this problem. Again to Alexander Conte my thanks for supplying original photographs of his technique of cervical esophageal reconstruction. During the two years of pressure to complete this work, my surgical partner, Louis J. Wagner, M.D., has unselfishly covered our practice to allow me the necessary undisturbed time. From him, I have also learned a number of operative steps which have been successful in the solution of some technical problems. When this atlas was in its infancy, it was only through the cooperation of John L. Madden and the administration of Saint Clare's Hospital, specifically the late Mother M. Alice, O.S.F, and her successor Sister M. Columcille, O.S.F., that actual work began. At Saint Clare's Hospital I met Robert Wabnitz, the sole illustrator of this volume, who since then has spent many hours in the operating room making sketches and at the drawing board completing the art work. Without his skills as an artist and his knowledge of anatomy, the illustrations would have been impossible. Both he and I are grateful to the University of Rochester where he now heads the Medical Illustration Department for allowing him time to complete this work. If it were not for the skill in its reproduction, the best of art work would be for naught. The W.B. Saunders Company has excellently completed this endeavor. I am deeply indebted to the staff of the Company for their advice, suggestions and patience. I am grateful to my colleague William J. McCann, M.D., for initiating this most fortunate association with the Saunders Company. I wish also to acknowledge the cooperation of the Administrator and Assistant Administrator of Good Samaritan Hospital, Sister Miriam Thomas and Sister Joseph Rita, as well as the Operating Room Supervisor, Miss Martha Henry, and the entire nursing staff for their help and vision in the treatment and care of the patients with many of these operative and postoperative problems. I would be remiss if I did not add the aid of the administration and staff of Tuxedo Memorial Hospital. My thanks to Anthony Paul for drawing many of the lead lines and some of the labels and to David Hastings for his care in photographing the x-rays in Chapter I. JOHNM. LORE,JR.
xxxv
CONTENTS
1
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
ANATOMIC RADIOGRAPHS .......•..•.......................•......... john M. Lore, Sr., 1938 Sagittal Section Through the Midportion of the Maxillary Sinus and Orbit
Contrast Medium-Enhanced
1 1
2
Sagittal Section Through the Lateral Wall of the Nose, Lateral Border of the Tongue, and Lamina of the Thyroid Cartilage Showing Its Superior and Inferior Cornua .............................................•..............
4
Sagittal Section Through the Floor of the Nose and the Body of the Tongue .................................•...•........
6
Sagittal Section Through the Middle of the Skull
8
High-Resolution CT
40
CT Angiography of the Neck: Venous Malformation With Traumatic Arteriovenous Fistula
42
CT Venography of Facial Venous Malformation
44
CT Angiogram of ECAjICA Bypass
45
Three-Dimensional CT of Vascular Tumor Relationship
46
Endoluminal and Cut-Away View of the Trachea With Medial Deviation of the Carotid Artery ........••.......... 47 EXAMPLES OF MRI IN THE SUPERIOR MEDIASTINUM .•...........•.............•..........•....••......•.........
48
john M. Lore, jr.
OTHER EXAMPLES OF CT AND MRI .............•............•..
52
john M. Lore, jr.
Frontal Coronal Section in the Region of the Second Molar Teeth
10
Multinodular Goiter in the Mediastinum
52
Frontal Coronal Section Just Beyond the Third Molar Teeth
12
Paraganglioma (Second Primary Thoracic Chain, T4 by CT Scan)
53
14
Metastatic Papillary Carcinoma of the Thyroid (Usual Type) .....................................................•...............
53
16
Magnetic Resonance Angiography ..........................•.•.••.......
54
ULTRASOUND
54
Frontal Coronal Section in the Region of the Anterior Faucial Pillar and Tonsil CT AND MRI ....•.............•.............••........•.•.•.......•..•....... David F. Hoyes and Scott Cholewinski
Single-Plane CT Scans
16
............•..........•......................•............•...
David F. Hayes
Frontal Coronal Section in the Region of the Second Molar Teeth .......................................•.........
16
Frontal Coronal Section Just Beyond the Third Molar Teeth .............................................•.......
17
Frontal Coronal Section in the Region of the Anterior Faucial Pillar and Tonsil
18
Role of FDG-PETin Head and Neck Cancer ......•................... 57
Three-Dimensional Reconstructed CT Scans
18
Conclusion
Example Uses of Ultrasound
54
POSITRON EMISSION TOMOGRAPHy
.......•.•..........•....
Role of PETin Oncology
MR Images
26
Imaging in the Diagnosis and Treatment of Head and Neck Disease Overview ................................................•.....................
26 26
2
57 63
EMERGENCY PROCEDURES
VENOUS AIR EMBOLISM
Scott Cholewinski
56
Rabert S. Miletich and john M. Lore, jr.
65
......•...........•.......•.•.....•....•......
65
john Lauria
ADVANCED TECHNIQUES FOR CT IN THE HEAD AND NECK ....•.•...........•.........••.•........•.•.........•.....
34
Ronald A. Alberico and Ahmed Abdehalim
The Role of Imaging in the Head and Neck
34
Detection of Perineural Disease at the Skull Base
35
Oblique Imaging of the Oral Pharynx to Avoid Dental Artifact
36
MALIGNANT
HYPERTHERMIA ...•.•.......•.•....•.•.•..•......•.•.
Other Untoward Events Associated With Endotracheal Anesthesia
66
BLINDNESS AND OPHTHALMIC COMPLICATIONS OF SURGERY OF THE HEAD AND NECK ....•.................
66
Daniel P. Schaefer and Arthur
Multiplanar Techniques to Evaluate Tumor Location and Margins
37
Three-Dimensional CT of the Inner Ear .............•..................
39
65
john Lauria
f.
Schaefer
Blindness ...............................................•..•..........................
66
xxxvii
CONTENTS
CARDIOPU~MONARY RESUSCITATION
70
William M. Marris
Emergency Cardiac Care ........................................•.............
70
Sequence of BLS .................................................•.•..............
70
Closed Cardiac Massage
72
Open Cardiac Massage Resuscitation ...............•...................
72
Thoracentesis ............................................•.......•..................
74
Insertion of Intercostal Catheter
74
Open Thoracotomy for Empyema Drainage
78
Intercostal Catheter Suction Drainage With Underwater Seals ..........................•..........................
80
Cricothyroidotomy
82
Management of Acute Respiratory Emergencies
84
Emergency Establishment of Airway
3
84
BASIC CONSIDERATIONS
87
Needle Biopsy Techniques .......................................•...........
87
Ashok Koul
Needle Aspiration Biopsy ................................•........ Core Needle Biopsy
··· .. 87
·.·········
· 87
Common Departures From Sound Management -"Pitfalls"
123
Donald P. Shedd
Open Biopsy of a Lump in the Neck Before Performing a Complete Head and Neck General Examination
124
Inadequate Incisional Biopsy of an Oral Cavity Lesion
124
Inadequate Excisional Biopsy of a Suspicious Oral Cavity Lesion
124
Failure to Review Previous Histopathologic Slides
124
Permitting a Single Histopathologic Benign Diagnosis to Override a Clinical Diagnosis of Carcinoma .
.. 125
Biopsies of the Laryhx, Hypopharynx, Nasopharynx, Esophagus, or Trachea Before Radiologic Studies and Imaging Techniques
125
Lack of Multidisciplinary Approach When Indicated
125
Tailoring the Scope of Surgical Resection to the Ability of the Surgeon Rather Than to the Objective Requirements Imposed by the Lesion
125 126
Large-Needle Aspiration Biopsy
89
Commonly Used Terminology for Squamous Epithelium
A Compromise of the Ablative Phase of Surgery to Accommodate Limited Reconstructive Skills
91
Commonly Used Special Stains for Head and Neck Lesions
Compromise of Surgical Margins Because Radiation Therapy or Chemotherapy Was or Is to Be Given
126
91
Mucosal Biopsy: Toluidine Blue Staining Technique
91
Performing the Right Operation on the Wrong Patient
126
Exfoliative Cytology Biopsy Technique
91
Assessing the Degree of Successor Failure of Radiation Therapy on the Basisof the Response of the Lesion During or Immediately on the Completion of Treatment
126
Failure to Realize the Implication of the "Condemned Mucosa" or Multiple Primary Syndrome
127
Failure to Perform a Complete General Physical Examination as Well as a Complete Head and Neck Examination
127
Prolonged Watch-and-Wait Attitude in the Face of an Asymptomatic Mass
127
107
Inadequate Search for an "Occult" Primary Tumor
127
107
Abandonment of the Patient With Neck Metastasis From an Undetectable Primary Tumor
128
Enucleation of Tumors of the Major Salivary Glands and Thyroid Gland
128
Treating a Patient With Antibiotics for an Extended Period of Time Without a Biopsy
128 128
Ashok Koul
,
Z-Plasty
91
Definition ..................................•..........................••....... Technique of Basic Z-Plasty .................................•......... Types and Modifications of Z-Plasty Tissue Expansion ...................................................•............ Effects of Tissue Expansion .......................•..................
91 92 98 100 100
W-Plasty ..........................................................•..................
102
Rhombic Flap .........................•........................••.................
104
Excision of Dog-Ears .....................................•.•..................
106
Bone, Cartilage, and Nerve Grafts Basic Principles Relative to Bone and Cartilage Grafts and Implants Rib, Iliac, and Costochondral Grafts
107
Iliac Bone Graft-"Trap
110
Door Type"
Auricular Cartilage Graft
110
Sural Nerve Grafts ......................•..................•....•........
112
Skin Incision ...........................................................•..........
112
The Place for Chemotherapy in Management of Squamous Cell Carcinoma of the Head and Neck
Nonabsorbable Sutures for Mucosal Repair
112
Monica B. Spaulding
Preoperative and Postoperative Care
114
William R. Nelson and R. Lee Jennings
Preoperative Care .....................................•.•...............
114
Postoperative Care
116
Recurrent or Metastatic Head and Neck Cancer Preoperative Chemotherapy, Uncompromised Surgery, and Selective Radiotherapy in the Management of Advanced Squamous Cell Carcinoma of the Head and Neck John M. Lore, Jr., Sol Kaufman, Nan Sundquist, and Kandala Chary
.. 129
132
CONTENTS
A Comprehensive, Interdisciplinary Head and Neck Service john M. Lore, jr., A. Charles Massaro, and Angela Bontempo
141
Bone Imaging and Pathology
142
Scott Cholewinski, john Asirwatham, Daniel Broderick, ond john M. Lore, jr.
Methods of Bone Involvement: Mandible VOICE, SPEECH, AND SWALLOWING REHABILITATION OF THE HEAD AND NECK PATIENT ..................................................•..............•....
Telescopic Endolaryngeal Surgery
204
Nasopharyngoscopy
205
Rigid and Flexible Direct Optical Nasopharyngoscopy, Laryngoscopy, Cervical Esophagoscopy, and Rhinoscopy
210,.
142
143
Rigid Nasopharyngoscopes
210
Flexible Nasopharyngoscopes
210
Rigid and Flexible Direct Optical Rhinoscopy
210
Cervical Esophagoscopy
212
Allen M. Richmond
Total Laryngectomy Conservation Surgery: Cancer of the Larynx Swallowing
143 144 144
Glossectomy
146
5
THE SINUSES AND MAXILLA
Intranasal Antrostomy Rhinoscopy ........................................................•........
214 214 214
Palatal Surgery
147
Caldwell-Luc Antrotomy
217
Voice
147
Intranasal Ethmoidal Surgery for Benign Disease
220
Hearing, Cochlear Implants, and Middle Ear Surgery
148
Uncapping of Anterior Ethmoidal Cells
220
Malignant Melanoma Constantine P. Karakousis
149
Ethmoidectomy
220
Soft Tissue Sarcoma
152
External Ethmoidectomy
Endoscopic Diagnosis and Surgery for Sinusitis
Constantine P. Karokousis
Thyroid-Related Orbitopathy
154
Sphenoidal Sinusotomy Puncture of Anterior Wall of Sphenoidal Sinus
Daniel P. Schaefer
Pathogenesis
154
Epidemiology
154
Clinical Course
155
Differential Diagnosis
156
Treatment Plan
160
Dental and Prosthetic Considerations in Head and Neck Surgery
Other Approaches to the Sphenoidal Sinus
DIAGNOSTIC ENDOSCOPy
232
Osteoplastic Approach to the Frontal Sinus
234
Anatomy of Frontonasal Duct Partial and Radical Maxillectomy ..............................•.........
Indirect Mirror Laryngoscopy and Nasopharyngoscopy and Cervical Esophagoscopy Direct Optical Laryngoscopy and Nasopharyngoscopy Cervical Esophagoscopy
179 180 181
Direct Rigid Laryngoscopy and Nasopharyngoscopy
181
Direct Rigid Laryngoscopy and Hypopharyngoscopy
182
Rigid Bronchoscopy
188
Flexible Bronchoscopy
192
Tracheal Lengths
192
Esophagoscopy Cervical Esophagoscopy After Total Laryngectomy or Cervical Esophageal Surgery
194
236 237
Case 2: Esthesioneuroblastoma, Nonresectable, Stage C
238
Case 3: Neuroendocrine Carcinoma, Nonresectable, Stage C
238
Removal or Saving Remainder of Soft Palate After Partial Maxillectomy
238
Radical Resection of Maxilla With Orbital and Partial Ethmoidal Exenteration
239
171
PERORAL ENDOSCOPY OF THE HEAD AND NECK ..... 179
234
Case 1: Esthesioneuroblastoma
166
179
228 230
Maureen Sullivan
4
226
External Frontoethmoidectomy
Dovid M. Cosey
Osseointegrated Implants in Head and Neck Reconstruction
226 226
Frontal Sinusotomy (Trephination)
161
David M. Casey
Maxillofacial Prostheses ......................................•...............
Enlargement of Natural Sphenoidal Ostium or Anterior Wall Puncture Site
222 223
Resection of Maxilla Including the Floor of the Orbit With Preservation of the Globe ...............•....................... En-Bloc Resection for Chondrosarcoma
246 246
Limited Resection of the Maxilla
248
Cysts of Maxilla ................................................•................
250
Excision of Nasoalveolar Cyst
252
Excision of Nasopalatine Duct Cyst
254
Closure of Oroantral Fistula
256
ENDOSCOPIC SINUS SURGERy
258
Keith F. Clark
194
Rigid Esophagoscopy
196
Microscopic Endolaryngoscopy
200
6
THE NOSE AND THE NASOPHARYNX
Anatomy of the Lateral Wall of the Right Nasal Cavity
267 267
CONTENTS
Uncinate Process Bulla Ethmoidalis Infundibulum Ethmoidalis
267
Total Resection of Nose for Carcinoma
356
267
Resection of Nasal Glioma-External
358
267
Excision of Rhinophyma
Ethmoid Approach
362
Anatomy of Epistaxis
270
Anterior and Posterior Packing for Epistaxis
272
Ligation of Ethmoidal Arteries
276
External Ethmoidectomy Approach to Epistaxis
279
Anatomy of Facial and Scalp Muscles
367
Septal Dermoplasty
280
Basic Technique for Facial Excisions
369
Ligation of Internal Maxillary Artery
286
Transpalatine Exposure of the Nasopharynx and the Sphenoidal Sinus
288
Transmaxillary Approach to Nasopharynx and Base of the Skull
294
Posterior Choana I Atresia
295
Newborn and Young Children ........•...........................
295
Older Children and Adults
296
Submucous Resection of Nasal Septum
300
Septoplasty Type I
304
Septoplasty Type II
310
Rhinoplasty
THE FACE
Sebaceous Cysts
282
Removal of Nasal and Nasopharyngeal Polyps
Alternate Techniques of Rhinoplasty
7
367
369
Dermabrasion
371
Excision of Tumors of Skin of Forehead
373
Excisions for Carcinoma of Skin of Temple
375
Basal Cell Carcinoma
375
Squamous Cell Carcinoma
376
Rotation Flaps
377
Temporal Scalp Flap
377
Cheek Flap
378
Excision of Tumors of Cheek by Cheek Flap Rotation
379 380
316
Facial Paralysis Shirley A. Anain and Jahn M. Lare, Jr. Management Possibilities
324
Facial Reanimation
381
381
Correction of Broad Nasal Tip
325
Augmentation of Dorsum of Nose
326
Additional Nasal Tip Procedures
326
Upper Lid Gold Weights
382
Columellar Graft for Collapsed Nasal Tip
328
Hypoglossal-Facial Nerve Anastomosis
384
328
Masseter Muscle Transposition-Intraoral
386
328
Fascial Slings for Facial Paralysis
388
Nares and Columella Procedures
330
Nasofacial and Nasolabial Flaps
332
Treatment of Paralysis of the Depressors of the Lower Lip
390
Septal Flap for External Nasal Defect
334
Trigeminal Neuralgia (Tic Douloureux)
392
Nasolabial Flap
336
Incision and Drainage of Abscesses
394
Type I Type II
Excision and Reconstruction of Ala Nasi
336
Excision and Reconstruction of Columella
336
Resection of Tumor of Tip of Nose
338
Resection and Reconstruction of Tumor of the Superior Dorsum of the Nose
340
Full-Thickness Graft to Nose Composite Graft From Ear to Nose
340 342
Type of Flap
342 344
Nasal Reconstruction With Lateral Forehead Flap
346
The Sickle Flap
348 348
The "Scalping" Flap
348
Nasal Turn-in Flaps
350
Nasal Reconstruction
352
Transection of Forehead and Scalp Pedicle
352
Revision of Nasolabial Fold and Ala Nasi
352
Enlargement of Nares With Z-Plasty
352
Resection of Nasal Septum for Carcinoma (Lateral Rhinotomy Approach)
8
399
Classification of Large Transposed Myocutaneous Flaps
400
Limitations and Pitfalls with Major Standard Regional Flaps
401
Limitations and Pitfalls According to Specific Flaps
401
Blood Supply to Skin Flaps
402
Pectoralis Major Myocutaneous Flap
404
Reconstruction of the Entire Hypopharynx and Portion of Cervical Esophagus, Oropharynx, and Nasopharynx
412
Cross Section of Reconstructed Hypopharynx
412
Applications of the Pectoralis Major Flap
420
Deltopectoral Flap
425
Reconstruction of Oropharynx, Hypopharynx, and Portion of Cervical Esophagus Applications of Deltopectoral Flap Apron Flap
354
381
GENERAL PURPOSE FLAPS
Introduction: Flap Selection and Design
Reconstruction of Nose With Arm Flap Nasal Reconstruction With Combined Scalp and Forehead Flaps
Cross-Face Nerve Grafts with Microvascular Muscle Transfer
425 434 436
CONTENTS
Laterally Based Chest Flap ...........................•......................
438
Unilateral Cleft Lip Repair
Mutter (1842) Nape of Neck Flap
440
Posterior Scapula Flap .........................................•..............
442
Triangular Flap Cleft Lip Repair: Tennison-Randall Technique
496
Forehead Flap (Temporal Flap) ..............................•............
444
Rotation Advancement Cleft Lip Repair
498
Bilateral Cleft Lip Repair
500
Reconstruction of Cheek with Forehead Flap .........•.•......... 446
494
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 (RotationAdvancement Technique)
504
•
THE LIPS
458
Cleft Palate ....................................................•................... Lip Excision and Reconstruction
458
Planing of Lip .................................•.•..........................
458
Shield Excision of Lower Lip .............•...•......................
458
Cupid's Bow
460
Elliptical Excision of Benign Lip Lesion
460
Distortion of Mouth Corrected by Z-Plasty
460
Excision of Large Benign Lesions of Upper Lip with Nasolabial Flap
460
Repair of Large Vermilion Defects .............................•........
Types of Cleft Palate Deformities ...............•.................
462
Abbe-Estlander Lip Operation
464
Correction of Rounded Commissure of Lips
467
11
506 506
Reconstructive Goals ................................•...•..............
506
Optimal Age for Operation
506
Repair of Complete Cleft of Secondary Palate
506
Repair of Incomplete Cleft of Secondary Palate
512
Repair of Complete Unilateral Cleft Palate
514
Pharyngeal Flap in Cleft Palate Repair
516
Pharyngeal Flap for Velopharyngeallnsufficiency
517
PERIORBITAL REGION
Plication of the Orbicularis Oris Muscle to Repair Partial Paralysisof the Lower Lip
468
Anatomy
Modifications of Abbe-Estlander Lip Operation
469
Repair of Lids and Conjunctiva
523 523
.........................•................
523
..........................•.............
524
469
Wounds of the Conjunctiva
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 Center Lower Lip Defect
Reconstruction of Large Defects of Upper Lip
472
Reconstruction of Lids ................................................•.......
524
Reconstruction of Upper Lip with Cheek Flap
472
Reconstruction of Lower Lid
Fan Flap Reconstruction for Large Defects of Upper Lip
474 476
Resection of Large Basal Cell Carcinoma of Lower Lid With Reconstruction Using Lateral Cheek Flap
532 534
Excision and Repair of Large Lesions of Upper Lip
526
Burow's Technique
476
Reconstruction of Upper Lid
Gillies' Technique
476
Repair of Large Defects of Upper Lip
478
Bridge Flap Repair of Large Upper Lid Defects, Cutler-Beard Technique
542
Bitemporal ("Visor") Flap for Large Upper Lip and Cheek Defects
480
Resection of Large Basal Cell Carcinoma Involving Both Lids and Nose
544
Resection of Lower Lip with Bernard Reconstruction
482
Excision of Superficial Basal Carcinoma in Region of Lateral Canthus of Lower Lid
546
Reconstruction of the Lower Lip
484
Excision of Benign Lesion of Upper Lid
548
484
Reconstruction of Superficial Horizontal Defect of Portion of Lower Lid
548
Eyelash Reconstruction ...........•.•..................................
550
Reconstruction of the Lower Lip after the Extirpation of a Lip Cancer ..........................•........... Reconstruction of the Upper Lip after an Operation of Lip Cancer
10
Reconstruction of the Lower Lip from the Cheeks after an Operation of a Lip Cancer with the Resection of a Part of the Lower Jaw
ClEFT LIP AND PALATE
485
550
486
Excision of Lesions at the Medial Canthus
552
Medial Canthoplasty and Repair of Related Injuries
554
486
Dacryocystorhinostomy
558
Correction of Scar Contracture of the Lids and Ectropion
560
Tarsorrhaphy
562
Lateral Permanent Tarsorrhaphy or Canthorrhaphy
562
493
ROBERTJ. PERRYand JOHN M. LORE,JR. Cleft Lip .................................................................•...........
Eyebrow Reconstruction
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 Resection of Adenoid Cystic Carcinoma of the Lacrimal Gland
12
THE EAR
569
Repair of Large Mandibular Defects Utilizing the DBDB Plate
618
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 and Portion of Maxilla
622
573
Otoplasty Cartilage Incision Technique ............................••......... Mattress Suture Technique (Correction of Prominent or Deformed Ears)
573
Early Reduction ........................•.•................................
622
573
Late Reduction
622
576
Early Reduction of Depressed Comminuted Fracture of Anterior Wall of Maxilla
624
Surgical Treatment of Hematoma of the Auricle: "Cauliflower Ear"
580
Z-Plasty for Stenosis of External Auditory Canal
582
Excision of Small Malignant Tumor of Cartilaginous Portion of External Auditory Canal Excision of Malignant Tumors of the Auricle
· 584
586
En Bloc Resection of the External Auditory Bony Canal
588
Technique
13
626
"Tent Peg" Method of Reduction and Fixation of Facial Bone Fractures
628
Open Reduction of Complete Fracture of Upper Dental Arch of Maxilla (Le Fort I or Guerin)
630
586
Excision of Hemangioma of the Face Involving Lobule of the Ear Total Resection of the Auricle With a Portion of the External Auditory Canal, Parotidectomy, and Radical Neck Dissection for Recurrent Malignant Melanoma
Intraosseous Wiring for Facial Fractures
590 590
Suspensory Wire Technique
630
Direct Intraosseous Wiring Technique
630
Internal Fixation of Fracture Through Middle Third of Maxilla (Le Fort II or Pyramidal Fracture)
632
Open Reduction of Fractures Through Glabella, Orbit, and Zygomatic Arch (Le Fort III or Craniofacial Dysjunction)
634
Techniques of the Use of Miniplates in Le Fort I, II, and III Fractures
636
Posterior Approach to the 7th (Facial) Nerve
590
Le Fort I-Basic
Final Pathology Diagnosis
592
Le Fort I-Complicated
FRACTURES OF FACIAL BONES
595
JOHN M. LORE,JR.and DOUGLASW. KLaTCH Basic Principles
595
Reduction of Fractured Nose
596
Depression of Right Nasal Bone with Lateral Displacement of Left Nasal Bone
597
Depression of Nasal (Frontal) Process of Right Maxilla
598
Fractures of Mandible-Outline
..............................•..........
Fracture of Condylar Process-Outline
..............•................
FRACTURES OF MANDIBLE
636
Le Fort II ..................................................•..................
636
Le Fort III
637
Internal Fixation of Fractured Hard Palate
638 638
Fractures of Floor of Orbit
640
External Traction for Depressed Facial Fracture
646
Management of Zygomatic (Malar) Fractures
648
Douglas W. Klotch
Repair of Simple Fractures
649
Repair of Complex Fractures
650
600 602
Overview of Fracture Repair
602
Open Reduction of Fractures of the Mandible
603
Technical Aspects of Fracture Repair
605 610
Douglas W. Klotch and Joachim Prein
Outline of Procedures for Rigid Internal Fixation
................................•.......•......
636
Fractures Involving the Frontal Sinus
599
Douglas W. Klotch
Compression Plating for Treatment of Mandibular Fractures
..................................................•........
612
Fracture in Row of Teeth
614
Fracture Posterior to Row of Teeth ..............•...............
614
Fractures at Angle of Mandible
616
Use of Eccentric Dynamic Compression Plate
616
Use of Dynamic Mandible Defect-Bridging Plate
616
Fracture in the Edentulous Mandible
618
Treatment of Oblique Fractures by Utilizing the Lag Screw Principle
618
14
CYSTS AND TUMORS INVOLVING THE MANDIBLE
Excision of Cysts of the Mandible
653 653
Radicular Cyst ................................•............................
653
Dentigerous Cyst
656
Marginal Segmental Resection of Mandible
658
Resection of Large Benign Tumors of Mandible
660
Mandibular Reconstruction
664
Reconstruction of Mandible Using Steinmann Pin and Tie Wires
665
Mandibular Reconstruction Using Steinmann Pin
666
Other Options Relative to Mandibular Reconstruction
672
Results of Reconstruction With Kirschner Wire and Steinmann Pin
672
CONTENTS
Reconstruction of the Mandible Using Plates With or Without Free Autogenous Nonvascularized Bone Grafts
675
Resection and Second-Stage Reconstruction of Anterior Portion of Mandible Using Iliac Bone Graft
678
Resection and Reconstruction of Major Portion of Body of Mandible With Bent Steinmann Pin and Tie Wires and Forehead Flap
682
~=~
~
Marginal Resection of Mandible, Partial Glossectomy, and Radical Neck Dissection for Carcinoma of the Floor of the Mouth
688
Buccal Wall lesions: Benign, Premalignant, and Malignant Squamous Cell Carcinoma
742
Plan for Resection of Premalignant and Malignant lesions of the Buccal Wall
744
Radical Resection of Buccal Wall With Mandibulectomy Associated With Oropha~ngeal and Retromolar Trigone Invasion: Advanced Squamous Cell Carcinoma
745
Reconstruction of Buccal Wall lesions
746
Resection of Carcinoma of the Retromolar Trigone and the Buccal Wall
747
Excisions of lesions of Soft and Hard Palate Resection of Extensive Benign Minor Saliva~ Gland Tumors of the Soft Palate
t5
ORAL CAVITY AND OROPHARYNX
698
Excision of Dysplasia (leukoplakia) and/or E~throplasia (Erythroplakia) of Tongue and Buccal Mucous Membrane
698
Excision of Carcinoma In Situ or Small limited Carcinoma of Tongue
700
Excision of Small Midline Cancer of Anterior Third of Tongue Median labiomandibular Glossotomy (Trotter Approach to Base of Tongue, Pha~nx, and Baseof Skull)
702
704
Resection of Stage T1 Carcinoma of the Midline of the Floor of the Mouth
708
Inlay Graft to Floor of Mouth for Carcinoma
710
Resection of Malignant Tumors of the Oral Cavity and Oropha~nx With Extension Above Into the Nasopha~nx and Below to the Hypopha~nx With Cervical Metastasis With or Without Involvement of the Mandible Including the Parapha~ngeal Space Approaches Bone Involvement:
Mandible ...........................•..•.......
Guidelines
Resection of Hemimandible, lateral Oropharyngeal Wall, and Portion of Soft Palate and Hemiglossectomy With Reconstruction Using a Forehead Flap Versus Pectoralis Major Flap Combined Radical Neck Dissection, Partial Glossectomy or Hemiglossectomy, and Hemimandibulectomy Including Retromolar Trigone Base of Tongue Anatomy of the Tongue
760
Resection of Carcinoma of Soft Palate
764
Excision of Ranula
766
Resection of Hemangioma and Neurofibroma of Tongue
768
Tonsillectomy and Adenoidectomy
770
Adenoidectomy
770
Salivary Duct Calculi
773
Repair of laceration of the Stensen Duct (Parotid)
773
Reconstruction and Reimplantation of Stensen's Duct in the Buccal Wall
774
Pierre Robin Syndrome
774
16
THE NECK
780
JESUSE. MEDINA and JOHN M. LORE,JR. Cervical lymph Nodes
780
Spinal Accesso~ Nerve
781
Cervical lymph Node Metastatic Guide
781
714
Classification
786
714
Radical Neck Dissection
788
716
Evaluation of Cervical lymphadenopathy on Computed Tomography and Magnetic Resonance Imaging
797
Modifications of Radical Neck Dissections
797
716
Resection for Carcinoma of Tonsil, Soft Palate, or Baseof Tongue by Mandibulotomy and Reconstruction
752
720
Parotid Extension of Radical Neck Dissection (High Exposure of Internal Jugular Vein and Internal Carotid Artery)
798
724
Modified Radical Neck Dissection Preserving the Spinal Accesso~ Nerve (Type I) Incision Modifications of Radical Neck Dissection
802 804
726 732
Modified Radical Neck Dissection Preserving the Spinal Accesso~ Nerve, the Internal Jugular Vein, and the Sternocleidomastoid Muscle (Type III)
808
732
Selective Neck Dissections
811
Resection of Baseof Tongue
732
Approaches to Base of Tongue
733
Resection of Baseof Tongue via Midline Mandibulotomy (Mandibular Swing)
Extended Neck Dissections Resection of lower Margin of Mandible Combined with Radical Neck Dissection
814
734
Posterior Neck Dissection ...........................................•.......
818
736
Keun Lee
Midline Mandibulotomy
(Mandibular Swing)
814
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
Phrenic Nerve Crush
832
18
ENDOCRINE SURGERy
892
JOHN M. LORE,JR.,MEGAN FARRELL and NIEVAB. CASTILLO
Scalene and Infraclavicular Internal Jugular Node Biopsy
832
Muscle Lengthening for Torticollis .............•.......................
834
THYROID GLAND
892
Branchial Cleft Cysts
836
Diagnostic Evaluation
892
First Branchial Cleft
836
History ...................................•.•.•.•..............................
892
Second Branchial Cleft (Most Common)
838
Physical Examination
893
Third Branchial Cleft (Rare)
838
Fine-Needle Aspiration of the Thyroid Gland
893
Fourth Branchial Cleft ......................................•..•.......
838
Thyroid Scans ('231 and 99mTc)
895
840
Sonography ...................................................•............
895
840
Computed Tomography
896
Resection of Branchial Cleft Cysts ..........................•.•......... Second Branchial Cleft ................................•...............
..............................•.•............
Excision of Branchial Fistula and Sinus Tract ..........•.•.......... B43
Magnetic Resonance Imaging
Excision of Cystic Hygroma (Lymphangioma)
845
Positron Emission Tomography
Excision of Benign Lesions of the Submental Space
848
896 ...........•.•.....................
Anatomic Considerations
896 896
Posterior Suspensory Ligament .........•.•.......................
897
850
Recurrent Laryngeal Nerve
897
Excision of Neuroma
852
Inferior Thyroid Artery
898
Incision and Drainage of Abscessesof the Neck
8S4
External Branch of the Superior Laryngeal Nerve
899
Parathyroid Glands
899
Access to the Superior Mediastinum
900
Motor Nerve Supply to the Strap Muscles
901
Thyroglossal Duct Tract
901
Normal Ectopic Thyroid
901
Resection of Ganglioneuroma of the Neck and Superior Mediastinum
Abscess of Tongue and Floor of Mouth Presenting in Submental Space (Ludwig's Angina)
854
Lateral Cervical Abscess
854
Penetration Wounds of the Neck ...............................•.......
856
Diagnosis and Treatment ...................................•........
856
17
THE PAROTID SALIVARY GLAND AND MANAGEMENT OF MALIGNANT SALIVARY GLAND NEOPLASIA
861
General Considerations
861
Basic Surgical Technique
903
Definition of Terms ............................................•.•.............
904
Evaluation of Laryngeal Nerve Function
905
Arytenoid Dislocation
906
Management of Thyroid Cancer
907
Fine-Needle Aspiration Biopsy
861
Total Thyroidectomy Versus Subtotal Thyroidectomy or Lobectomy
Total Lateral Lobectomy of the Parotid Salivary Gland
862
Nerve Paralysis
908
Facial Nerve in Infants
866
Hypoparathyroidism
908
Deep Lobectomy of Parotid Salivary Gland
868
Potential Problems in Management
909
Mandibulotomy and Deep Lobe Lobectomy of the Parotid Salivary Gland with Dissection of Parapharyngeal Space ..........................................•.•.......
Hormonal Replacement
910
872
Free Facial Nerve Graft .......................................•..••...........
876
Additional Evidence Supporting Total Thyroidectomy
910
Gustatory Sweating (Frey's Syndrome)
876
Excision of the Recurrent Benign Tumor of the Parotid Gland
878
Management of Salivary Gland Tumors
880
Thorn R. Loree
Additional Caveats Relative to Malignant Tumors of the Parotid Salivary Gland
882
lohn M. Lore, If.
Adenocarcinoma Not Otherwise Specified (NOS)
883
Management of Well-Differentiated Thyroid Cancer (Includes Papillary, Follicular, and HOrthle Cell Oncocytic Carcinoma) Pathologic Classification
907
914 914
Nieva B. Castillo
Danger of Underestimating Malignancy
919
Treatment
919
Imaging
922
Medullary Carcinoma of the Thyroid
922
Origin and Characteristics
922
Nievo B. Costilla
Types
923
Parotid Extension of Radical Neck Dissection .......•............. 886
Classification of Multiple Endocrine Neoplasia
923
Malignant Mixed Tumor
High Exposure of Internal jugular Vein and Internal Carotid Artery .......................•.•............ Parotitis ...........................................................•.•...............
884
Diagnosis
923
886
Familial MCT
924
888
Suggested Follow-up Regimen .......................•.•..........
924
Family Screening .......................................•.................
925
CONTENTS
Management of Residual or Recurrent MCT
926
Overview of Surgical Principles
985
Scope of the Operation
926
Detailed Review of Surgical Principles ...........•....................
986
Prognosis .......................................................•............
927
Excision of Parathyroid Adenomas
990
Hurthle Cell Carcinoma
927
Papillary Tall Cell Carcinoma
927
Excision of Mediastinal Parathyroid Adenomas and Cystadenoma
Undifferentiated or Anaplastic Carcinoma
928
Mediastinoscopy
997
Squamous Cell Carcinoma
928
Anatomy
997
Summary of Management of Thyroid Cancer
929
Discussion
997
Excision of Posterior Superior Mediastinal Parathyroid Cystadenoma via Median Sternotomy
996
Substernal Goiter (Median Sternotomy and Total Thyroidectomy With Superior Mediastinal Node and Radical Neck Dissection)
929
Graves' Disease ........................................•.........................
932
Osteoporosis
1002
Exophthalmic Graves' Disease
934
Hypocalcemia
1002
Toxic Multinodular Goiter
934
Total Thyroid Lobectomy
93S
Subtotal Thyroid Lobectomy
946
Modified Radical Neck Dissection with Preservation of the Sternocleidomastoid Muscle and the Spinal Accessory Nerve
Postoperative Care
1
THE TRACHEA AND MEDIASTINUM
Tracheoscopy 950
Total Thyroidectomy Without or With Radical Neck Dissection
955
Autonomous Thyroid Nodule
960
999 1002
1015 1015
Tracheostomy
1015
Cervical Mediastinotomy and Tracheomediastinotomy
1024
Tracheal Resection
1026
Closure of Cutaneous Tracheal Fistula
1034
Closure of Cervical Tracheoesophageal Fistula
1036
960
Mediastinum Anatomy
1036
960
Mediastinoscopy .....................•........................................
1038
Lingual Thyroid
962
Mediastinal Dissection
1040
Complications of Thyroid Surgery
963
Suggested Postoperative Orders After Thyroid Surgery
966
Suprasternal Approach via the Superior Thoracic Inlet (Limited Dissection)
966
Resection of the Medial Third of the Clavicle on One Side
1040
Median Sternotomy
1041
Resection of the Manubrium With or Without a Portion of the Sternum and Medial Portion of the Clavicle
1041
Endemic Goiter Not Due to Iodine Deficiency (Beierwaltes) Hashimoto's Thyroiditis (1912}-Struma
PARATHYROID GLANDS
Lymphomatosa
...•...............•...............•.........
Pathology of the Parathyroid Glands
966
john E. Asirwatham
Embryology
966
Anatomy ......................................................•..............
966
Diseasesof Parathyroid
966
Intraoperative and Frozen Section Examination of Parathyroid
967
Hypercellularity
968
Surgery of Parathyroid Glands
968
Blood Supply of the Parathyroid Glands ...............•...... 968 Hyperparathyroidism Hyperparathyroidism Associated With MEN Syndromes Preoperative and Intraoperative Techniques for the Surgical Management of Sporadic Hyperparathyroidism: Adenoma and Hyperplasia
972 975
976
john M. Lore, jr.
Section 1: The Author's (JML) Experience and Suggestions Regarding Imaging Section 2: Summary Evaluations, Pros and Cons, for Each Imaging and Nonimaging Modality
976 980
Exposure of the Mediastinum by Resection of the Medial Third of the Clavicle DiseasesAmenable to the Approach With Medial Third Clavicle Resection
1040
1041 1041
Median Sternotomy, Total Thyroidectomy, With Superior Mediastinal Node and Radical Neck Dissection
1046
Mediastinal Dissection for Tracheostoma Recurrence (Sisson Procedure) Transcervical Total Thymectomy
1056 1062
20
THE LARYNX
1069
Indirect Mirror Laryngoscopy
1069
Anatomy of Superior Laryngeal Nerve
1069
Punch Biopsy of Lesions of Larynx and Hypopharynx
1073
Stripping (De-Epithelialization) of a Vocal Cord
1074
Section 3: Pearls and Pitfalls Regarding Parathyroid Imaging
982
Indications for Surgery in Primary Hyperparathyroidism
Endoscopic Removal of Congenital Cyst of Ventricle in Newborn (Internal Laryngocele)
1076
984
CO2 Laser in Laryngeal and Endobronchial Surgery
1077
Chemical Diagnosis of Hyperparathyroidism
984
Microlaryngoscopy Using the CO2 Laser
1077
CONTENTS
Endoscopic Intracordallnjection
of Teflon Paste
1078
Thyroplasty;Vocal Cord Mediallzation
1080
Laryngofissure (Thyrotomy)
1082
Cordectomy and Arytenoidectomy for Bilateral Abductor Cord Paralysis
1086
Cancer of the Larynx
1089 1094
Radiation Therapy for Laryngeal Cancer Dhiren K. Shah
Partial Laryngectomy (Outline)
1100
Cordectomy for Small Carcinoma of True Vocal Cord
1105
Vertical or Frontolateral Laryngectomy
1106
Omohyoid Muscle Laryngoplasty
1114
Strap Muscle Laryngoplasty
1116
Horizontal or Supraglottic Laryngectomy
1118
Simultaneous Radical Neck Dissection Laryngeal Suspension
1181
Introduction to Reconstruction of Pharynx and Esophagus
1186
1084
Laterallzation of Arytenoid Cartilage (Arytenoidopexy) for Bilateral Abductor Vocal Cord Paralysis Treatment
Resection of Carcinoma at Posterior Wall of Hypopharynx and Oropharynx and Radical Neck Dissection (Lateral Pharyngotomy Approach)
Carcinoma of the Hypopharynx and Cervical Esophagus Myomucosal Tongue Flap and Dermal Graft for Reconstruction of Entire Hypopharynx, Posterior Wall of Oropharynx, and Nasopharynx Associated With Total Laryngectomy and Total Hypopharyngectomy Cervical Esophagoscopy
1187
1188 1190
Reconstruction of Hypopharynx and Cervical Esophagus Using PMF With Dermal Graft
1190
Reconstruction After Partial "Cuff" Cervical Esophagectomy, Hypopharyngectomy, and Total Laryngectomy Above the Thoracic Inlet Using Local Cervical Flaps
1192
1120
Free Skin Graft Over Tantalum Gauze
1196
1125
Thoracic Skin Flap
1196
Resection for Cancer of the Cervical Esophagus
1199
Total Laryngectomy
1126
Tracheostomal Problems
1134
Gastric Pull-Up
1200
1134
Gastric Pull-Up With Extrathoracic Esophagectomy
1200
Correction of Tracheal Stomal Stenosis
1135
Total Laryngectomy and Radical Neck Dissection
1136
Resection of Cancer of Cervical Esophagus at the Thoracic Inlet
1206
Technique of Construction of Large Tracheal Stoma
Tongue Flap (Myomucosal) for Reconstruction of Portion of Hypopharynx Associated With Total Laryngectomy Voice Prostheses: Post-Total Laryngectomy
1142
Cervical Esophagocolostomy Reconstruction of Esophagus Using Transverse and Descending Colon Stamm Gastrostomy
1143
1213 1216 ·..· 1222
Tracheal Esophageal Puncture (TEP) .............•............ 1143
Janeway Gastrostomy
Singer-Blom Technique (Modified)
1144
Percutaneous Endoscopic Gastrostomy .................•.......... 1227
panje Voice Button Prosthesis
1146
Total Laryngectomy and Radical Neck Dissection
1148
Resection of External Laryngocele
1152
Laryngeal Trauma
1154
Correction of Laryngeal Web ......................•....................
1162
Technique of McNaught (1950)
1162
Technique of Frazer (1968)
1162
Aspiration ....................................•............................
1162
Carbon Dioxide Laser
1164
21 THE HYPOPHARYNX AND THE ESOPHAGUS
1171
Repair of Pharyngoesophageal Diverticulum Exposure of the Superior Portion of the Thoracic Esophagus Repair of Iatrogenic Injury to the Esophagus Resection of Adenocarcinoma From the Cervical Esophagus Cricopharyngeal Myotomy Transhyoid Pharyngotomy Anterior Pharyngotomy
1171 1176 1176
Daniel Sette Camara
22
VASCULAR PROCEDURES
1233
JOHN M. LORE,JR.,JOSEPHM. ANAIN, NIEVAB. CASTILLO,and L. NELSONHOPKINS Vascular Surgery in Operations of Neck, Extracranial Portions of Head, Face, and Thoracic Outlet Basic Principles Degenerative Vascular Disease
1233 1233 1240
Extracranial Cerebrovascular Disease
1242
Exposure of Bifurcation of Carotid Arteries and Endarterectomy
1244
Endarterectomy With Patch Graft
1248
Intraluminal Shunts Used in Endarterectomy
1248
Complications of Carotid Artery Surgery
1250
Controversies of Carotid Artery Surgery
1252
Carotid Artery Stenting: Indications, Technique, and Results
1254
L. Nelson Hopkins
1176
Exposure of Cervical Portion of Subclavian Arteries and Proximal Portion of Vertebral Arteries
1256
1180
Vertebral Artery Reconstruction
1258
1180
Surgical Treatment of Occlusion of Vertebral Arteries
1258
............................••............ ·..· 1178 ............................••.................
· 1224
CONTENTS
Exposure of Distal Common Carotid Artery and Placement of Bypass Graft
1262
Subclavian Steal Syndrome
1262
Thoracic Outlet Syndrome-Scalenotomy
1340
Surgical Treatment of Occlusion of Common Carotid and Subclavian Arteries and Subclavian Steal
1264
Atherosclerotic Aneurysm
1266
Parapharyngeal Space
1350
1266
Anatomy of the Parapharyngeal Space
1350
CT versus MRI
1351
Approaches to the Parapharyngeal Space
1352
Anomalies of the Internal Carotid Artery
23
Exposure of Innominate Artery and Proximal Portion of Right Subclavian and Common Carotid Arteries via Sternal-Splitting Incision
1268
BypassGraft for Obstruction of Innominate Artery
1270
Resection of Kinked Obstruction in Internal Carotid Artery
1272
Alternate Method to Correct Kinked Internal Carotid Artery
1274
Fibromuscular Dysplasia
1274
Vasculitis
1275
Radiation Arteritis
1275
Spontaneous Carotid Artery Intimal Dissection Neoplastic Disease
1275
BASE OF THE SKULL SURGERy
Base of Skull and Parapharyngeal Space
Glossopharyngeal Neuralgia
Surgery of the Parapharyngeal Space
1365
Advanced Radical Exposure
1368
Mandibular Swing
1374
Craniofacial Resection
1377
Bilateral Total Maxillectomy for Chondrosarcoma
1386
Supraorbital Approach to the Orbit and Paranasal Sinuses
1391
Cranial Portion
1276
Gregory /. Castiglia and Daniel P. Schaefer
Resection of Portion of Common and Internal Carotid Arteries Involved by Cancer
1277
john M. Lore /r. and Daniel P. Schaefer
Results of Resection and Reconstruction of the Internal Carotid Artery in Metastatic Carcinoma
1283
Paragangliomas-Head
and Neck
1283
Resection of Carotid Body Tumor
1294
Resection of Intravagale Paraganglioma With Preservation of Major Vessel Continuity
1300
Trauma to Vessels
1361 1365
Metastatic Squamous Cell Carcinoma
Intravascular (Glomus) jugulare Paraganglioma Tumor
1349
Infratemporal Approach to the Skull Base Ernesto A. Diaz-Ordaz
1276
Intravagale Paragangliomas and Bilateral Superior Sympathetic Ganglion Paragangliomas and Unilateral Carotid Body Tumors
1348
Facial Portion Reconstruction Transseptal Transsphenoidal Hypophysectomy -Cryosurgical and Surgical
1391 1394 1394 1395
Cryosurgical Hypophysectomy
1400
Surgical Ablative Hypophysectomy
1400
Endoscopic Endonasal Transsphenoidal Approach to the Pituitary Gland
1404
Douglas B. Moreland
1302
Temporal Bone Resection
1408
fohn S. Lewis
1307 1310
Vascular Trauma Outline
1310
Immediate Sequelae of Vessel Injuries
1310
ROBERTw. DOLAN
Late Sequelae of Vessel Injuries
1313
Microvascular Free Flaps
Resection of Arteriovenous Aneurysm of the Face
1314
Historical Perspective and Introduction
1417
Resection of Aneurysm of Common or Internal Carotid Artery
Flap Classification
1418
1320
Typical Donor Flaps
1418
Recipient Defects and Microvascular Flap Selection
1420
Microsurgery
1422
Advantages and Disadvantages of Specific Flaps
1428
Transection of Internal Carotid Artery/Internal jugular Vein Fistula With Resection of False Aneurysm , Lateral Venotomy
for Foreign Body
Control of Hemorrhage Effects of Cancer: Carotid Artery Blowout
1320 1326 1328 1328
Prevention and Management of Carotid Artery Blowout
1328
Protection for Carotid Artery
1331
24
MICROVASCULAR SURGERy
1417 1417
Radial Forearm
1429
Fibular Osteocutaneous
1436
Rectus Musculocutaneous
1441
Scapular Osteocutaneous
1448
Latissimus
1456
Jejunal
1462
Protection for Carotid Artery and Sources of Muscle Bulk
1334
Iliac Crest Osteocutaneous
1464
Ligation of More Proximal Vessel
1336
Gracilis
1468
INDEX
1471
External Carotid Artery Ligation
1336
Harvesting Saphenous Vein for Graft
1338
1
SECTIONAL RADIOGRAPHIC
ANATOMY AND SCANNING
ANATOMIC RADIOGRAPHS John M. Lore, Sr., 1938
The following seven radiographic plates (see Figs. 1-1 to 1-7) are part of a series of sagittal and frontal sections of the head and neck made in 1938 by John M. Lore, Sr. Their purpose at that time was to study the anatomy primarily in relation to deep infections of the head and neck. Since then, such infections have become almost a surgical curiosity, yet the basic anatomy portrayed by this technique is believed to be of considerable value to both the surgeon and the radiologist. Both the actual relationship of bony structures and that of soft tissue are well depicted in the original radiographs, with some interpretation in the facing color illustration. The technique of their preparation began with cadaver sections, for the most part one-half-inch thick. The sections were fixed in formaldehyde and allowed to dry a little so that there would be some separation of the various structures in the specimens. Radiographs were then made of the sections. In the original presentation of this material, read at the New York Academy of
Medicine, Section on Otolaryngology, December 21, 1938, and published in Laryngoscope, June 1939, Dr. Lore, Sr. acknowledged assistance in. this work thus: "For the material, the late Professor Senior and his successor, Professor Sheehan, of the Anatomy Department of the Medical School of New York University, have been more than generous. For the X-ray work, Dr. Frederick Law, of the Manhattan Eye, Ear, Nose and Throat Hospital, and the X-ray Department of St. Vincent's Hospital have been most helpful and unstinting in their aid." More recently, the color illustrations have been developed with the aid of Robert Wabnitz. Each figure alone, and all as a group, should aid in the understanding of sinus surgery, both limited and radical, as well as fractures of the facial bones, related skull fractures, and neoplasm, especially of the base of the skull. In addition, the fibrofatty tissue planes are clearly demonstrated, thus relating these radiographic studies to computed tomographic (eT) scans of the head and neck. These fibrofatty tissue planes are of significant diagnostic help, especially in relation to lesions of the pharyngomaxillary space, as delineated by Peter Sam.
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Sagittal Section Through the Midportion of the Maxillary Sinus and Orbit (Fig. 1-1)
The posterior relations of the maxillary sinus to the floor of the middle cranial fossa are clearly depicted. The roof of the maxillary sinus forms the floor of the orbit, and the floor of the maxillary sinus forms the roof of the alveolar ridge. Within this latter structure are seen the upper teeth protruding almost into the sinus cavity. This anatomy is important in minor operations on the maxillary sinus, in partial or total resections of the maxilla for carcinoma, and in operations at the base of the sheath. The course of the internal carotid artery and the carotid canal in the base of the skull is seen,with the jugular foramen slightly posterior. Temporal bone resection reaches almost this depth, being somewhat lateral to this.
b. c. d. e. f. g. h. i. j. k.
Optic nerve Anterior clinoid process Maxillary sinus Lateral pterygoid plate of sphenoid bone Pterygomaxillary fissure Carotid canal Jugular foramen Foramen spinosum (for middle meningeal artery) Petrous portion of temporal bone Upper and lower heads of external pterygoid muscle I. Deep and superficial head of internal pterygoid muscle. The internal carotid artery is deep and lateral to the pterygoid muscles. m. First cervical vertebra or atlas n. Internal carotid artery o. External carotid artery p. Hyoid bone q. Portion of thyroid cartilage r. Thyroid gland
a. Frontal sinus
FIGURE1-1
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-1 Continued
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Sagittal Section Through the Lateral Wall of the Nose, Lateral Border of the Tongue, and Lamina of the Thyroid Cartilage Showing Its Superior and Inferior Cornua (Fig. 1-2) The relationship of the posterior ethmoidal sinus cells to the lateral wall of the sphenoidal sinus is shown. The surgical approach to the sphenoidal sinus must be more medial. The section includes the medial wall of the orbit, which is the lateral wall of the ethmoidal sinus and, incidentally, very thin. With the major portion of the middle turbinate excluded, the underlying maxillary sinus is visible. The anatomy of the base of the skull is clearly depicted. The main extrinsic tongue muscle-the genioglossus-is easily seen with its attachment to the mandible. Also noteworthy are the relationships of the hyoid bone, thyroid cartilage, and cricoid cartilage. a. Frontal sinus b. Orbital plate of frontal bone forming floor of anterior cranial fossa
c. d. e. f. g. h. i. j. k. I. m. n. o. p. q. r. s. t. u. v. w. x. y. z.
FIGURE 1-2
Anterior clinoid process Ethmoidal sinus or labyrinth Sphenoidal sinus, lateral wall Underlying maxillary sinus Inferior turbinate Carotid canal leading to foramen lacerum Pterygopalatine fossa Pterygoid canal Medial pterygoid plate of sphenoid bone Hamulus of pterygoid Hard palate and floor of nose Longus capitis muscle Internal auditory meatus Hypoglossal canal Jugular bulb First cervical vertebra or atlas Second cervical vertebra or axis Vertebral artery Lingual artery within genioglossus muscle Geniohyoid muscle Epiglottis Hyoid bone Thyroid cartilage Cricoid cartilage
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-2 Continued
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Sagittal Section Through the Floor of the Nose and the Body of the Tongue (Fig. 1-3)
Except for the superior turbinate, the structures of the lateral wall of the nose are well visualized. The prevertebral space is seen extending from the base of the skull inferiorly toward the thorax. Note the relationship of the ethmoidal sinus to the floor of the anterior cranial fossa and its continuity posteriorly with the sphenoidal sinus. Within the sphenoidal sinus is the cradle for the pituitary gland, the sella turcica. Behind the uncinate processof the ethmoid bone is the hiatus semilunaris and the bulla of the ethmoid. Slightly superior IS the osteomeatal complex leading to the natural ostium of the antrum laterally and the frontal sinus duct recess.Seealso p. 267. a. Frontal sinus
b. c. d. e. f. g. h. i. j. k. I. m. n. o. p. q. r. s. t.
FIGURE 1-3
Cribriform plate of ethmoid Ethmoidal sinus or labyrinth Pituitary gland Uncinate processof ethmoid bone Sphenoidal sinus, septum Middle turbinate Inferior turbinate Pterygoid processof sphenoid bone Lingual artery within genioglossus muscle and hyoglossus muscle Genioglossus muscle Epiglottis Hyoid bone Geniohyoid muscle Thyroid cartilage Trachea Foramen magnum Longus capitis muscle Spinal cord Prevertebral space
SECTIONAL
RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-3 Continued
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Sagittal Section Through the Middle of the Skull (Fig. 1-4) The relationship of the nasal septum to the anterior wall of the sphenoid sinus is visualized, demonstrating the route of the transseptal approach to the pituitary. Also shown is the approach to the sphenoidal sinus via the ethmoid labyrinth. Staying as close as possible to the midline avoids injury to the internal carotid artery and optic nerve, which are more lateral. The surface anatomy at the base of the tongue and the inte~ior of the larynx is seen. At the entrance to the cervICal esophagus, the lowermost fibers of the inferior pharyngeal constrictor muscle-the cricopharyngeus-are hypertrophied with an S-type curve to the lumen. ThiS explains some of the difficulty that may be encountered during the introduction of the esophagoscope. The tendency of the so-called postcricoid carcinoma of the larynx to esophageal spread is explained by this view. a. Frontal sinus b. Cribriform plate of ethmoid c. Ethmoidal sinus or labyrinth
d. e. f. g. h. I.
j. k. I. m. n. o. p. q. r. s. t. u. v. w. x. y. z.
FIGURE 1--4
Perpendicular plate of ethmoid Pituitary Sphenoidal sinus Vomer bone Soft palate and uvula Superior pharyngeal constrictor muscle Genioglossus muscle Geniohyoid muscle Vallecula Hyoid bone Epiglottis Arytenoid Ventricular band Thyroid cartilage Ventricle True vocal cord Posterior aspect of cricoid cartilage Cricopharyngeus portion of inferior constrictor muscle of pharynx Lumen of cervical esophagus Trachea Thyroid isthmus Prevertebral space Straight sinus
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE1-4 Continued
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Frontal Coronal Section in the Region of the Second Molar Teeth (Fig. 1-5)
Note the thin wall forming the boundary between the ethmoidal sinus and the orbit. The variable relationship of the floor of the maxillary sinusto the floor of the nose is represented. Between the sublingual gland and the submaxillary gland is the mylohyoid muscle originating from the mylohyoid line on the mandible. Fracturesof the infraorbital rim usually occur through the thinned area of the infraorbital foramen, always involving, to a greater or a lesserdegree, the maxillary sinus itself.
a. b. c. d. e. f. g. h. i.
Frontal sinus Anterior ethmoidal sinus Perpendicular plate of ethmoid Middle turbinate Inferior turbinate Vomer bone Maxillary sinus Infraorbital foramen Masseter muscle J. Buccalfat pad k. Mandible I. Submaxillary salivary gland m. Sublingual salivary gland n. Tongue o. Orbit p. Mylohyoid muscle
FIGURE 1-5
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-5 Continued
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Frontal Coronal Section Just Beyond the Third Molar Teeth (Fig. 1-6)
a. b. c. d.
As in the previous section, the thin bony boundary between the ethmoidal sinus and orbit is depicted. The conservative approach to the ethmoidal sinus for drainage purposes and moderate exenteration is just above and lateral to the attachment of the middle turbinate. This is easily seen on the right side of the section. Also visualized is the hamulus of the pterygoid process around which courses the tensor veli palatini. It is this process that is fractured in cleft palate repair. For extensive carcinoma of the maxillary sinus, inclusion of the ethmoidal sinus en bloc is clearly shown to be the aim of the radical resection including the orbital contents. The relationship of the floor of the maxillary sinus to the floor of the nose is demonstrated, as is the roof of the maxillary sinus to the orbit in blowout fractures.
e. f. g. h. I.
j. k. I. m. n. o. p. q. r. s.
Frontal sinus Cribriform plate of ethmoid with frontoethmoid cells Ethmoidal sinus Medial wall of orbit formed by lacrimal bone and lamina papyracea of ethmoid bone Superior turbinate Middle turbinate Inferior turbinate Perpendicular plate of ethmoid Vomer bone Maxillary sinus Body of malar bone Temporalis muscle Ascending ramus and coronoid process of mandible Masseter muscle External pterygoid muscle Internal pterygoid muscle Hamulus of pterygoid process of sphenoid bone Tongue Submandibular salivary gland with external maxillary artery
FIGURE 1-6
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-6 Continued
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Frontal Coronal Section in the Region of the Anterior Faucial Pillar and Tonsil (Fig. 1-7)
This section demonstrates the structures that are encountered laterally and posteriorly in radical resection of the maxilla and ethmoidal sinus for carcinoma. The zygomatic arch is vividly depicted as vulnerable in fractures of the facial bones. Extensive carcinoma of the soft palate involving the tonsil usually requires resection of the pterygoid process of the sphenoid with at least the internal pterygoid muscle. Hemimandibulectomy is also warranted when the mandible is involved. The fibrofatty tissue planes are clearly demonstrated. a. Orbital plate of frontal bone b. Cribriform plate of ethmoid
c. d. e. f. g. h. i. j. k. I. m. n. o. p. q. r. s.
FIGURE 1-7
Posterior ethmoidal cells Rostrum of sphenoid bone Lateral pterygoid plate of sphenoid bone Medial pterygoid plate of sphenoid bone Hamulus of pterygoid process Upper and lower headsof external pterygoid muscle Internal pterygoid muscle Temporalis muscle Zygomatic arch Masseter muscle Parotid gland Internal maxillary artery Soft palate Tongue Mandibular canal Anterior faucial pillar and tonsil Submandibular salivary gland
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-7 Continued
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
CT AND MRI David F Hayes and Scott Cholewinski The single-plane CT scans in Figures 1-8 to 1-10 and the three-dimensional reconstructed CT scans in Figures 1-11 to 1-17 were prepared by David F. Hayes, MD, chairman of the Department of Diagnostic Imaging at Sisters of Charity Hospital, Buffalo, New York. The magnetic resonance (MR) images in Figures 1-18 to 1-24 are courtesy of Buffalo MRI, Buffalo, New York (J. E. Gardner, AAS, RT, MR, chief technologist). The MR images in Figures 1-25 to 1-40 were prepared by Scott Cholewinski, MD, Director of Magnetic Resonance Imaging at Sisters of Charity Hospital, Buffalo, New York.
Single-Plane to 1-10)
CT Scans (See Figs. 1-8
Frontal Coronal Section in the Region of the Second Molar Teeth (Fig. 1-8) Compare this CT scan with the radiograph in Figure 1-5. b. c. d. e. f. g. k. n.
FIGURE 1-8
Anterior ethmoidal sinus Perpendicular plate of ethmoid Middle turbinate Inferior turbinate Vomer bone Maxillary sinus Mandible Tongue
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Frontal Coronal Section Just Beyond the Third Molar Teeth (Fig. 1 -9)
Compare this CT scan with the radiograph in Figure 1.6. b. Cribriform plate of ethmoid c. Ethmoidal sinus
d. Medial wall of orbit formed by lacrimal bone and lamina papyracea of ethmoid bone f. Middle turbinate g. Inferior turbinate i. Vomer bone j. Maxillary sinus k. Body of malar bone r. Tongue
FIGURE 1-9
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Three-Dimensional Reconstructed CT Scans (See Figs. 1-11 to 1-1 7)
Frontal Coronal Section in the Region of the Anterior Faucial Pillar and Tonsil
(Fig. 1-10) Compare this CT scan with the radiograph in Figure 1-7. a. c. j. k. I. p.
Orbital plate of frontal bone Posterior ethmoidal cells Temporalis muscle Zygomatic arch Masseter muscle Tongue
Three-dimensional reconstruction of images is an interesting CT application. Closely spaced transverse images are stacked upon each other, as in a layer cake, and the edges are smoothed together (the icing) to produce the unified anatomic structure. It may then be viewed from any projection.
Frontal Projection (Fig. 1-11) Notice the orbital rim, zygomatic bone, infraorbital foramen, supraorbital notch, canine eminence, and superior orbital fissure.
FIGURE 1-10
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
a. Orbital rim e. Infraorbital foramen g. Superior orbital fissure
i. Supraorbital notch j. Canine eminence m. Zygomatic bone
FIGURE 1-11
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Lateral Projection (Fig. 1-12)
Notice the roof, floor, and medial wall of the orbit; pterygoid plates, including hamulus of medial plate; and mandibular foramen.
b. c. d. k. I.
Medial wall of orbit Orbit floor Orbit roof Pterygoid plates Mandibular foramen
FIGURE 1-12
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Oblique Waters' Projection (Fig. 1-13)
Notice the zygomatic bone, including zygomatic arch, ramus of mandible with coronoid process,orbital rim, roof of orbit, and infraorbital foramen. a. Orbital rim
d. e. m. n. o. p.
FIGURE 1-13
Orbit roof Infraorbital foramen Zygomatic bone Zygomatic arch Mandible Coronoid process of mandible
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Oblique Lateral Projection (Fig. 1-14)
Notice the supraorbital notch, infraorbital foramen, coronoid process of mandible, and perpendicular plate of ethmoid bone.
e. Infraorbital foramen i. Supraorbital notch m. Zygomatic bone n. Zygomatic arch p. Coronoid process of mandible q. Perpendicular plate of ethmoid bone
FIGURE 1-14
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Interior of Skull, Viewed From Posterior Oblique Projection (Fig. 1-15)
Notice the crista galli, superior orbital fissure, petrous bone, clivus, dorsum sellae, and sella turcica.
g. s. t. u. v.
FIGURE 1-15
Superior orbital fissure Petrous bone Clivus Dorsum sellae Sella turcica
SECTIONAl RADIOGRAPHIC ANATOMY AND SCANNING
Interior of Skull, Viewed from Frontal Projection, With Facial Bones Removed (Fig. 1-16)
Notice the sphenoidal sinus, sphenoid rostrum, petrous bone, pterygoid plates, zygomatic arch, and internal occipital protuberance.
k. Pterygoid plates n. Zygomatic arch s. Petro us bone w. Sphenoidal sinus x. Sphenoid rostrum y. Sagittal sinus
FIGURE 1-16
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Interior of Skull, Viewed From Above Anteriorly in Frontal Projection (Fig. 1-1 7)
Notice the crista galli, roof of orbit, zygoma, zygomatic arch, mandible, infraorbital groove, and inferior orbital fissure.
a. d. f. h. m. n. o. r.
FIGURE 1-17
Orbital rim Orbit roof Infraorbital groove Inferior orbital fissure Zygomatic bone Zygomatic arch Mandible Crista galli
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
MRlmages
(Figs. 1-18 to 1-40)
Imaging in the Diagnosis and Treatment of Head and Neck Disease The technologic advancement in diagnostic imaging has virtually revolutionized the entire field of medicine. Nevertheless, there is a serious problem developing in medicine at this time: the reliance on imaging as the "be all and end all" in determining the extent of disease or even the presence of disease. Imaging technology is a great help, but it must be evaluated in conjunction with clinical examination. Most important, all images, even those produced by highly advanced computerized processes, must be reviewed by the examining physician and the radiologist. Overview Scott Cholewinski CT and MRI are critical in the diagnosis and management of head and neck tumors, with MRI playing an increasingly important role. These modalities localize lesions and demonstrate tissue characteristics, which are important in determining prognosis. They are also important in evaluating for adenopathy (Hudgins and Gussack, 1992). CT and MRI are best viewed as complementary in the evaluation of head and neck pathology. Each modality has unique, inherent strengths and weaknesses. MRI provides better soft tissue contrast resolution and allows for direct, multiplanar scanning. There is no ionizing radiation, and non-iodine-based contrast material is used. CT is relatively quick and inexpensive compared with MRI and is very sensitive to calcification, making it valuable in the evaluation of osseous destruction, particularly in the skull base region. I have found MR superior to CT in the evaluation of lesions involving the salivary glands, nasopharynx, oropharynx, tongue, and floor of the mouth. A detailed discussion of MR physics is beyond the scope of this chapter. However, understanding a few key concepts and terms is essential. Spin-echo MR images can be Tl weighted with short TR (repetition
time) and short TE (echo time); T2 weighted (long TR and long TE); or intermediate weighted, also termed proton density weighted; (long TR and short TE). Tissues have inherent and unique Tl and T2 relaxation times, which can be short or long. Water and cerebrospinal fluid have both long Tl and long T2 relaxation times; and both are low signal on Tl-weighted images and high signal on T2-weighted images. Fat has a short Tl relaxation time and an intermediate to short T2 relaxation time and is high signal on Tl-weighted images and intermediate signal on T2weighted images. Standard MRI of the neck is performed using a head and neck array coil. A typical examination includes Tland T2-weighted images in the axial plane, followed by Tl-weighted images in the axial and coronal planes after the administration of gadolinium. Gadolinium is a paramagnetic intravenous contrast material that shortens Tl relaxation times. Tl-weighted images demonstrate exceptional anatomic detail, whereas T2-weighted images are helpful in the identification of abnormal tissue. Neoplasms in the head and neck tend to be hypointense to isointense relative to muscle on Tlweighted images and may be low or high signal on T2weighted images. Fat suppression techniques can also be extremely valuable in the assessment of head and neck lesions. Table 1-1 lists characteristic MR findings in typical tumors of the parapharyngeal space and upper neck (Som et al., 1987). As previously mentioned, CT and MRI are important in the evaluation of cervical lymphadenopathy. Cervical lymph nodes are typically of intermediate signal on Tl-weighted images relative to fat and hyperintense to fat on T2-weighted sequences. CT and MR size criteria allow level 1 and level 2 lymph nodes to measure up to 1.5 cm in maximal dimension and 1.0 cm elsewhere. Nodes of larger size should be considered highly suspect for metastatic involvement, particularly in patients with a known primary lesion (Hudgins and Gussack, 1992). The choice in cross-sectional imaging modalities between MR and CT will vary with individual patients, specific diagnostic concerns, clinical questions, available technology, and clinician acceptance. What remains important is to exploit the inherent strengths of each modality to best obtain the necessary diagnostic information for the patient.
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
MRI Characteristics of Parapharyngeal Space 1\unors Signal Intensity
Thmor
Tl-Weighted Image
T2-Weighted Image
Paraganglioma
Intermediate
Metastatic vascular tumor
Intermediate
Moderately high; salt-and-pepper appearance except when < 1.5 cm Moderately high; salt-and-pepper appearance
Hemangioma
Intermediate
High
Salivary gland tumor
Intermediate
High
Neurogenic tumor
Intermediate
Lymphoma Soft tissue sarcoma
Intermediate Intermediate
High; salt-andpepper in one case Moderately high Moderately high
Liposarcoma Chordoma
High Variable
Moderately high High
Contour
Overall Appearance
Calcification, Fibrosis, or Bone Fragments
Smooth
Flow voids common
Sites of fibrosis
Irregular
Flow voids "may not be as numerous as in paragangliomas" Flow voids
Bone fragments possible
Homogeneous
Focal calcium, fibrosis
Homogeneous
Focal calcium, fibrosis
Smooth, but irregular in some cases Usually smooth; irregularity may indicate high-grade malignancy Smooth
Smooth Irregular in some areas, smooth in others Irregular Smooth
Homogeneous Homogeneous
Homogeneous Homogeneous
Bone fragments
Focal calcium, fibrosis, bone fragments
FromSam PM, et al: Thmorsof the parapharyngeal space and upper neck: MRimagingcharacteristics.Radiologyt64:823, 1987.
SECTIONAl RADIOGRAPHIC ANATOMY AND SCANNING
Masseter muscle
Mandible
Mandible
Submandibular gland
Soft palate
Masseter muscle Medial pterygoid muscle Facial vein
Trachea
Submandibular gland Oropharynx
Trachea
Sternocleidomastoid muscle
Sternocleidomastoid muscle
FIGURE 1-19
FIGURE 1-18
Sternocleidomastoid muscle
Thyroarytenoideus muscle
Hypopharynx
Anterior commissure Aryepiglottic fold
Vocal cord Posterior commissure
Vertebral artery
Levator scapulae muscle
Sternocleidomastoid muscle
Pyriform sinus
Spinal cord
FIGURE 1-20
Trapezius muscle
Internal jugular vein
Spinal cord
FIGURE 1-21
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Tongue base
Masseter muscle
Nasopharynx
Mandible
Lingual tonsil
Maxillary sinus
Oropharynx
Torus tubarius
Medulla oblongata
Internal jugular vein
Internal carotid artery Lateral pterygoid muscle
FIGURE 1-22
Internal carotid artery FIGURE 1-23
Retropharyngeal space
Inferior turbinate
Odontoid Nasopharynx
Lateral pterygoid muscle
Torus tubarius
Tongue
Masseter muscle
Fossa of Rosenmuller Vallecula
Mandible
Internal carotid artery
Mastoid air cells
Mandible
Internal jugular vein
Epiglottis
Cricoid cartilage
Medulla
FIGURE 1-25
Larynx
Subarachnoid space
Esophagus
FIGURE 1-24
Spinal cord
Left vertebral artery
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Masseter muscle
Hard palate
Maxilla
Soft palate
Para pharyngeal space fat
Medial pterygoid muscle
Lingual septum
Mandible
Tongue Uvula Parotid gland
Palatine tonsil
Facial vein Parotid gland External carotid artery
Jugular vein
Internal carotid artery
Faucial tonsil
Longus capitis muscle
Internal jugular vein
Facial vein
Masseter muscle
Odontoid process
FIGURE 1-27
FIGURE 1-26
. Facial vein
Masseter muscle
Tongue
Palatine tonsil
Parotid gland tail
Mandible Tongue
Median glossoepiglottic
fold
Vallecula
Submandibular gland Internal jugular vein
Splenius capitis muscle
Semispinalis cervicis muscle FIGURE 1-28
Internal jugular vein
Vertebral artery
Epiglottis FIGURE 1-29
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Digastric muscle
Epiglottis
Body of mandible
Median glossoepiglottic
fold
Hyoepiglottic ligament
Laryngeal vestibule
Pyriform recess
Submandibular gland
External jugular vein Internal carotid artery
External jugular vein
Vertebral artery
Internal jugular vein
Internal jugular vein
Common carotid artery
FIGURE 1-30
Anterior commissure
Aryepiglottic fold
FIGURE 1-31
True vocal cord
Thyroid gland
Sternocleidomastoid muscle
Trachea
Arytenoid cartilage
/-~
Common carotid artery
I . (.
' .. \-.~,':.-
",
•
.·~.....rr.;•.'. ....• "
"
'.
'.'''''''
..... ~~.
Internal jugular vein
Sternocleidomastoid muscle
FIGURE 1-32
'fJI ..... ~.'~." .
,.~.\..
Common carotid artery
"
.
.
",'
--
".,.-'L .. _
Vertebral artery
FIGURE 1-33
Internal jugular vein Esophagus
SECTIONAl RADIOGRAPHIC ANATOMY AND SCANNING
Sternocleidomastoid muscle
Trachea
Frontal sinus
Thyroid gland
Tongue
Sphenoidal sinus
Optic chiasm Pituitary gland Pons
Internal jugular vein
Cerebellum Clivus Cisterna magna
Esophagus
Nasopharynx Soft palate Spinal cord Epiglottis Subarachnoid space Vallecula Pulmonary apex
Common carotid artery
Medial and posterior scalene muscles
Body of mandible
Buccinator muscle
Trachea
FIGURE 1-35
FIGURE 1-34
Maxillary sinus
Inferior nasal concha
Lateral pterygoid muscle
Lateral rectus muscle
Superior rectus muscle
Superior oblique muscle Ethmoidal sinus
Medial pterygoid muscle
Optic nerve Medial rectus muscle
Internal carotid artery
Maxillary sinus Middle nasal turbinate
Levator scapulae muscle
Inferior nasal turbinate
Jugular vein
Mandible
Submandibular gland
FIGURE 1-36
Inferior rectus muscle
Tongue
FIGURE 1-37
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Torus tubarius
Sphenoidal sinus
Lateral pterygoid muscle
Lateral pterygoid muscle
Optic chiasm
Internal carotid artery, cavernous portion Trigeminal cistern Foramen ovale Nasopharynx Medial pterygoid muscle Uvula Oropharynx Epiglottis Submandibular gland Hypopharynx Aryepiglottic fold
Masseter muscle Nasopharynx Medial pterygoid muscle Tongue
Mandible
Epiglottis
Trachea
Submandibular gland
FIGURE 1-38
Internal carotid artery
Lateral mass of C1
Trigeminal nerve
Parotid gland Odontoid process Longus capitis muscle
C4-5 intervertebral disc
Sternocleidomastoid muscle
FIGURE 1-40
Trachea
Cricoid cartilage
Thyroid cartilage
FIGURE 1-39
Internal jugular vein
C4 vertebral body
Arytenoid cartilage
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
ADVANCED TECHNIQUES FOR CT IN THE HEAD AND NECK (See Figs. 1-41 to 1-50) Ronald A. Alberico and Ahmed Abdehalim
Many aspects of modern medicine change rapidly over time as we continually revise and relearn our specialties in an effort to improve patient care. Few areas have changed as rapidly in recent years as diagnostic imaging. This revolution in imaging technology has been driven by faster more powerful computers and equipment, enabling us to obtain more information faster and more accurately than ever before. As a consequence of this change, variations in practice techniques occur regionally and even locally depending on the equipment available to the radiologists and the skill of the radiologists using that equipment. Controversy also exists as to the preferred technique of imaging the head and neck: MRI or CT. While we will leave those arguments to the scientific literature, it should be stated that the two modalities outperform each other in certain specific areas and when appropriate we make efforts to point out which study is preferred for a given application.
The Role of Imaging in the Head and Neck Patients presenting for head and neck imaging studies generally have a specific clinical symptom or finding on examination requiring evaluation. Our goal as head and neck radiologists is to allow the clinician to evaluate the source of findings on physical examination and to define the extent of disease that is occult to the examining physician so that more appropriate therapeutic planning and prognostic determination can be obtained. We hope to obtain sufficient detail about the specific location and imaging characteristics of the lesion
to make an educated guess as to the specific diagnosis. It is very important to maximize the information obtained from the scan by providing the radiologist with all pertinent physical examination findings and the clinical impression. Any postoperative history is also very useful for planning the best imaging technique. As a general rule, suspected lesions of the salivary glands should be evaluated with non enhanced CT followed by enhanced CT. Patients with adenopathy or known head and neck cancer require only enhanced CT whereas thyroid cancer patients may require the use of alternative contrast agents such as gadolinium to avoid an unnecessary iodine load. Communication with the radiologist is the key to getting the most appropriate imaging for your patient the first time. Standard CT evaluation of adenopathy is obtained with section thickness of 2 to 5 mm from the lower orbital rim to the thoracic inlet with intravenous contrast. This approach avoids unnecessary radiation to the lens. Evaluation for head and neck cancer requires inclusion of the skull base so that perineural spread of disease can be assessed at the level of foramen ovale, the pterygopalatine fossa, stylomastoid foramen, and superior jinferior orbital fissure (see Fig. 1-41). Thin sections of 1 tD 2.5 mm will enable detailed evaluation of these small structures routinely as well as routine high-quality multiplanar and three-dimensional reconstructions. We frequently obtain reverse coronal angles through the patients' oropharynx in those patients with dental related artifacts to improve visualization of that area. Using that technique, we occasionally detect the primary tumor in patients with tumors of unknown etiology (see Fig. 1-42). In the following plates we attempt to illustrate the power of modern CT equipment and the details that image reconstruction and post processing can bring to the head and neck surgeon enabling maximum information and planning preoperatively. All images are derived from our daily clinical practice and are made available for surgical planning.
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Detection of Perineural Disease at the Skull Base (Fig. 1-41) In head and neck cancer, malignant cells may spread along the neural sheath. Perineural spread may be asymptomatic, thus the importance of its detection. The cranial nerves most often involved in perineural tumor spread are the trigeminal and facial nerves. The first division of the trigeminal nerve (ophthalmic) with potential tumor carrying from the lacrimal gland, eyelid, and conjunctiva passes through the superior orbital fissure. The second division (maxillary) with connections to the face, palate, and maxillary sinus traverses the pterygopalatine fossa and the foramen rotundum. The third division (mandibular), which can carry tumor from the lower face, oral cavity, and submandibular and parotid glands passes through the foramen ovale. The facial nerve passes through the stylomastoid foramen.
There are several findings on CT that suggest perineural spread, including destruction of neural foramina, loss of the normal fat pad adjacent to a foramen, excessive enhancement within the neural foramina, and excessive abnormal enhancement or widening of the cavernous sinus, pterygopalatine fossa, or Meckel's cave.
A An axialcontrast medium-enhanced CT scan shows tumor in the left pterygopalatine fossa (arrow). Note the normal fat pad in the contralateral side (asterisk).
B Coronal contrast medium-enhanced CT shows intracranial tumor extension into the left Meckel's cave and cavernous sinus (arrows). Again note the normal fat pad in the contralateral side (asterisk).
A
B FIGURE 1-41
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Oblique Imaging of the Oral Pharynx to Avoid Dental Artifact (Fig. 1-42)
B An artifact results from this patient's dental hardware.
All imaging of the head and neck requires thoughtful input on the part of the radiologist to maximize available information.
C, D A simple adjustment of the scan angle reveals the mass in the left oropharyngeal wall and soft palate in this patient (arrows in D). This additional scan plane is only needed if dental hardware severely limits views of the oropharynx and soft palate.
extensive
A A standard CT scan of the neck for cancer evaluation is shown. The lines are parallel to the scan plane.
B
A
c
D FIGURE 1-42
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Multiplanar Techniques to Evaluate Tumor Location and Margins (Fig. 1-43)
A Axial section shows a mass in the medial canthus 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 localization of tumor margins and may give clues to their origin.
B An enlarged left nasal lacrimal duct (arrow) is evident at the level of the petrous carotid arteries (G).
A
B FIGURE 1-43
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Multiplanar Techniques to Evaluate Tumor Location and Margins (Continued) (Fig. 1-43)
C, D Same findings shown in sagittal (C) and coronal (D) reformatted images. A, Lacrimal sac mass; B, nasal lacrimal duct extension of the mass; C, sphenoidal sinus; D, frontal sinus. E The patient's surface anatomy and skin are seen in this volume-rendered three-dimensional model (arrows).
c
E FIGURE 1--43 Continued
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Three-Dimensional CT of the Inner Ear (Fig. 1-44) To emphasize the detail possible with multidetector scanning, the following two images were created from a standard multidetector scan of the temporal bone. Note the ability to rotate the image and add or subtract structures. Note also the posterior ampullar nerve (curved arrow), a structure measuring less than 1 mm in diameter!
A A base view of the left inner ear structure (membranous labyrinth). A, Cochlea; B, internal auditory canal; C, lateral semicircular canal; D, posterior semicircular canal; E, superior semicircular canal. Arrow indicates posterior ampullar nerve. B Lateral view of the left inner and middle ear with ossicles and facial nerve. A, Cochlea; C, lateral semicircular canal; D, posterior semicircular canal; E, superior semicircular canal; F, malleus; G, incus; h, stapes; I, facial nerve.
A
B FIGURE 1--44
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Contrast Medium-Enhanced Resolution CT (Fig. 1-45)
Hlgh-
pyramidal eminence; G, facial recess.
The addition of contrast material to rapidly acquired high-resolution CT can provide detailed views of vascular anatomy that rival conventional angiography.
A Presented is an axial section of a contrast medium-enhanced high-resolution image of the temporal bone and skull base. A, Petrous carotid artery; B, foramen ovale (short arrow: accessory meningeal artery); C, foramen spinosum (long arrow: middle meningeal artery); D, temporal mandibular joint; E,
F, common
crus of the labyrinth;
B A three-dimensional lateral volume-rendered image of the temporal and sphenoid bones is shown without vessels. A, External auditory canal; B, mastoid process; C, styloid process; D, pterygoid plate; E, pterygopala-. tine fossa (arrow: stylomastoid foramen). C A three-dimensional lateral volume-rendered image of the temporal and sphenoid bones is shown with vessels. A, Maxillary artery; B, superficial temporal artery; C, occipital artery; D, middle meningeal artery. Arrow indicates foramen spinosum.
A FIGURE 1-45
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
c
B FIGURE 1--45 Continued
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
CT Angiography of the Neck: Venous Malformation With Traumatic Arteriovenous Fistula (Fig. 1-46) The usefulness of very rapid imaging with thin sections reconstructed into three-dimensional volume-rendered images has been fully evaluated in the literature over the past decade. These techniques can assess vascular structures directly to evaluate stenosis, aneurysms, malformations, and injuries. Risk to the patient is negligible, and information is comparable to that obtained from conventional angiography. CT angiography, although requiring intravenous contrast material and some radiation exposure, is less susceptible to artifacts than MR angiography and frequently provides more detailed vascular images. It is our preferred choice for noninvasive vascular imaging in the head and neck.
A Axial CT angiographic hyoid bone demonstrates
image at the level of the that the venous malfor-
mation enhances more slowly than the artery. A, Common carotid artery; B, internal jugular vein; C, enhancing venous malformation (arrow: superior thyroidal artery); D, external jugular vein; E, hyoid bone; F, unenhanced portion of the'large venous malformation. A sagittal reformatted image of the CT angiogram in A is shown. A, Venous malformation; B, internal jugular vein; C, malformation draining into the jugular vein; D, common carotid artery. B
C Three-dimensional volume rendering of the CT angiogram in B is presented with the veins removed. A, Common carotid artery; B, internal carotid artery; C, external carotid artery; D, lingual artery; E, facial artery; F,occipital artery; G, distal external carotid artery; H, superior thyroidal artery; I, vertebral artery. D Three-dimensional volume-rendered CT angiogram is presented with veins in place, A, Venous malformation (arrows: superior thyroidal artery runs in a ventral groove in the malformation); B, internal jugular vein; C, connection between malformation and jugular vein.
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
A
B
c
D FIGURE 1--46
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
CT Venography of Facial Venous Malformation (Fig. 1-47)
transparency to see the lesion while also providing superficial landmarks
Venous malformations
of the face are frequently treated with sclerotherapy and percutaneous embolization. CT venography helps the interventionist target these lesions.
A Three-dimensional volume rendering of the skin helps target the lesion (arrows) by providing enough
B Three-dimensional volume-rendered CT venogram has increased transparency allowing views of vascular detail and bony landmarks. A, Zygoma; B, facial vein; C, superficial temporal artery; D, external jugular vein (thin arrows: embolic material from previous treatment; thick arrow: residual venous malformation).
B
A FIGURE 1-47
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
CT Angiogram (Fig. 1-48)
of ECA/ICA Bypass
CT angiography demonstrates the anastomosis between the superficial temporal artery and the middle cerebral artery in this patient with previous bypass. Simultaneous display of bone and vessel as well as limitless possible views provide sufficient detail to avoid repeated serial conventional angiography and associated risks.
A Three-dimensional volume-rendered CT angiogram. a, Superficial temporal artery; b, anastomosis between superficial temporal artery and middle cerebral artery (arrows: surgical craniectomy site); c, surgical microplate; d, maxillary artery; e, infraorbital foramen. B Three-dimensional volume-rendered CT angiogram with upper cranium removed. a, Superficial temporal artery; b, anastomosis between superficial temporal artery and middle cerebral artery. C Three-dimensional CT angiogram of intracranial vessels including bypass, bone removed. a, Superficial temporal artery; b, anastomosis between superficial temporal artery and middle cerebral artery; f, vertebral arteries; g, basilar artery; h, posterior cerebral arteries; i, anterior cerebral arteries; j, middle cerebral artery.
A
c
B FIGURE 1--48
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Three-Dimensional CT Vascular Tumor Relationship (Fig. 1-49) Rapidly acquired contrast medium-enhanced CT can be used for mapping tumor vessel relationships both in the neck and the brain. The following images show a large neck mass with its relationship to the carotid arteries and other soft tissues. Any visible structure in the neck can be modeled in this way preoperatively, from a single scan.
A
A This three-dimensional volume rendering of a large squamous cell carcinoma shows neck vessels and bone. A, Left common carotid artery; B, left internal carotid artery; C, left external carotid artery; D, tumor; E, innominate artery; F, right subclavian artery.
B A three-dimensional volume-rendered CT shows vessels and tumor on a soft tissue cut-away view. A, Left common carotid artery; B, left internal carotid artery; C, left external carotid artery' D tumor' G thyroid gland; H, trachea. '" ,
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Endoluminal and Cut-Away View of the Trachea With Medial Deviation of the Carotid Artery (Fig. 1-50)
A Endoscopic view is presented of a contrast medium-enhanced CT of the neck. a, Epiglottis; b, vallecula. Arrows indicate retropharyngeal mass.
The function of the head and neck radiologist is to inform the surgeon of a pathologic process and its relationship to normal structures and to point out potentially dangerous variations from normal. The following images demonstrate a fairly common finding-tortuous carotid arteries and their relationship to the pharynxusing CT-derived endoscopic views. This patient has known malignant adenopathy, but the endoscopic subcutaneous mass does not always represent extension of the tumor.
B This cut-away view of the CT endoscopic image is at the same level as in A. a, Retropharyngeal enhancing mass (carotid artery); b, contralateral carotid artery; c, pyriform sinus. C CT angiographic view is of the same scan as in A and B. Arrows indicate the midline position of the proximal internal carotid artery.
A
B
c FIGURE 1-50
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
It is our hope that the detailed CT scans provided here will begin to inform you of the potential that this rapidly evolving technology has to offer the head and neck surgeon. From detailed anatomic assessment to three-dimensional modeling of tumor/vessel relationships, advances in imaging technology will continue to provide maximum preoperative and perhaps even intraoperative information that will help the surgeon obtain the best possible outcome for each patient.
EXAMPLES OF MRI IN THE SUPERIOR MEDIASTINUM
______________
John M. Lore, Jr.
The following MR images (Figs. 1-51 to 1-57) of the mediastinum demonstrate the importance of viewing this area of anatomy with MRI performed at an up-todate facility. The sagittal views are extremely important 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 confirmed 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
OTHER EXAMPLES OF CT AND MRI John M. Lore, Jr.
Multinodular Goiter in the Mediastinum (Fig. 1-58)
The orthogonal projections afforded by MRI allow the routine and accurate depiction of substernal extension of a thyroid mass. a, Thyroid gland; b, clavicle; c, left innominate vein; d, aortic arch; e, internal jugular vein; f, manubrium; g, trachea.
FIGURE 1-58
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
Paraganglioma (Second Primary Thoracic Chain, T4 by CT Scan)
Metastatic Papillary Carcinoma of the Thyroid (Usual Type) (Fig. 1-60)
(Fig. 1-59)
Axial (transverse) CT scan of the upper thoracic region demonstrates a second primary lesion (1) in pedicle/ lamina/transverse process on the right.
Pathologic lymph nodes (1) in the submandibular region are demonstrated on parasagittal image.
FIGURE 1-59
FIGURE 1-60
SECTIONAL RADIOGRAPHIC
ANATOMY
AND SCANNING
Magnetic Resonance Angiography One problem with the MR "angiogram" is that there are minimal to no landmarks of the exact relationship to the other structures. On the other hand, there is no concern, for example, in the diagnosis of a carotid body paraganglioma, because there is typical splaying of the internal and external carotid arteries.
ULTRASOUND ---------------
David F Hayes
Ultrasound may be the most artful tool in the medical imaging armamentarium. While our quiver is resplendent with elegant tools of electronic wizardry, ultrasound requires the imagination and intuition of the imager like no other imaging modality. To wit, the operator variable in the ultrasound imaging chain is huge. The outcome, the value, and the meaning of an ultrasound test are largely dependent on the skills of the ultrasound technician and the radiologist. That is, notwithstanding all the electronic gadgetry, the importance of the human factor cannot be overstated. This is why ultrasound has such a "bad rap" in some locales and is held to be so valuable in other locales. Stated differently, it simply depends on who is doing the looking.
Example Uses of Ultrasound I. Ultrasound as a diagnostic tool: characterizes texture of a mass (cystic or solid); establishes relationship to other organs, muscles, and vessels in the neck. 2. Ultrasound as an interventional tool: given state-ofthe-art equipment (machine, probes), the experienced imager, with exquisite precision, can place a needle into the neck, avoiding vessels, trachea, and esophagus. The precise placement of the needle is valuable in:
a. Fine-needle aspiration. When the mass is palpable, the needle may be positioned without imaging assistance. If needle location is in doubt, or if the lesion is not palpable, ultrasound-guided needle positioning is the logical tool to objectively establish needle location at the time of sampling. Ultrasound can remove needle location issues from the equation of tissue sample adequacy. The tissue sample may be inadequate or misleading but not because the needle was in the wrong place. b. Diagnostic/therapeutic cyst aspiration. Needle tip can be precisely positioned in the cyst. c. Abscess drainage/sampling. Although percutaneous drainage is not routine treatment, it is a spectacular alternative to surgery for patients who are too sick for exploration or who cannot have or do not want to have surgical drainage. d. Preoperative localization of nonpalpable lesion of interest. Preoperatively with ultrasound, the lesion can be identified and localized with placement of a needle and hooked wire.
Figure 1-61 is an ultrasound image of the thyroid area. The red area is the common carotid artery, and the blue area is the internal jugular vein. Beneath the two of these is a darkened area where the arrow indicates a needle puncture was done, which resulted in 1.5 mL of xanthochromic fluid. Histology was acellular. Just to the left of the common carotid artery is a portion of the left lobe of the thyroid, and slightly below this is an area suggestive of a parathyroid adenoma. This demonstrates the accuracy and safety of doing a fineneedle aspiration in the vicinity of two major vessels without any untoward sequelae. The probable origin of the cyst is the thymus gland, which is juxtaposed to the parathyroid adenoma.
SECTIONAL RADIOGRAPHIC ANATOMY AND SCANNING
FIGURE 1-61
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POSITRON EMISSION TOMOGRAPHY
nitrogen, oxygen, fluorine, or rubidium. These nuclides are extremely short lived. Oxygen-IS and nitrogen-B, used for the measurement of brain or heart blood flow, have half-lives of 2 and 10 minutes, respectively. Carbon11, used for measuring receptor or drug mechanisms, has a half-life of 20 minutes. Fluorine-18, used for measuring glucose utilization by cells, has a half-life of 110 minutes. A special device, usually a cyclotron, is required to produce these radionuclides. Radiochemists then incorporate them into radiotracers using specialized chemical synthetic methods. Once quality control is performed by radiopharmacists, measuring the radiotracer's purity and amount, the radiotracer is shipped to the imaging facility. Although the outside of the PET device looks like a conventional CT scanner, the inner workings are entirely different. Inside are rings of many detectors, which encircle the body. What we are measuring with PET is the simultaneous triggering of detectors on opposite sides of the body. After a positron is emitted from the atom's nucleus, it travels a short distance until it collides with an electron. The mass of both particles is converted into energy. It is this energy, in the form of two Sl1-keV gamma rays traveling 180 degrees opposite to each other, that we are detecting with PET. This simultaneous detector triggering on opposite sides of the body provides to PET better localizing ability and control of the interfering effect from other parts of the body as compared with standard nuclear medicine procedures, such as SPECT. Improved spatial resolution and more accurate quantitation of the radiotracer signal also result. Ultimately, the sensitivity and specificity of PET as a medical diagnostic tool is improved as well. Simultaneously, the radiation dose that a patient receives is of the same order as that received for standard nuclear medicine and radiology tests. It is from the measurement of the radiotracer's behavior in the body that PET can assay organ or
Robert S. Miletich and John M. Lore, Jr. Unlike CT or MRI, which mainly provide images of the internal organs' structural anatomy, positron emission tomography (PET) provides anatomic images of the functional activity of the internal organs (Table 1-2). This revolutionary imaging technique noninvasively supplies an entirely new type of imaging information. Any physiologic process in the body can potentially be measured with PET. Essentially what we are measuring with the PET scanner is the rate, amount, distribution, and localization of uptake in the body of a biologically compatible drug, also called a radiotracer. This drug is usually administered intravenously. It has no clinical effect because the amounts administered are extremely low. Because the radiotracer is similar, if not identical, to endogenous molecules in the body or to therapeutic drugs, its behavior in the body will be similar to the endogenous molecules or drugs that it mimics. By measuring this behavior with the PET scanner, we can assay the physiologic processes that the endogenous molecules or drugs are involved in. These physiologic processes include sugar and oxygen utilization by cells, drug metabolism, organ blood flow and receptor function, and interaction of drugs with their endogenous chemical messengers. Even DNA/RNA metabolism and gene mechanisms can potentially be measured noninvasively with PET. Single-photon emission CT (SPECT) agents, on the other hand, are often bulky molecules that cannot act as true tracers of endogenous compounds. There are four sequential stages in the performance of PET: radioisotope production, radiochemical synthesis of radiotracer, PET scan acquisition, and scan reconstruction/analysis. Unlike nuclear medicine, PET uses radioactive nuclides of elements either endogenous or analogous to those found in the body: carbon,
TABLE l-Z
Comparison of PET with Other Imaging Modalities PET
SPECT
MRI
CT
Measures
Function
Function
Structure
Structure
Spatial Resolution
3.S-7 mm
8-14 mm
0.5-1.0 mm
1.0-1.5 mm
Physical Event
Gamma rays from positron annihilation
Gamma ray emission
Nuclear magnetic resonance
Tissue x-ray absorption
Potential Harmful Effects
Radiation exposure
Radiation exposure
None
Radiation exposure
Cost'
$2000-3000
$500-800
$400-1000
$300-600
"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.
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cellular function. Fluorine-18 incorporated into the radiotracer, fluorodeoxyglucose (FOG), is used to measure how much of the cellular fuel, glucose, is used. This amount is altered by disease. FOG has proved to be very useful in detecting and characterizing cancer.
Role of PET in Oncology FOG-PET is playing an increasingly important role in oncology and is becoming a standard tool in the management of cancer patients. This results from the high diagnostic accuracy of PET in most neoplasms. Warburg and colleagues, in 1930, first demonstrated that cancer cells have higher utilization of glucose than regular cells (Warburg et aI., 1930; Warburg, 1956). This elevated glucose utilization increases with increasing grade of tumor malignancy. As such, FOG-PET has proven utility in the diagnosis, staging, and restaging of cancer and in the evaluation of treatment effects (Gambhir et aI., 2001; Glaspy et aI., 1993; Andrich and Neumann, 1994; Ichiya et aI., 1991; Hoh et aI., 1993). This is also evident in the wide array of indications that have been approved and are under consideration for approval, by the Center for Medicaid and Medicare Services (CMS) and by third party payers for reimbursement. In a comprehensive literature review on upwards of 18,402 patient studies, the average FOG-PET sensitivity and specificity across all oncology indications and applications was 84% and 88%, respectively (Gambhir et aI., 2001). This high diagnostic accuracy translated into an average management change in 30% of patients. FOG-PET not only can characterize the behavior of the primary tumor but also has repeatedly been shown efficacious in identifying unsuspected metastatic disease (Gambhir et aI., 2001; Hoh et al., 1993). Changes of staging from that derived by conventional methods, both upstaging and downstaging, has also been demonstrated. FOG-PET is proving invaluable to the assessment of treatment effects, including surgery, radiation therapy, and chemotherapy (Andrich and Neumann, 1994; Gambhir et aI., 2001; Ichiya et aI., 1991). Positive therapeutic responses, reflected in improved clinical outcomes, are associated with decreases of tumor glucose utilization.
Role of FDG-PET in Head and Neck Cancer There are a number of potential indications for the use of FOG-PET in head and neck cancer. These occur principally in three clinical settings: initial or early presentation; after tumor therapy; and evaluation for possible tumor recurrence during follow-up, usually
associated with either clinical or structural imaging abnormalities. These indications include diagnosis of mass lesion, localization of tumor, tumor grading, staging, evaluation of metastases of unknown origin, assessment of tumor therapy efficacy, distinction of tumor recurrence or necrosis, restaging, and prognostication. Because the principles underlying these indications are similar for all tumors of the head and neck region, further discussion focuses on the two most common head and neck cancers: squamous cell carcinomas and thyroid cancer. The published literature has been somewhat inconsistent in the assessment of the utility of FOG-PET in the management of patients with proven or suspected head and neck cancer (Assar et aI., 1999; Chisin, 1999; Keyes et aI., 1997; Myers et aI., 1998; Schechter et aI., 2001). Reasons given for not using PET have included that it has marginal benefit from a high-cost test, that PET has poor anatomic localization as compared with that from CT or MRI, and that it provides little additional information above physical examination and endoscopy. On the other hand, it is rare for patients to have CT or MRI at a single anatomic position. Cost of PET becomes comparable to CT and MRI during a patient's staging work-up (see Table 1-2). Furthermore, in our clinical practice we have witnessed potential diagnostic problems related to questionable FOG uptake and exact localization of uptake. Nevertheless, both of these PET diagnostic conundrums can be corrected or minimized with imaging methodologic changes. The significance of questionable FOG uptake can be made more certain by using two methods. First, much of the PET literature is based on a measurement technique called the standard uptake value (SUV), which is regional activity normalized to injected dose and body mass. In our experience, a more reliable measurement method is one in which lesional activity is normalized to the regional activity of a reference tissue, called relative uptake value (RUV). Second, we have found that measuring the temporal behavior of the FOG uptake of lesions is a helpful discriminator. Both methods facilitate distinguishing neoplasm from inflammatory or desmoplastic changes, the principal differential diagnostic consideration when foci of FOG activity are seen. In terms of anatomic localization, a new generation of PET instrumentation allowing near-simultaneous PET with CT or MRI and their spatial co-registration is appearing in clinical practice. Even without this capability, however, anatomic localization of FOG uptake is achievable by cross-correlation of FOG uptake (from emission PET) with tissue density images (from transmission PET). Both sets of data are routinely obtained during a PET scan session. These low-grade CTs (i.e., transmission scan images) provide sufficient contrast to ascertain compartmental and geometric position within the head
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RADIOGRAPHIC ANATOMY AND SCANNING
TABLE1-3 FDG-PETin Head and Neck Cancer· Sensitivity Indication
from Gambhir
Accuracy
(%)
No. Patients
PET
CT
PET
CT
PET
CT
298 591 360 511 169
93 87 88 93 84
66 62 69 54 60
70 89 83 83 95
56 73 85 74 39
87 88 88 87 96
58 67 73 65 54
Diagnosis Staging Diagnosis/staging Recurrence Treatment response 'Key data extracted 1S-93S, 2001.
Specificity (%)
(%)
ss.
Czernin
J, Schwimmer
J, et al: A tabulated
and neck region, as well as elsewhere in the body. These simple methods correct many of the problems leveled at PET but unfortunately are currently employed by few PET facilities. The criticisms against the use of PET listed earlier have been applied to the initial or early clinical presentation. Most authors agree on the utility of FOG-PET in the post-therapy setting. However, when the findings of multiple publications are collated together, FOG-PET appears to have applicability in each of the three clinical settings listed earlier. Gambhir and associates have published a landmark paper that provides a tabulated summary of FOG-PET patient studies published from 1993 to 2000 (Gambhir et a!., 2001). FOG-PET had high sensitivity and specificity and resulting diagnostic accuracy in all three clinical settings of diagnosis/ staging, treatment response, and recurrence/restaging (Table 1-3). The utility of FOG-PET is reflected in the impact PET had on patient management. Both for diagnosis and staging and for recurrence or restaging, FOG-PET had a 33% management change effect based on IS patient studies. Although it is true that physical examination with endoscopic examination accompanied by CT/MRI is likely to adequately diagnose and stage many patients presenting with head and neck tumors, often these findings may be equivocal or indeterminate. It is in this situation that FOG-PET can be of benefit. The differential diagnosis of lesions identified by these diagnostic methods can be narrowed by characterizing their metabolic attributes. Inflammatory lesions, such as reactive lymphadenopathy, can be distinguished from neoplasm based on FOG uptake characteristics. Size and distribution of the primary neoplasm and local nodal and remote metastatic spread are the most important staging, and thus prognostic, factors for head and neck cancers. Nodal involvement is particularly important, with the S-year survival of patients with node disease less than half that of those without nodal tumor spread
summary
of the FOG PET literature.
J Nucl Med 42:
(Myers et aI., 1998). The increased concentration of FOG by cancer cells facilitates definitive diagnosis of suspected nodal metastases and detection of unsuspected nodal metastases (Fig. 1-62). FOG-PET can dramatically alter patient management by the detection of remote disease. Although metastatic involvement of the thorax can be seen with squamous cell carcinoma of head and neck origin, if metastases are present it is typically local or regional disease. However, for other types of cancer involving the head and neck, including lymph node metastases, lymphoma, and more rare tumors, there often is disease in other body regions. FOG-PET is particularly useful in staging because imaging can easily be performed in the same session not only of the head and neck region but typically also of the thorax as well as more rostral and caudal aspects of the body. Detection of remote metastatic disease is particularly important in thyroid carcinoma either in the neck or to the lungs or bone (Fig. 1-63). With metastatic thyroid cancer, scans with iodine-131 often show no or equivocal uptake. The primary histologic types where this occurs is with tall cell papillary carcinomas and Hiirthle cell carcinomas, as well as with anaplastic carcinomas. FOG-PETcan be particularly useful in these cases in identifying iodine non-avid metastases. Cancer often presents itself as metastases of unknown origin (MUD). Asymptomatic cervical adenopathy in patients older than 40 is often either lymphoma or carcinoma. Controversy exists in the literature on the utility of FOG-PET for head and neck MUD (Greven et a!., 1999; Jungehulsing et a!., 2000; Keyes et a!., 1997; Stokkel et a!., 1999), despite its documented ability to identify the primary tumor (Bohuslavizki et a!., 2000). Because FOG-PET is performed as a whole body scan, its ability to find additional unknown and unsuspected metastatic sites is important in the definition of the total body tumor burden (Lonneux and Reffad, 2001) (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 threedimensional 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.
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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, nonsmall 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 number of metastatic sites has been shown to be a major prognostic variable (Le Chevalier et aI., 1988; Nieder et aI., 2001). Given that conventional work-up methods for MUO are often unsuccessful and costly, PET may help target subgroups of patients for the most appropriate treatment (Hainsworth and Greco, 1993; Schapira and Jarrett, 1995). 1t is with treatment response evaluation that PET may have its most unique impact. By measuring cellular metabolism, PET is essentially measuring the biologic behavior of the tumor. Effective therapy, manifested with decreased tumor cell number or decreased cellular activity, will be reflected in decreased FOG uptake. These changes can occur in the total absence of any structural changes within the tumor bed. Thus, the diagnostic accuracy for FOG-PET is near perfect, whereas CT showed an accuracy little better than a flip of the coin (see Treatment Response in Table 1-3). This ability to accurately gauge treatment response is seen with radiation therapy (Peng et aI., 2001; Stokkel et aI., 1998) (Fig. 1-65), chemotherapy (Haberkorn et aI., 1993), or combined radiochemotherapy (Gambhir et aI., 2001) (Fig. 1-66). Evaluation for the presence of recurrent disease is a major element in the follow-up of patients who, at least
initially, have been successfully treated for head and neck cancer. In this post-therapy setting, distortion of normal architecture and scarring by surgery and radiation therapy confounds physical examination and endoscopy and limits the accuracy of structural imaging with CT and MRI (Chisin, 1999). FOG-PET has a very high, 93 %, sensitivity for recurrence detection, in contrast to 54% for CT (see Table 1-3). 1t is in this setting that all authors agree as to the utility of FOG-PET (Fig. 1-67). The published results for the diagnosis and staging of thyroid cancer have been slightly less impressive than those for head and neck squamous cell carcinomas, with an overall diagnostic accuracy of 84% (Gambhir et aI., 2001). However, in the context of disease recurrence and restaging, FOG-PET is proving to be of considerable value in thyroid cancer. Based on 601 patients, FOG-PET had a sensitivity of 77%, specificity of 91%, and an overall diagnostic accuracy of 86 %. This results in a highly significant management change effect of 53 %. Thus, the indications for which FOG-PET can play a key role in thyroid cancer are in assessment of recurrences, therapeutic effects, and staging, particularly of tumors with low avidity for iodine-131, and in detecting remote metastatic disease. An inherent property of measuring the biologic 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 consistent 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
A
POl 046
Lateral
B
P0194l
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 (Chisin, 1999). Although this capability has not been used to any great extent in oncology for body cancers, it has been known since the early 1980s for primary brain tumors (Di Chiro et a!., 1982; Di Chiro and Fulham, 1993). This ability to grade tumors is used in our daily clinical practice for assisting neuro-oncologists in the management of their patients. The capability of grading tumors and determining proliferative activity does exist for head and neck tumors (Minn et aI., 1988). Prognostication directly flows from grading and staging information (Minn et al., 1997; Patronas et al., 1985). Patient management must be rationally designed for each individual patient based on the array of diagnostic and prognostic information available.
Conclusion FDG-PET is a functional imaging modality in which the regional concentration of FDG provides an index of glucose utilization. Because neoplasm has heightened glucose utilization, FDG-PET has many uses in the management of head and neck cancer patients. There are indications for its use in three different clinical settings: initial presentation/early work-up; after therapy to assess treatment response; and during follow-up for detection of disease recurrence. The indications for FDG-PET include diagnosis of mass lesion, localization of tumor, tumor grading, staging, evaluation of metastases of unknown origin, assessment of tumor therapy efficacy, distinction of tumor recurrence or necrosis, restaging, and prognostication. The diagnostic accuracy of FDG-PET has been recognized by the CMS and other third party payers, with authorization for payment for the diagnosis, staging, and restaging of head and neck cancer. Thyroid cancer is currently in evaluation for clinical reimbursement by the CMS. In the future, the capability of FDG-PET of grading neoplasms and in prognostication may play a greater role in the management of head and neck cancer patients.
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patients
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primary carcinoma. Arch Intern Med 155:2050-2054, 1995. Schechter NR, Gillenwater AM, Byers RM, et al: Can positron emission tomography improve the quality of care for head-and-neck cancer patients? [Review] Int J Radiat Oncol Bioi Phys 51:4-9, 2001. Shulman HS, Noyek AM, Steinhardt MI: CT of the larynx. J Otolaryngol 11:395-406, 1982. Som P: The present controversy over the imaging method of choice for evaluating the soft tissues of the neck. Am J Neuroradiol 18: 1869-1872,1997. Som P, Curtin H, Mancuso A: An imaging-based classification for the cervical nodes designed as an adjunct to recent clinically based nodal classifications. Arch Otolaryngol Head Neck Surg 125:388-396, 1999. Som PM, Sacher M, Stollman AL: Common tumors of the parapharyngeal space: refined imaging diagnosis. Radiology 169:81-85, 1988. Som PE, et al: Tumors of the parapharyngeal space and upper neck: MR imaging characteristics. Radiology 164:823-829, 1987. Stokkel MP, Terhaard CH, Hordijk GJ, van Rijk PP: The detection of unknown primary tumors in patients with cervical metastases by dual-head positron emission tomography. Oral Oncol 35:390-394, 1999. Stokkel MP, Terhaard CH, Mertens 11, et al: Fluorine-18-FDG detection of laryngeal cancer post radiotherapy using dual-head coincidence imaging. J Nucl Med 39:1385-1387, 1998. Warburg 0: On the origin of cancer cells. Science 123:309-314,1956. Warburg 0, Wind F, Neglers E: On the metabolism of tumors in the body. In Warburg 0 (ed): Metabolism in Tumors. London, Constable, 1930, pp 254-270. Williams L: Advanced concepts in the imaging of perineural spread of tumor to the trigeminal nerve. Topics Magn Reson Imaging 10:376-383, 1999. Woodruff W Jr, Yeates A, McLendon R: Perineural tumor extension to the cavernous sinus from superficial facial carcinoma: CT manifestations. Radiology 161:395-399, 1986.
2
EMERGENCY PROCEDURES
VENOUS AIR EMBOLISM ----------------
John Lauria
Venous air embolism can occur whenever a vein is opened and the pressure within the vein is negative relative to atmospheric pressure. The presence of subatmospheric pressure in the vein causes air to be entrained and carried to the right atrium. The relative negative pressure will be enhanced in the head-up position, whenever the opened vein is elevated above the level of the right atrium, and in conditions of low central venous pressure, as in hypovolemia. Although small quantities of air may be dissipated in the lungs with no effect on the circulation, larger quantities of air may prevent proper circulation to the alveoli, causing an effective increase in the physiologic dead space. This may manifest by decreasing end-tidal carbon dioxide levels and hypoxia. Larger quantities of air may accumulate in the outflow tract of the right ventricle and effectively block it, because of the heart's inability to pump a compressible medium. When this occurs, severe hypotension accompanied by a marked increase in central venous pressure and hypoxemia will develop. Unless immediate corrective measures are taken, cardiac arrest will soon follow. A venous air embolism is best avoided by eliminating positioning factors that may contribute to it and using meticulous surgical technique. Diagnosis depends on a high index of suspicion and attention to changes in the expired carbon dioxide levels. In the case of massive air embolism a distinct change in the heart sounds may be heard, the so-called mill wheel murmur. A properly placed and calibrated Doppler device may detect small quantities of air. The early changes in carbon dioxide are probably most noteworthy because the continuous monitoring of Doppler sounds may be impractical. Transesophageal echocardiography can also detect air in the heart. Highpoints
Treatment of massive embolism causing circulatory failure must be rapidly instituted. I. The patient must be returned to the level of slightly head-down position, preferably left side down.
2. External cardiac massage must be started if extremely low or no blood pressure is obtained. 3. The patient must be ventilated with 100% oxygen. 4. The circulation must be supported by the administration of fluids and the appropriate vasopressors. Although it is commonly taught that the patient should be turned with the left side down while slightly head down to allow the air to rise to the apex of the right ventricle to relieve the outflow tract obstruction, care should be taken that this maneuver does not prevent effective external cardiac massage. Wellmanaged external cardiac massage may be effective in moving the air. If a central venous catheter is in place, air may be aspirated from it. Performance of head and neck surgery in which a significant probability of air embolism exists should warrant the preoperative placement of a central venous catheter capable of being flow directed into the right ventricle for use both diagnostically and therapeutically (Yee et aI., 1983).
MALIGNANT ----------------
HYPERTHERMIA John Lauria
Malignant hyperthermia (MH) may present as an emergency usually during or soon after the induction of anesthesia. The anesthetics most commonly associated with this condition are the halogenated hydrocarbons, such as halothane, and the muscle relaxant succinylcholine. Although the incidence of MH is low, if it is not treated properly the effects of it are so devastating that every surgeon and every operating suite should be prepared to prevent, diagnose, and treat this condition. Prevention depends on obtaining a reliable history from the patient or the family. The basis of this disorder is a genetically inherited trait that is autosomal dominant. In families in which it exists there may be a high level of awareness and information concerning successful treatment and prevention protocols. In the absence of a positive family history, any history of an untoward event occurring during an operative procedure leading to cardiac arrest in a family member should be investigated for the characteristic signs of MH.
65
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The diagnosis and successful treatment of MH require that every patient be monitored to determine his or her oxygen saturation, exhaled carbon dioxide levels, and temperature. Because the characteristic feature of an MH reaction is a hypermetabolic response to the offending agent, tachycardia, increasing expired carbon dioxide, and decreasing oxygen saturation occur early. The development of an elevated temperature may be delayed until the problem is well developed, and the absence of fever in the presence of other signs should not delay treatment. Spasm of the masseter muscles after administration of succinylcholine should alert one immediately to the possibility that the patient is susceptible to the development of MH. The surgical care of patients who are known to be MH susceptible can be safely accomplished by avoiding the known triggering agents: the halogenated inhalation agents and succinylcholine. The prophylactic administration of dantrolene may also be advised. A presurgical consultation with an anesthesiologist familiar with MH is certainly warranted. Highpoints
1. When MH presents unexpectedly during a surgical procedure the procedure should be terminated as soon as possible. 2. The administration of any halogenated anesthetic must be terminated immediately. 3. Intravenous access if not established previously should be accomplished by whatever route is immediately available. 4. Hyperventilation with 100% oxygen should be started immediately. 5. Intravenous fluids including sodium bicarbonate must be administered as soon as possible. 6. Measures to cool the patient must be instituted. 7. Dantrolene must be immediately available in the operating suite along with all of the necessary items to prepare it for administration. A large placard displaying the treatment protocol should be present in each operating room. Dantrolene must be administered according to the protocol. 8. After resolution of the initial crisis, the patient must be followed closely in a fully monitored setting for at least 24 hours.
Other Untoward Events Associated With Endotracheal Anesthesia The following complications endotracheal anesthesia:
may also occur with
I. Dislocation of arytenoid cartilage may mimic vocal cord paralysis (see Chapter 20).
2. An endotracheal tube inserted in the right mainstem bronchus can have a fatal outcome if not recognized and corrected. 3. Insertion of an esophageal cardiac monitor without care may perforate Zenker's diverticulum.
BLINDNESS AND OPHTHALMIC COMPLICATIONS OF SURGERY OF THE HEAD AND NECK Daniel P. Schaefer and Arthur J. Schaefer Periocular, facial, sinus, and cranial surgeries are commonly performed for the treatment of infections, neoplasms, cosmesis, and other conditions. Generally these procedures are relatively safe, but serious ocular complications may and do occur. Comprehensive and detailed knowledge of orbital, periorbital, nasal, and sinus anatomy and of the pathophysiology of complications is mandatory for a complete understanding of the mechanisms of injury, the significance of clinical findings, and the main way to prevent and treat these complications. In addition, meticulous surgical technique is essential to minimizing these potential surgical complications. Combined teams of ophthalmology, otolaryngology, and/or neurosurgery often facilitate surgery. Because of the proximity of the orbits to the nose and paranasal sinus cavities, ophthalmic complications may occur in association with sinonasal surgery. These include infection, hemorrhage, epiphora, diplopia, ptosis, eyelid defects, nasolacrimal duct obstruction, visual compromise, or even the devastating ocular complication of a complete and permanent loss of vision. The orbital structures at greatest risk are those structures closest to the area that is being operated on. The reported incidence of orbital complications secondary to sinus surgeries varies from 2.8 % to 47%.
Blindness Blindness, whenever it occurs, is an obvious calamity. When it is iatrogenic it becomes such a serious sequela of any surgical procedure that the axiom primum non nocere is most pungent. Therefore, care must be taken even while prepping the patient. Accidental exposure to solutions such as Hibiclens has resulted in a permanent decrease in vision, owing to its corneal toxicity. Hibiclens will cause corneal epithelial defects or corneal edema that may take more than 6 months to resolve or may progress to a bullous keratopathy, corneal opacification, vascularization, thinning, or ectasia, which may require a corneal transplant.
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Operations that have been complicated by blindness are too numerous to present a complete list here. Fortunately, these are infrequent occurrences. Some of the surgical procedures that may be associated with blindness include the following: 1. Ethmoidal surgical procedures, especially those injuring the lamina papyracea 2. Endoscopic sinus surgery 3. Reduction of fractures involving the periorbital region 4. Surgical procedures involving the contents of the orbit: a. Lacrimal gland resection b. Any intraorbital tumor resection c. Release of entrapped intraocular muscles 5. Blepharoplasty 6. Ligation of ethmoidal vessels for epistaxis 7. Simultaneous or staged radical neck dissection (very rare, but it can occur) Table 2-1 lists numerous mechanisms that can lead to blindness or a loss of vision as a result of surgery. These causes are obviously overlapping, but the main reason for blindness appears to be the interruption of the blood supply to the optic nerve. Treatment is initiated as soon as possible to lower the intraocular pressure, and to restore the posterior ciliary artery circulation. Mannitol, acetazolamide, topical antiglaucoma medications, and high-dose steroids are administered when indicated. Hypotension, anemia, and other abnormal systemic conditions must be corrected. If there is orbital swelling, hemorrhage, or proptosis creating a "tight orbit,"
TABLE 2-1 Mechanisms Leading to Vision Impairment After Surgery
a lateral canthotomy and cantholysis of the inferior crus and, occasionally, the superior crus, and of the lateral canthal tendon is performed. Treatment is as follows, especially when there is proptosis and a tight orbit, which is evident by a marked increased resistance to retropulsion of the globe: 1. Remove sutures if present, open the wound, evaculate the clot, and obtain hemostasis. 2. If the first step is not successful, a lateral canthotomy and then a cantholysis of the superior and inferior crus of the lateral canthus is required. 3. If the second step is not successful, a decompression of the bony orbit can be done. 4. For intermediate cases, treat as follows: a. 500 mg of acetazolamide and/or I to 1.5 g/kg body weight delivered at 3 to 5 mL/min of 20% mannitol intravenously, or 1 to 1.5 g/kg body weight of glycerol orally if not considering general anesthesia. b. head elevation, steroids, and intermittent ice applications. Optic Nerve Injury
Direct injury or damage to the optic nerve has little in the way of promising treatment. These complications must be avoided through meticulous knowledge of the anatomic variations in the relationship between the optic nerves and ethmoidal sinus. Chronic infection and inflammation makes recognition of the anatomy in this area difficult, and thickened mucosa, polyps, scar tissue, and hemorrhage add to the problem. Even polypectomies can result in orbital injury. Orbital Walls and Soft Tissue Damage
--'-
1. Hemorrhage into the orbit 2. Compressionof the optic nerve and its vascular supply from various causes 3. Stretchingor shearing forces to the optic nerve 4. Optic nerve ischemia 5. Packing the maxillaryantrum with oxidized cellulose 6. Frontal sinus irrigation 7. Any sinus surgery that violates the orbital walls (e.g., an antral trocar that is directed superiorly) 8. Inappropriate or no ocular protection for the patient (and also the operating room personnel) when using the various lasers 9. Sustained intraoperative or postoperative pressure on the eye 10. Microembolism 11. Pulmonary venous gas emboli with the use of neodymium:yttrium-aluminum-garnet(Nd:YAG) laser for endobronchial lesion 12. Severeedema of face and neck
Frontal sinus surgery can lead to injury of the superior oblique muscle, tendon, and trochlea or even to the fourth cranial nerve. Even extensive manipulation of the orbital fat around these structures can result in postoperative scar tissue formation and restriction. When the orbital wall is violated, this can result in entrapment of muscle and orbital tissue. For the extraocular muscle to be involved, orbital contents must be pulled, cut, or torn, which will result in complications secondary to the direct effect on the muscle, causing more scarring and reaction than that seen with traumatic orbital fractures. The creation of a larger defect of the orbital walls can result in enophthalmos. A most frustrating complication to the patient and the physician is ocular motility problems. Persistent diplopia can be extremely disabling, and treatment can be very frustrating. Transient diplopia can result from multiple causes, including orbital hemorrhage or orbital fractures, or secondary to postoperative swelling and infections. Permanent ocular motility problems may
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result from direct muscle or nerve injury, orbital fractures with entrapment, and postoperative scarring. It may take up to 6 months for some transient motility complications to resolve. It is important to determine if there is significant restriction secondary to scarring by performing forced adduction testing. When restriction is significant, exploration of the muscle with possible lysis of the cicatricial tissue is indicated. When paralysis is significant, the correction should be performed using the standard techniques. Injuries of the orbital floor should be treated similar to traumatic orbital floor fractures. Often these patients are not referred to someone familiar with proper treatment until weeks after the injury and the opportunity for an early and possibly more successful repair may be lost. If the patient is examined months after the injury, it may be difficult to differentiate between the scarring, entrapment, or injury secondary to muscle injury. Direct laceration or damage to the extraocular muscle itself may result in much more severe scar tissue formation and restriction than entrapment does. Orbital Hematoma
Another mechanism that can cause a loss of VISIOn during ethmoidal surgery is orbital hematoma or hemorrhage, which needs to be managed with urgent control of the hemorrhage. Severe periocular and orbital edema and hematomas may occur if adequate hemostasis is not obtained during surgery, clotting mechanisms are impaired, the patient has a severe coughing spell, or the patient performs a Valsalva maneuver postoperatively. If the hematoma is localized in the lid, it can often be drained through the incision or through a small stab incision with a No. 11 Bard-Parker blade. If the hematoma dissects into the orbit, intraorbital pressure can be increased as a result of the edema or hemorrhage, which may be sufficient to produce an orbital compartment syndrome. The increased orbital pressure extrinsic to the globe produces a compression of the optic nerve and the vessels supplying the nerve and globe. This can compromise vision from compression of the optic nerve and the vascular supply to the globe. If an orbital hematoma occurs in a patient who has had a tight pressure dressing applied, the risk of loss of vision is greater owing to the increased orbital pressure that is generated in this confined space. Severe postoperative pain should alert the surgeon to the possible development of an orbital hematoma or hemorrhage, corneal abrasion, or a glaucoma attack. Pressure bandages should be avoided, owing to the possibility of masking and/or augmenting the effects of orbital hemorrhage, because this can add to the intraorbital tissue pressure, obscure lid and conjunctival signs of retrobulbar bleeding, and hinder the monitoring of pupillary reactions.
As described previously, treatment is initiated as soon as possible to lower the intraocular pressure and restore the posterior ciliary artery circulation. The use of mannitol, acetazolamide, topical antiglaucoma medications, and high doses of corticosteroids should be administered when indicated. The correction of hypotension, anemia, and other abnormal systemic conditions must be performed. If orbital swelling, hemorrhage, or proptosis creates a "tight orbit," which is evident by a marked increased resistance to retropulsion of the globe, then surgical intervention is indicated. The optimal period of time in which to observe the patients under treatment and the time window in which successful surgical treatment may be performed are unknown. No light perception vision is not necessarily a contraindication but is actually an indication for aggressive medical and surgical treatment. One must never hesitate to take the appropriate steps to preserve the sight of the affected eye. Most orbital hemorrhages after blepharoplasty or eyelid procedures are caused by bleeding from vessels within the orbital fat or from diffuse bleeding of the orbicularis muscle. Hemostasis must be achieved intraoperatively but will not eliminate the possibility of late hemorrhage. Traction on the orbital fat should be avoided to decrease this complication from occurring. Patients should be instructed to call immediately if they develop pain, proptosis, or visual loss, especially in the early postoperative period. Treatment of a postblepharoplasty orbital hemorrhage is an ophthalmologic emergency. Decompression of the hemorrhage is the most effective means of eliminating the orbital compartment syndrome (see Highpoints). Corticosteroids and osmotic and ocular hypotensive agents are not effective as primary therapy. If the orbital pressure is not extremely severe, and there are no signs of visual impairment (e.g., decreased visual acuity or pupillary defects), temporizing measures may be instituted (e.g., ice, prednisone, head elevation, intermittent pressure). If the patient develops any signs of visual compromise or progression of the hematoma or hemorrhage, or when the increased orbital pressure compromises the globe or optic nerve, then emergency measures are required to reduce the orbital pressure (see Highpoints). Heroic measures must be instituted at the first sign of any progressive hematoma or hemorrhage, reduced vision, pupillary defects, or sign of a central artery occlusion. Highpoints
Table 2-2 describes surgical intervention. Paracentesis of the eye has been advocated by some as a treatment of visual loss secondary to an orbital hematoma or hemorrhage, but we do not recommend this because the pathogenic mechanism that must be
EMERGENCY PROCEDURES
SurgkallnterventioB for the 'D'eatment of Orbitallf;A IKI'hap . TABLE Z-Z
1. Removesutures if present, open the wound, evacuate the clot, and obtain hemostasis. 2. If not successful, then a lateral canthotomy and then a cantholysis of the superior and inferior crus of the lateral canthal tendon should be performed. 3. If not successful, then a decompression of the bony orbit, through a combined lateral and inferior approach, should be performed to preserve vision (this treatment is rarely needed). For intermediate cases: a. 500 mg of acetazolamide and/or 1 to 1.5 g/kg body weight delivered at 3 to 5 mL/min of 20% mannitol intravenously,or 1 to 1.5 g/kg body weight of glycerolorally if not considering general anesthesia. b. head elevation, steroids, and intermittent ice applications. corrected in these extreme situations is the elevated orbital pressure not the intraocular pressure. If a globe that is under intense orbital pressure is opened, or an anterior chamber tap is performed, this may cause a loss of the intraocular contents. Ischemic Optic Neuropathy
Unilateral or bilateral blindness may occur secondary to anterior or posterior ischemic optic neuropathy. This devastating event can occur with ophthalmic, head and neck, cardiothoracic, or even general surgical procedures. Factors predisposing to it include anemia, hemorrhage, hypotension, arteriosclerosis or small vessel disease, carotid and/or vertebral stenosis or occlusion, and factors that increase the intraocular pressure (see Table 2-1). The posterior ciliary arteries, branches of the ophthalmic artery, supply the optic nerve head in a "watershed fashion." Circulation in the optic nerve head is dependent on the difference between perfusion pressure of the posterior ciliary arteries and the intraocular pressure. Therefore, anything that causes a decrease in perfusion pressure to the optic nerve head can be categorized into local vascular factors, including stenosis, occlusion, or spasm of the posterior ciliary, ophthalmic, or carotid arteries. Systemic factors that influence the perfusion of the optic nerve include atherosclerotic vascular disease, temporal arteritis, hypertension, hypotension, diabetes, migraine, collagen vascular disease, emboli, or hemorrhage. The factors that can increase the intraocular pressure include glaucoma and increased concentration of carbon dioxide in expired lung gases, which also increase the central venous pressure. Hypothermia decreases cerebral blood flow and increases blood viscosity, which may cause ischemia in the posterior ciliary arteries.
Hypotension becomes more critical when combined with factors such as anemia, excessive fluid replacement, and individual variations in the neural microvascular pattern, leading to a higher incidence of hypoperfusion of the optic nerve's capillary bed. An optic neuropathy may also result from tractional stretching of the optic nerve, ischemia of the optic nerve caused by torsion, traction, interruption of the small nutrient vessels to the optic nerve, or repeated abrupt elevations in intraocular pressure, as from excessive retraction of the globe during surgery, vasospasm of the central retinal artery and/or posterior ciliary artery, or postoperative orbital edema or hemorrhage. Close postoperative monitoring of visual acuity, pupillary responses, color vision, intraocular pressure, and retinal perfusion is imperative. A compromise of the retinal perfusion can be evaluated on funduscopic examination. If there are spontaneous pulsations of the retinal arteries or these are easily induced with minimal additional pressure on the globe, then there is inadequate perfusion pressure to open vascular channels during diastole. Transient perfusion occurs only during systole. Perfusion compromise can arise from elevated intraocular and/or intraorbital pressure. Central retinal artery occlusion can be identified by the characteristic narrowing or box-carring of vessels, edematous whitening of the retina, and appearance of a foveal cherry-red spot where the thin overlying retina does not obscure the normal coloration of the choroid to the extent that the edematous retina does elsewhere. Venous "Congestion"
Blindness is an infrequent but devastating complication of simultaneous bilateral neck dissections. The resection or ligation of both internal jugular veins increases the risk factor for blindness, as does venous congestion or ischemia caused by local compression or central hypotension. The ligation of the internal jugular vein may cause venous hypertension and increased intracerebral and cerebrospinal fluid pressure, leading to papilledema. The increased intraorbital pressure may lead to a reduced drainage of the orbital venous plexus into the ophthalmic vein and a reduced flow in the pial venous plexus in the optic nerve sheaths. Orbital Injections Perforation of the globe or injections into the optic nerve or nerve sheath, during the administration of local anesthesia, is a rare occurrence; but it is more likely to occur when one uses a long (38-mm) sharp needle, especially if a protective contact lens was not placed. Improper insertion angle of the needle and
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highly myopic eyes (anteroposterior axis greater than 24 mm) can increase the incidence of globe perforations during orbital injections. Scleral perforations due to injection can manifest with immediate ocular pain, intraocular hemorrhage, restlessness, or hypotony of the globe. The planned surgery should be discontinued immediately and the patient evaluated by a vitreoretinal surgeon. In children, care should always be taken to avoid the development of amblyopia (deprivational amblyopia). Prolonged occlusion of the eye (secondary to patching or swelling of the periocular structures and eyelids), induced paralysis of one or more extraocular muscles, or even the development of secondary cataracts may lead to a severe amblyopia, especially in children younger than 5 years of age. Complications of orbital decompression surgery for thyroid-related orbitopathy are infrequent but can be serious. Postoperative hemorrhage, infection, exacerbation of Graves' inflammatory reactions, and damage of the infraorbital nerve and artery or the nasolacrimal drainage system are generally avoided with good visualization and knowledge of the anatomy. Contraction scarring or keloid formation may result from skin incisions, and fistulas may develop with mucosal approaches. Comprehensive and meticulous knowledge of orbital, periorbital, nasal, and sinus anatomy and the pathophysiology is mandatory for a complete understanding of the mechanisms of injury, the significance of clinical findings, and the main way to prevent and manage complications.
CARDIOPULMONARY RESUSCITATION
ventricular arrhythmias, and the prompt initiation of rhythm and oximetry monitoring. The two components of emergency cardiac care are basic life support (BLS)and advanced cardiac life support (ACLS).Cardiopulmonary resuscitation (CPR) is an integral part of both. BLS is intended to prevent inadequate or arrested circulation or respiration and to provide cardiorespiratory support of the arrested patient through CPR. ACLSincludes BLSplus the use of adjunctive equipment to support ventilation (e.g., intubation, the establishment of intravenous access), the administration of drugs, cardiac monitoring, and arrhythmia control including defibrillation and the arrangement of care after resuscitation. In a patient with cardiorespiratory arrest, if CPR is initiated within 4 minutes, and ACLS including defibrillation where appropriate is initiated within 4 minutes thereafter, the chances of full recovery are excellent. If CPR is initiated after 6 minutes, brain damage will almost always occur.
Sequence of BLS (Fig. 2-1) When faced with an unresponsive patient an orderly sequence of steps should be followed. CPR should not be initiated until a proper assessment has been made and the need for resuscitation established. Unresponsiveness should first be established, followed by the determination of breathlessness, and pulselessness, the so-called ABC sequence of BLS (Airway, Breathing, Circulation).
A Gently tap or shake the patient to determine unresponsiveness and call for help if there is no response. William M. Morris
Emergency Cardiac Care Emergency cardiac care includes all responses necessary to deal with sudden and frequently lifethreatening events affecting the cardiovascular and pulmonary systems and often leading to cardiorespiratory arrest. The most common events are malignant ventricular arrhythmias, including ventricular fibrillation caused by myocardial ischemia or infarction due to underlying coronary artery disease. However, other catastrophic events may be the cause. These events are frequently initiated by respiratory arrest followed by full cardiopulmonary arrest. In the surgical patient these include upper airway obstruction, drug intoxication, including sedative narcotics or anesthesia, chest trauma, pneumothorax, or stroke. Prompt recognition of these events and resuscitation frequently is life saving. Emergency cardiac care involves both recognizing the early warning signs, especially signs of hypoxemia, chest pain, or electrocardiographic (ECG) changes including
B Place the patient supine and open the airway using the head tilt/chin lift maneuver. Assess for the presence of spontaneous breathing by placing your ear over the mouth and nose, to feel or hear the flow of air while observing the chest for movement (3 to 5 seconds). If breathing is not detected, two breaths should be given, mouth to mouth or mouth to mask. Ifventilation is unsuccessful despite head repositioning, airway obstruction is likely. The airway should be cleared using a finger sweep maneuver or by direct visualization and foreign body removal using a clamp or forceps if available. Ventilation should then be reinitiated at a rate of 10 to 12 breaths per minute. C, C1 Palpate the carotid artery for a pulse (5 to 10 seconds). If pulse is present, continue ventilation. D If pulse is absent, begin chest compressions. The patient should be supine on a firm surface with a backboard if necessary. The heel of one hand should be placed over the lower one half of the sternum, with
EMERGENCY PROCEDURES
the long axis of the heel parallel to the long axis of the sternum. The other hand should be placed parallel over the first. The shoulders should be positioned directly over the sternum and the elbows locked and the finger kept off the chest. The sternum should be depressed 1.5 to 2 inches with each compression. With two rescuers, one breath should be administered for every five compressions, and with one, two breaths after each 15 compressions. Chest compressions should be maintained at a rate of 80 to 100 per minute.
The rescuer providing ventilation should check the carotid pulse periodically for adequacy of compression and pause every 1 to 2 minutes for spontaneous return of pulse. If pulse is restored, spontaneous ventilation should be assessedand ventilatory support continued if necessary. ACLS measures should be initiated as soon as effective CPR has been established and ACLS-trained personnel arrive.
A. Determine Unresponsiveness
B. Determining Breathlessness
C. Determining Pulselessness
D. Chest Compression FIGURE 2-1
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PROCEDURES
For a more detailed review, please refer to Basic Life by the American Heart Association. Formal BLS and ACLS training are strongly encouraged.
Support for Health Care Providers, published
Closed Cardiac Massage There is little doubt that closed cardiac massage is just as effective-maybe more so-as open cardiac massage. The exceptions in which open cardiac massage may be indicated are outlined in the following section.
Open Cardiac Massage Resuscitation (Fig. 2-2) The supportive measures for open cardiac massage are the same as those for closed cardiac massage resuscitation.
Indications • Patient in operating room undergoing open thoracotomy • Patient with severe chest injury • Cardiac tamponade • Massive intrathoracic hemorrhage • Possibly in postoperative patient having had an open thoracotomy or median sternotomy
Technique A An inframammary incision is made. This will be in the region of the fourth or fifth interspace. Clamping vessels at this stage is unnecessary.
B The pleural cavity is immediately entered, exposing the pericardium medially and the lung laterally. C If a suitable rib retractor is available, it is used to open the thoracotomy incision farther. A triangular wedge of wood is satisfactory. Using fingers of both hands, begin compression. The rate of massage is between 45 and 60 beats per minute. Pressure by the thumb is to be avoided because rupture of the heart muscle may occur. Adequate time is allowed for the filling phase of the heart. From time to time the massage is interrupted to observe whether the heartbeat has returned. D If preferred, the pericardium may be opened longitudinally and the massage continued from within the pericardial sac. Injury to cardiac muscle and coronary vessels should be avoided. E After resuscitation, the wound is inspected for bleeding, especially from the internal mammary and intercostal vessels. A large catheter is inserted through a dependent intercostal space near the anterior axillary line and connected to an underwater drainage bottle. Pericostal sutures of 1-0 chromic catgut in double strands are inserted, avoiding the intercostal neurovascular bundle, and the lung is expanded by positive pressure. F If available, a rib approximator is used while the intercostal sutures are tied. The intercostal muscles may be approximated with either interrupted or continuous sutures. The remainder of the wound is closed in layers. The catheter is secured with an encircling suture of 2-0 silk. G The underwater drainage bottle is kept below the level of the patient and on return to the recovery room it is secured to the floor (see Fig. 2-5A).
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FIGURE 2-2
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Thoracentesis (Fig. 2-3A and B) Indications • Rapid decompression of a pneumothorax pneumothorax • Aspiration of intrapleural fluid • Diagnosis
or tension
Selected Etiologic Factors of Pneumothorax Relative to Head and Neck Surgery I. Puncture of the mediastinal pleura, for example: a. Median sternotomy b. Tracheostomy, particularly associated with severe coughing during and after the procedure-this complication may be minimized by use of a local anesthetic (10% cocaine, 4% lidocaine, or 2% tetracaine) injected into the tracheal lumen with a SIB-inch 2S-gauge needle to facilitate topical anesthesia. Air is first withdrawn from the trachea to be sure that the needle is in the tracheal lumen. 2. Puncture of the apical pleura: a. Neck dissection b. Any surgery in the vicinity of the clavicle Highpoints 1. Insert needle at upper border of selected rib. 2. Use second anterior interspace for pneumothorax. 3. Use seventh or eighth interspace at posterior axillary line for intrapleural fluid or place according to radiographic localization. 4. In pneumothorax a single aspiration may suffice, but it is usually safer to replace the needle with an intercostal catheter connected to underwater drainage. This is mandatory in a tension pneumothorax or persistent air leak. If a large leak is present, as evidenced by almost continual bubbling of air through the underwater seal bottle, two or more large catheters may be necessary, each connected to a separate set of underwater drainage bottles. 5. When a tension pneumothorax associated with severe respiratory distress exists, it may be lifesaving to insert any type of needle, knife, or sharp instrument into the chest without syringe or any other equipment. A For pneumothorax or tension pneumothorax the patient is preferably placed in a supine position. A 15to 18-gauge needle is inserted in the second anterior
interspace (X) along the midclavicular line. This location will avoid the internal mammary vessels. If the patient is in acute distress and sitting in an upright position, it is better not to have the patient lie down. The needle is guided along the superior edge of the third rib to avoid the intercostal vessels. In an emergency, no anesthesia is necessary; if time permits, local anesthesia is used intradermally with infiltration down to the parietal pleural level. For aspiration of fluid, the sitting position at the side of the bed resting over a bed stand elevated to breast height is ideal. The site of insertion of the needle depends on the radiographic findings; however, the classic location is through the seventh or eighth interspace at the posterior axillary line. B A 20- or 50-mL syringe with an interposed threeway stopcock is ideal. Rubber tubing or a catheter may be connected to the stopcock if a hydrothorax is present. This facilitates removal of the fluid. In a tension pneumothorax, the barrel of the syringe may be pushed out by the increased intrathoracic pressure. When the proper depth of insertion is reached, a straight hemostat immediately clamps the needle at the skin surface, preventing the needle from going any farther into the intrapleural space.
Insertion of Intercostal Catheter (See Fig. 2-3C to J) Indications • Prolonged underwater drainage • In an emergency tension pneumothorax equipment is not available
when other
Highpoints The high points of this procedure listed under Thoracentesis.
are similar to those
C A No. 11 blade knife is inserted in the selected interspace hugging the superior edge of the rib to avoid the neurovascular intercostal bundle. D With a curved Kelly clamp, the incision is widened both horizontally and vertically. Continued
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FIGURE 2-3
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PROCEDURES
Insertion of Intercostal Catheter (Continued) (See Fig. 2-3C to J)
H As the cannula inserted.
E Using the Kelly clamp as a guide in the stab wound, a multi-holed No. 26 to No. 30 French plain rubber catheter is inserted in the thoracic cavity. A straight hemostat is used to grasp the catheter and passit in through the stab wound. F Silk sutures are used to close the stab wound tightly and are wound snugly around the catheter to help hold it in place. A small dressing of petrolatum and plain gauze with supporting adhesive completes the dressing. The catheter is unclamped after it is connected to the tubing from the underwater drainage system (see Fig. 2-5). G When a large-bore trocar with cannula is available, an intercostal catheter is easily inserted. The technique is similar to the method described in the previous plate. The trocar is kept close to the superior border of the rib. A clamp is placed on the catheter before insertion.
IS
withdrawn, the catheter is
I After a sufficient length of the catheter has been inserted-at least until all the holes are within the thoracic cavity-the trocar is gradually removed. When the catheter is visible at the skin margin, a clamp grasps the catheter to prevent it from being withdrawn. After the trocar is completely removed, the catheter is connected to the underwater drainage system, as shown in Figure 2-5. In infants and children similar results can be achieved by inserting plastic tubing through the lumen of a large-bore needle that has been inserted into the pleural space. The needle can then be removed by withdrawing it along the tubing. Such smaller tubing, however, may become plugged.
J
Minithoracentesis: Pictured is a simple selfcontained intercostal catheter with an attached needle (after Algird, 1966).
FIGURE2-3 Continued
EMERGENCY PROCEDURES
J FIGURE 2-3 Continued
EMERGENCY
PROCEDURES
Open Thoracotomy for Empyema Drainage (Fig. 2-4) Although thick, purulent empyema of the pleural space is uncommon after head and neck surgery, when this complication does occur, open thoracotomy is necessary. Rarely, it may follow deep abscesses of the neck that extend into the mediastinum and then perforate into one or both pleural cavities. Perforation of the esophagus causing mediastinitis may likewise cause empyema and, in addition to drainage of the mediastinum (see Fig. 21-4), open thoracotomy then becomes necessary. Highpoints
1. Local anesthesia can be used. 2. The most dependent point should be drained. 3. A section of rib is resected to make a large opening in the pleura. 4. The neurovascular bundle is resected. S. An underwater drainage system is not used. A An incision is made over the selected rib, removing about a 6-cm section of the rib (see
Fig. 21-12E to H). An elliptical incision is then made in the posterior periosteum and pleura, removing a portion of the periosteum and pleura and making an opening that is larger than would seem necessary, because there is a marked tendency for the wound to close too rapidly. It is likewise recommended to excise the dependent neurovascular bundle to minimize pain and delayed hemorrhage resulting from pressure of the drainage tubes. B One or two large (1.0 to 1.5 cm in diameter) rubber or plastic tubes with multiple holes are then inserted into the empyemic cavity for drainage. Sutures are either passed through or tied securely around the tubes to prevent their loss in the pleural cavity. Frequent changes of dressings are necessary. If the pus is thick, the qlbes may be irrigated with saline and changed as necessary. As the cavity becomes smaller, the tubes are replaced by a catheter and drainage is continued until the cavity has a volume capacity of less than 5 mL. Prolonged drainage is usually the case and premature removal is to be avoided.
EMERGENCY PROCEDURES
A
B FIGURE 2-4
EMERGENCY PROCEDURES
Intercostal Catheter Suction Drainage With Underwater Seals (Fig. 2-5) To facilitate sealed chest drainage, a variety of devices are available, which eliminates the cumbersome multiple drainage bottles depicted. Yet, it is worthwhile to describe the older multiple bottle technique if these devices are not available and also to aid in the understanding of the basic mechanical principles involved. Highpoints 1. Be certain nursing personnel understand the following: a. Bottles are not elevated or removed from floor. b. Bottle stoppers are not removed. c. Fluid is not emptied. d. Tubing is not disconnected. e. All connections and stoppers are taped securely. 2. Tubing should be "milked" from time to time to prevent plugging. 3. Kinks and loops in tubing and catheter should be avoided.
A The intercostal catheter, No. 26 to No. 30 French with multiple holes, is usually connected to a single bottle, which acts as a water seal and drainage bottle. The bottle is securely taped to the floor. This arrangement usually suffices for the minor pleural leaks complicating head and neck surgery. The long glass tube extends 1 to 2 cm below the level of the water, acting as a water seal so that air will not be sucked back into the thoracic cavity. Bubbling of air out through the tube into the water indicates that the pleural leak is still present. The water column in the glass tube should rise and fall with respirations whether there is a pleural leak or not. If it does not, it indicates that the tubing is plugged. The catheter is removed 24 hours after there is no further evidence of air leak or evidence of significant drainage. A large curved clamp is kept in a conspicuous location for emergency clamping of the catheter close to the chest in the event of accidental break in the system.
B A three-bottle system connected to a source of suction facilitates more rapid expansion of the lung when there is a known or persistent air leak. In such cases two intercostal tubes are used, one being placed upward toward the apex, where it is secured to the parietal pleura. Each tube is then connected to separate underwater sealed bottles. Bottle 1 collects any fluid draining from the thoracic cavity and serves as a measure for this drainage. This bottle should be emptied only by the physician and then only when the intercostal catheter is clamped. Bottle 2 serves as the underwater seal and prevents the patient from sucking air back into the pleural space if the suction fails. It also indicates the presence or absence of a pleural leak by the presence or absence of bubbling. The long glass tube is 1 to 2 cm below water level. Bottle 3 is the negative pressure control bottle. By adjusting the depth of the long tube in the water, the amount of negative pressure is controlled. Using 8 to 10 cm of water is ideal. The normal intrapleural negative pressure is -8 to -15 cm of water, and if necessary, the negative pressure in bottle 3 may be increased to -15 cm of water. The source of suction can be any pump or apparatus or wall suction that is able to make the air tube bubble in bottle 3 even though the source of suction is much more powerful. Bottle 3 adjusts it exactly. C In the event a three-holed stopper is not available, this arrangement using a Y connector duplicates the physical principles of bottle 3. The only drawback is the danger of kinking of the tubing. The principles outlined under the use of a single bottle system apply to the three-bottle system, including the indications for discontinuance. D Pictured is the Pleur-Evac device for self-contained sealed underwater chest drainage, which replaces the previously described bottle system. Note: It is important to review the detailed description of the Pleur-Evac on the package insert.
EMERGENCY PROCEDURES
FROM PATIENT
D FIGURE 2-5
EMERGENCY
PROCEDURES
Cricothyroidotomy
(Fig. 2-6)
Highpoints 1. Procedure is utilized in emergency glottic or supraglottic airway obstruction or electively by some thoracic surgeons after midline sternotomy, when there may be an associated airway problem. Next to intubation, this is one of the fastest methods of establishing an airway. 2. Obstruction must be ascertained to be above the level of the cricoid cartilage. 3. Either a horizontal or vertical skin incision is made, with the former preferred. 4. A midline separation of strap muscles is done. 5. A horizontal incision is made through the cricothyroid membrane. 6. Bleeding may occur from the cricothyroid artery, which is a branch of the superior thyroid artery. 7. Conversion to a standard tracheostomy is done as soon as possible except when the procedure is used electively, in which case the tube should be removed as soon as possible, within a maximum of 5 to 7 days. Antibiotics should accompany the cricothyroidotomy during this period of time.
Comment Although this procedure was condemned by Chevalier Jackson in the early 1900s because of related complications of chondritis and glottic and subglottic stenosis, the procedure is justifiable and very useful. When reviewing Jackson's original articles, it becomes apparent that the procedure was often extended to include an incision through the cricoid and/or thyroid cartilages. These extensions contributed significantly to the complications listed here. In addition, in the early 1900s there was a preponderance of infectious disease causing glottic obstruction. Antibiotics, of course, were not available at that time. The immediate conversion to a standard tracheostomy except in patients with laryngeal trauma has been challenged by some authors (Boyd et aI., 1979), who emphasize that the complications of stenosis occur when the tube is left in place for 1 week.
Complications • Hemorrhage • Chondritis • Subglottic and/or
glottic stenosis
A With the head and neck extended, palpation of the cricothyroid ligament is usually quite easy. It is at this point that the airway is mos't superficial. A short horizontal skin incision is preferred. There is little to be gained by a vertical incision, because vessels can be in horizontal and/or vertical planes. In addition, a vertical incision carried too deeply may involve the cricoid and/or thyroid cartilages. B The anatomy of the cricothyroid membrane with blood vessels that may cause significant bleeding is shown. The arteries are branches of the superior thyroid artery, while the veins drain into superficial thyroid veins and/or the median cervical veins. The exposure depicted is for anatomic purposes; the actual surgical exposure is limited to the immediate area of the cricothyroid membrane. C The sternohyoid muscles may require retraction for additional exposure of the cricothyroid ligament. A horizontal stab incision is made through the ligament with cognizance of the blood vessels. D The stab wound is widened either with a clamp or with a tracheal dilator. The clamp may have to be rotated 90 degrees to separate the cricoid cartilage farther from the thyroid cartilage. Care must be taken not to injure either cartilage or the vocal cords, located superiorly. A standard tracheostomy tube is inserted. The skin edges are loosely approximated. The cricothyroidotomy should be converted as soon as possible to a standard tracheostomy.
Contraindication • Malignant
neoplasm
of larynx
EMERGENCY PROCEDURES
PYRAMIDAL LOBE
,
CRICOID CART.
~ (IRSTTRACHEAL "
CART.
f
B
FIGURE 2-6
c
EMERGENCY PROCEDURES
Management of Acute Respiratory Emergencies When medical management, including antibiotics with or without corticosteroids, racemic epinephrine mist, and ultrasonic aerosol therapy, fails in the management of acute croup, epiglottitis, and laryngotracheobronchitis, mechanical intervention to establish an emergency airway is necessary. The indication for this kind of intervention is progression of the symptoms characterized by supraclavicular retraction, cyanosis, substernal retraction, and a general picture of increased air hunger. The types of mechanical intervention for the emergency establishment of an airway include: 1. Insertion of an endotracheal tube 2. Placement of a laryngeal-mask airway. The laryngeal mask airway is recommended as the second most desirable way to establish an airway under emergency conditions because it can be successfully inserted at times when endotracheal intubation fails because of anatomically related difficult intubating conditions or the presence of secretions or blood, which make visualization of the glottis difficult. Once it is properly placed it is an efficient means for providing ventilation and may provide a passageway for suctioning and placement of a smaller caliber endotracheal tube (ASA Task Force, 1996). 3. Insertion of a bronchoscope 4. Percutaneous insertion of a large-bore needle into the tracheal lumen 5. Nasotracheal intubation using virtually any type of tubing available, for example, a portion of stethoscope tubing 6. Tracheostomy (see Fig. 19-1) 7. Cricothyroidotomy (see Fig. 2-6) 8. Oropharyngeal airway After the emergency establishment of an airway (if tracheostomy has not already been carried out), a tracheostomy is performed over the endotracheal tube, bronchoscope, percutaneous needle, or nasotracheal tube. If there is any doubt about the presence of any significant amount of retained tracheobronchial secretions or the possibility of a retained foreign body, bronchoscopy is then performed under topical, basal, or general anesthesia. At the same time a careful evaluation of the larynx is done by direct fiberoptic or rigid laryngoscopy. A variation of this generally accepted method involves the continuation of the use of the endotracheal tube without tracheostomy for a number of days in conjunction with antibiotics, corticosteroids, and ultrasonic aerosol therapy. When on a respirator the cuff on the endotracheal tube should usually be adjusted to "minimal leak," thus allowing a small amount of air to
leak by the cuff. This ensures that the cuff is not overinflated and can prevent damage to the tracheal mucosa and possibly the tracheal cartilages. Such complication leads to tracheal stricture and stenosis. It must be emphasized that with this method there exists the inherent possibility of temporary or permanent damage to the vocal cords as well as subglottic stenosis. Problems associated with the care of acute respiratory emergencies in which selective operative intervention is necessary include the following: 1. Pneumothorax, tension and nontension, unilateral and bilateral 2. Airway obstruction from any cause 3. Respiratory arrest and cardiac arrest 4. Tension pneumoperitoneum 5. Mediastinal emphysema 6. Perforated gastroduodenal ulcers in infants leading to tension pneumoperitoneum associated with aerophagia 7. Hemorrhage following neck surgery that compresses the airway (e.g., thyroidectomy). The operative wound must be immediately opened and the larynx examined. 8. Bilateral abductor vocal cord paralysis Emergency Establishment of Airway Airway obstruction and severe hemorrhage are two of the most important and life-threatening emergencies facing the head and neck surgeon. The important facet in the emergency establishment of an airway is to ascertain the location of the obstruction. This can have any of the following locations: 1. 2. 3. 4. 5. 6. 7. 8.
Oral cavity Oropharyngeal Hypopharyngeal Supraglottic-epiglottic or ventricular bands Glottic Subglottic Tracheal Bronchial
It is obvious that the location of the obstruction and the etiology of the obstruction govern the methodology of management. When appropriate, endotracheal intubation through either the oral or the nasal route or use of a nasal oropharyngeal airway is usually the fastest. Nasal intubation can be achieved "blindly" with any available tube having the correct diameter (e.g., a relatively stiff section of stethoscope tube inserted with the head and neck extended). The next method is the placement of a laryngeal-mask airway for supraglottic and glottic obstruction. Other methods are bronchoscopy and the percutaneous insertion of a large-bore needle into the trachea. To discuss this entire problem and
EMERGENCY PROCEDURES
method of management would be a treatise in itself. The previous figures depict cricothyroidotomy, which is a very rapid and satisfactory method for establishing an airway when the obstruction is located at the glottic level or above. A number of instruments are available that are useful for a cricothyroidotomy and can be carried by any physician in the shirt or coat pocket. "Anterior cricoid split" in infants and children to avoid tracheostomy after extubation has been reported by Holinger and colleagues (1987) as well as Cotton and co-workers with a 77 % success rate (1980). An anterior incision is made through the thyroid cartilage commencing 2 mm distal to the thyroid notch and then through the cricoid cartilage and the first and second tracheal rings. A wedge of thyroid cartilage can then be inserted at the site of the split in the cricoid cartilage. When airway obstruction is associated with possible cervical spine injury, either secondary to trauma or congenital osseous defects (e.g., Hallermann-Streiff syndrome), any procedure that involves hyperextension of the cervical spine must be avoided. Hence, the types of mechanical intervention as listed earlier that could be used are Nos. 3 to 8. BIBLIOGRAPHY Algird JR: A technique for thoracentesis utilizing a disposable catheter unit. Cancer 19:281-283, 1966. American Heart Association: Basic Life Support for Health Care Providers. Dallas, American Heart Association, 1994. ASA Task Force on Management of the Difficult Airway: Practice Guidelines for management of the difficult airway and the ASA difficult airway algorithm. Anesthesiology 84:688-699, 1996. Borja AR, Lansing AM: Technique of selective pulmonary embolectomy without bypass. Surg Gynecol Obstet 130:1073-1076, 1970. Boyd D, Romita MC, Conlan AA, et al: A clinical evaluation of cricothyroidotomy. Surg Gynecol Obstet 149:365, 1979. Brantigan CO, Grow JB Sr: Cricothyroidotomy: Elective use in respiratory problems requiring tracheotomy. J Thorac Cardiovasc Surg 71:72,1976. Britt BA, Kalow W: Malignant hyperthermia: A statistical review. Can Anesth Soc J 17:293-315, 1970. Carey JS, Mohr PA, Brown RS, Shoemaker WC: Cardiovascular function in hemorrhage,
trauma and sepsis: Determinants
of cardiac
output and cardiac work. Ann 5urg 170:910-921, 1969. Chillar RK, Farbstein M, Ellington DB, et al: Use of right atrial catheter for prolonged
IE support in cancer patients. Cancer Treat Rep 64:
243-246, 1980. Chutkow JG, Sharbough FW, Riley FC: Blindness following simultaneous bilateral neck dissection. Mayo Clin Proc 48:713-717,1973. Cole SL, Corday E: Four-minute limit for cardiac resuscitation.
lAMA
161:1454-1458,1956. Cotton RT,Seid AB: Management of the extubation problem in the premature child: anterior cricoid split as an alternative to tracheotomy.
Ann Otol Rhinol Laryngol 89:508-571, 1980. Fell T, Cheney FW: Prevention of hypoxia during endotracheal
suction.
Ann Surg 174:24-28, 1971. Fischer JE, Turner RH, Herndon JH, Riseborough
EJ: Massive steroid
therapy in severe fat embolism. Surg Gynecol Obstet 132:667-672, 1971. Flanagan JP, Gradisar I, Gross RJ, Kelly TR: Air embolus: A lethal complication of subclavian venipuncture. N EnglJ Med 281:488-489,1969.
Gordon AS, Palich WE, Fletcher EE: Emergency heart-lung resuscitation and external defibrillation. Presented before the Scientific Exhibit at 39th Congress of International Anesthesia Research Society, Washington, DC, March 1965. Greenfield LJ, Bruce TA, Nichols NB: Transvenous pulmonary embolectomy by catheter device. Ann Surg 174:881-886, 1971. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Circulation (Suppl 8) 102:1255-1290,2000. 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 53:721-748,1969. Hayreh ss: Posterior ischemic optic neuropathy. Ophthalmologica 182:29-41, ]981. Holinger LD, Stankiewicz JA, Livingston GL: Anterior cricoid split: The Chicago experience with an alternative to tracheotomy. Laryngoscope 97:19-24,1987. Hybels RL: Venous air embolism in head and neck surgery. Laryngoscope 6:945-954, 1980. Jackson C: High tracheotomy and other errors: The chief causes of chronic laryngeal stenosis. Surg Gynecol Obstet 32:392, 1921. James PM, Myers RT: Central venous pressure monitoring.
Ann Surg
175:693-701, 1972. Johnson J, Kirby CK: Surgery of the Chest, 2nd ed. Chicago, Year Book Medical, 1958. Jude JR, Kouwenhoven WB, Knickerbocker GG: A new approach to cardiac resuscitation. Ann Surg 154:311-319, 1961. Jude JR, Tabbarah HJ: Otolaryngological aspects of cardiac arrest. Ann Otol 79:889, 1970. Kanter MA, Geelhoed GW: How to manage cardiopulmonary arrest. Resident Staff Physician 30:28-36, 1984. Keenan RL, Boyan CP: Cardiac arrest due to anesthesia. JAMA 253:2373-2377,1985. Kiers K, King 10: Increased intracranial pressure following bilateral neck dissection and radiotherapy. Aust NZ J Surg 61:45B-61B, 1991. Kimmelman CP, Weisman RA, Osguthorpe JD: The efficacy and safety of trans antral ethmoidectomy. Laryngoscope 98:1178-1182,1988. Kirimli B, Kampschulte
S, Safar P: Resuscitation
from cardiac arrest
due to exsanguination. Surg Gynecol Obstet 129:89-97, 1969. Kotani J, Nitta K, Sakuma Y, et al: Effects of bilateral jugular vein ligation on intracranial
pressure and cerebrospinal
fluid outflow
resistance in cats. Br J Oral Maxillofac Surg 30:171-173,1992. Kouwenhoven WB, Jude JR, Knickerbocker GG: Closed-chest cardiac massage. JAMA 173:1064-1067, 1960. Lindskog G, Liebow AA: Thoracic Surgery and Related Pathology. New York, Appleton-Century-Crofts, 1953. Lore JM Jr, Gordon SG, Gordon EW: Successful use of hypothermia following cardiac arrest in twelve-day-old infant. NY J Med 60:278-279, 1960. Lucas eE, Ledgerwood
AM: Pulmonary response of massive steroids
in seriously injured patients. Ann Surg 194:256-260, 1981. Lundberg GD, Mattei IR. Davis CJ, Nelson DE: Hemorrhage from gastroesophageal
lacerations
following
closed-chest
cardiac
massage. JAMA 202:195-198,1967. McCabe BF: Hemorrhage in otolaryngologic surgery. Trans Am Acad Ophthalmol Otolaryngol 72:23-24, 1968. McLaughlin JS: Physiologic consideration of hypoxemia in shock and trauma. Ann Surg 173:667-679, 1971. Machiedo GW, Rush SF Jr: Comparison of corticosteroids and prostaglandins in treatment of hemorrhagic shock. Ann Surg
190:735-739,1979. Madden JL: Atlas of Techniques in Surgery. New York, AppletonCentury-Crofts, 1958. Mauney FM Jr, Ebert PA, Sabiston DC Jr: Postoperative myocardial infarction: A study of predisposing
factors, diagnosis and mortality
in a high risk group of surgical patients. Ann Surg 172:497-503. 1970.
EMERGENCY PROCEDURES
Millikan JS, Moore EE, Steiner E, et al: Complications of lube thoracotomy for acute trauma. Am J Surg 140:738-741, 1980. Morain WD: Cricothyroidotomy in head and neck surgery. Plasl Reconstr Surg 6S:424, 1980. Newmark SR, D1uhy RG: Hyperkalemia and hypokalemia. JAMA 231:631-633,1975. Pad berg FT, Ruggerio J, Blackburn GL, Bistrian BR: Central venous catheterization for parenteral nutrition. Ann Surg 193:264-270, 1981. Pappelbaum S, Lang TW, Bazika V, et al: Comparative hemodynamics during open vs. closed cardiac resuscitation. JAMA 193:6S9-662, 1965. Parker MM, Parrillo JE: Septic shock. JAMA 250:3324-3327, ]983. Phinney RB, Mondino BJ, Hofbauer JD, et al: Corneal edema related to accidental Hibiclens exposure. Am J Ophthalmol 106:210, 1988. Pierce WS, Tyers Fa, Waldhausen JA: Effective isolation of a tracheostomy from a median sternotomy wound. J Thorac Cardiovasc Surg 66:34], 1973. Puryear GH, Osborn JJ, Beaumont JO, Gerbode F: The influence of
adjuvant ventilators in the respiratory effort of acutely ill patients. Ann Surg 170:900-909, ] 969. Randall HT: American College of Surgeons Manual of Preoperative and Postoperative Care. Philadelphia, WB Saunders, 1967. Riker WL: Cardiac arrest in infants and children. Pediatr Clin North Am 16:661-669, 1969. Salyer JM: Management of spontaneous pneumothorax or pneumomediastinum in the newborn. Surg Gynecol Obstet 131: 11S-1I6, 1970. Samuel JR, Beaugie A: Effect of carbon dioxide pressure in man during general anesthesia. 58:62-67, 1974.
on the intraocular Br J Ophthalmol
Schechter DC: Role of the humane societies in the history of resuscitation. Surg Gynecol Obstet 129:811-8IS, 1969. Stankiewicz JA: Complications of endoscopic intranasal ethmoidectomy. Laryngoscope 97:1270-]273,1987. Stankiewicz JA: Blindness and intranasal endoscopic ethmoidectomy: Prevention and management. Otolaryngol Head Neck Surg 101:320,1989. Sweeney PJ, Breuer AC, Selhorst lB, et al: Ischemic optic neuropathy: A complication of cardiopulmonary bypass surgery. Neurology 32:S60-563, 1982. Sweet RH: Thoracic Surgery. Philadelphia, WB Saunders, 1950. Thompson OS, Eason CN: Hypoxemia immediately after operation. Am J Surg ]20:649-6S1, ]970. Tisi GM, Twigg HL, Moser KM: Collapse of left lung induced by artificial airway. Lancet 1:791-793, 1968. Trunet P, LeG all JR, Lhoste F, et al: The role of iatrogenic disease in admissions to intensive care. JAMA 244:2617-2620,1980. Twigg HL, Buckley CE: Complications of endotracheal intubation. AJR Am J Roentgenol 109:4S2-454, ] 970. Vernon S: The ideal initial infusion in unexpected shock. Surg Gynecol Obstet 13]:748-749, 1970. Weale FE, Rothwell-Jackson RL: The efficacy of cardiac massage. Lancet 1:990-992, 1962. Yee ES, Verrier ED, Thomas AN: Management of air embolism in blunt and penetrating thoracic trauma. J Thorac Cardiovasc Surg 85:66]-668, ]983. Zimmerman JE: Respiratory failure complicating post-traumatic acute renal failure: Etiology, clinical features and management. Ann Surg 174:12-18, 1971.
3
BASIC CONSIDERATIONS
Needle Biopsy Techniques There are two techniques of needle biopsy: needle aspiration biopsy and core needle biopsy. Needle Aspiration Biopsy Needle aspiration biopsy is a special method of biopsy that is not to be used indiscriminately and hence deserves some clarification of its role. There are basically two types of needle aspiration biopsy: fine-needle aspiration biopsy and large-needle aspiration biopsy. Fine-Needle Aspiration Biopsy
Fine-needle aspiration (used almost exclusively by this author) requires a 22- to 25-gauge needle without a stylet and a small syringe. No anesthetic is used. The aspirant is usually not drawn or is minimally drawn into the syringe unless the mass is cystic. Negative pressure is applied only while the needle is working back and forth at various angles in the mass, and then the needle is withdrawn without negative pressure. Ideally, the specimen is thus retained in the needle. The contents of the needle are then spread on glass slides by first removing the needle from the syringe and filling the syringe with air. This prevents the aspirate from being drawn into the syringe. The slides are fixed and/or air dried, depending on the wishes of the pathologist. At times some blood is aspirated into the syringe. When spreading the material it may well be that the last amount in the syringe has a concentration of the cells in question. Hence, care should be taken when ejecting the last amount of material from the syringe. To remove any residual aspirant in the hub of the needle, use a disposable interdental brush (Sunstar Butler GUM Proxabrush Trav-Ler Model 1614) inserted in the hub and smear on slides. Another technique (described by the French) when the aspirate is blood is to insert the needle a second time with the barrel of the syringe attached but without the plunger. The material is then more likely to be retained in the needle. After the needle and barrel of the syringe are removed from the area aspirated, the plunger is reinserted in the syringe and the material is spread on glass slides. When spreading the materials, spread as one would do a blood smear. The end of the slide is used to spread rather than facing another slide
over the material, which may crush the cells and make it very difficult for the cytologist to identify the characteristic of the cells. When aspirating a thyroid nodule, hyperextension is at times helpful; this is achieved by placing a pillow under the patient's shoulders. Care must be taken to avoid puncturing the great vessels and the trachea. Large-Needle Aspiration Biopsy (See Fig. 3-')
This technique is primarily of historical interest. Largeneedle aspiration uses an IS-gauge needle with a stylet and a large syringe. A small amount of local anesthesia is usually utilized, and a No. 11 blade knife is used to puncture the skin, thereby avoiding withdrawal of any squamous cells from the epidermis or dermis. Negative pressure is applied when working the needle back and forth in the mass. The negative pressure is usually continued as the needle is withdrawn, and the aspirate is collected on the base of the plunger and barrel and then removed with a small "rake" and smeared on the slides. The specimen is primarily in the syringe and possibly in the needle as well. This minimizes the question of implant along the needle tract. Again, the fixation of the slides depends on the wishes of the pathologist. Core Needle Biopsy Core needle biopsy requires, for example, a Silverman needle or Tru-Cut needle. The core is then fixed in formalin and sectioned as a histologic specimen. Silverman needle biopsies and Tru-Cut biopsies in the head and neck are very seldom used and never in any vascular structure, for example, a thyroid gland, unless the lesion is extremely hard and avascular on a fine-needle aspiration. Details of the utilization of the Tru-Cut biopsy technique are supplied by the manufacturer, which is Baxter Healthcare Corporation. Discussion
Various types of needles have been devised as well as various syringe devices. Close cooperation with the concerned pathologist is most important. Some centers have the pathologist present at the time or even have the pathologist perform the actual biopsy. If at all possible, the site of the needle puncture should be in a line of
87
BASIC CONSIDERATIONS
possible surgical excision for the definitive surgery. At times it is worthwhile to mark the needle site with India ink to facilitate excision of the entire needle tract. This is considered mainly when aspirating a lymph node in the neck and not in thyroid aspiration. Success of needle aspiration depends on both the surgeon's and the pathologist's knowing its restrictions and limitations. Only after a complete head and neck examination should it be considered as an aid in determining the nature of the mass in the neck, if its main use is for tumefactions in the neck when metastatic squamous cell carcinoma is suspected, or when a primary lesion cannot be found. A fine-needle aspiration biopsy of the thyroid offers the physician an opportunity to obtain a histologic diagnosis of thyroid pathology but has definite limitations. It is performed with neither special equipment nor local anesthesia and usually permits a prompt interpretation. Its reliability depends on the expertise and competence of the surgeon and cytopathologist. Fine-needle aspiration of thyroid masses that may be difficult to palpate but that appear on a radionuclide iodine thyroid scan and/or a sonogram can be performed by using highresolution ultrasound. This is accomplished with a small transducer placed laterally to the thyroid and directed medially and is a great help not only in locating the mass but also in directing the fine needle. The needle itself may or may not be visible on the screen, but, for example, its deflection of the anterior and posterior walls of a cyst is clearly visible. Ultrasound thyroid imaging is also useful in following the size of the thyroid mass when the patient is on suppression therapy. Limitations of cytologic diagnosis include difficulties in interpretation of follicular lesions and Hiirthle cell lesions and in trying to discriminate between benign and malignant lymphocytic lesions. Fine-needle aspiration of a follicular neoplasm cannot distinguish whether the neoplasm is benign or malignant. The latter diagnosis is based on histologic findings of vascular invasion and capsular invasion. If the fine-needle aspiration of a thyroid mass reveals clear fluid or slightly xanthochromiccolored fluid, then the diagnosis is almost certainly a parathyroid cyst (see section on fine-needle aspiration in Chapter 18). An example of fine-needle aspiration is the difficulty, if not impossibility, of differentiating a micro follicular pattern cytology, whether benign or malignant. Under these circumstances most surgeons would recommend lobectomy, isthmectomy, and frozen section. Well-documented studies indicate the reliability of positive interpretations to be about 95%, whereas negative interpretations are only 75 %. In the final analysis, needle aspiration, if it is utilized, must not be the sole methodology in making the diagnosis but most be correlated with the other clinical and laboratory findings as well as the important facets of the history. It is, however, of distinct value when enlarged cervical lymph nodes accompany a thyroid mass. When aspiration of such
nodes reveals thyroid tissue, the diagnosis of metastatic cancer of the thyroid is virtually certain, realizing the extremely low incidence of normal thyroid tissue in cervicallymph nodes. When aspiration of a lateral cervical lymph node reveals pinkish, dark, or yellowish cystic fluid, or even frank, slightly thickened blood (be sure not in vessel), the surgeon must first think of metastatic carcinoma of the thyroid even though no thyroid mass is palpable. Black or murky aspirants are suggestive of a branchial cleft cyst or metastatic thyroid carcinoma. Murky aspirant with slightly blood-tinged material is suggestive of a necrotized metastatic squamous cell carcinoma. Some surgeons question whether a fine-needle aspiration of the thyroid is indicated when the clinical diagnosis is very suspicious of carcinoma. The patient will likewise question the rationale of fine-needle aspiration under the circumstances. Nevertheless, fine-needle aspiration does serve several purposes, if it is positive for carcinoma: I. Ability to discuss the various aspects of the diagnosis and management of thyroid cancer with the patient and the family and make plans accordingly. On the other hand, some surgeons will say that if the fineneedle aspiration fails to reveal malignant cells, then the patient might defer surgery. If this is so, this may be a serious calamity when the clinical diagnosis points to malignant neoplasm. 2. If fine-needle aspiration is positive for malignant cells, then computed tomographic (CT) scanning and/or magnetic resonance imaging (MRI) of the neck and mediastinum is indicated to further evaluate the presence of cervical lymphadenopathy, which may not be clinically palpable. It also can aid in the differentiation of a solid from a cystic lesion. In lymphoma, needle aspiration usually cannot facilitate a definitive diagnosis (only a suggestion) and open biopsy is necessary. In tumors of the salivary glands, needle aspiration is used only in very selective situations, particularly when a positive diagnosis of a malignant tumor would significantly change the operative approach or if the mass is suspected to be a lymph node. If there is diffuse swelling of a major salivary gland, fine-needle aspiration may yield some diagnostic information (e.g., lymphoepithelial disease [Godwin's disease)). If a chemodectoma is suspected, fine-needle aspiration using a 22- or 25-gauge needle can usually be performed with minimal morbidity. Either frank blood may be obtained or, in fact, a smear with an adequate number of cells will facilitate the diagnosis. Obviously, a pulsatile mass-to be distinguished from transmitted pulsations-should not be aspirated. Apart from needle aspiration, CT with enhancement, magnetic resonance angiography (MRA),
BASIC CONSIDERATIONS
or MRI can lead the clinician to the definitive impression that a paraganglioma is present. These are noninvasive studies and offer a distinct advantage over the arteriogram. However, once CT, MRA, or MRI is positive, a bilateral arteriogram is usually indicated to obtain more detailed anatomy of the vessels. Paraganglioma can be bilateral (see Chapter 22). An acellular or "negative" needle aspiration should not be interpreted as a definitive diagnosis of a nonmalignant lesion. The limitation of fine-needle aspiration biopsy cannot be overemphasized under such circumstances. On the other hand, when it is certain that the aspiration needle is in fact inserted into a mass, and clear material is obtained (not cystic fluid), a lipoma is to be suspected. The cytology report usually states that the material is acellular. A report of an acellular aspirate in a very hard mass may also indicate a neurofibroma or traumatic neuroma (e.g., a small, sometimes tender, movable mass in the region of a transected cervical sensory nerve following a radical neck dissection). These are not to be construed as certain diagnoses but simply suspicious impressions. A not uncommon problem is the palpation of a lymph node overlying and suspected to be fixed to the bifurcation of the carotid artery or the internal carotid artery. If the estimated thickness of the node is close to or over 1 em, then insertion of the fine needle in a horizontal or oblique plane is done to avoid the underlying
vessel. Otherwise the aspiration can be done under sonography because the needle can be seen and thus avoid the vessel. In addition, clearance between the node and the vessel may be visualized with a sonogram. Another application of fine-needle aspiration is aspiration of the lung in conjunction with CT.
Large-Needle Aspiration Biopsy (After Martin, 1934) (Fig. 3-1)
A With a local anesthetic injected into the overlying skin and using a No. 11 blade, a small stab wound is made in the skin directly over the mass. Only the skin is entered, not the mass itself. The stab wound should be placed so that it can easily be included in the standard neck dissection incision if operation becomes necessary. B A large-bore needle (No. 17 is ideal) with stylet is inserted through the stab wound into the mass, with the index finger holding the stylet in place. The purpose of the stab wound and stylet is to facilitate ease of insertion and to avoid picking up cells from the skin and other overlying tissue.
FIGURE 3-1
Continued
BASIC CONSIDERATIONS
Large-Needle Aspiration Biopsy (Continued) (After Martin, 1934) (Fig. 3-1)
C With the stylet in place, the needle is moved back and forth in the mass a few millimeters, first in the same plane as the original insertion and then a few degrees to either side. This step is repeated with the stylet removed. D Negative pressure is then applied with a specially designed locking syringe with a metal plunger similar to those used in the old direct transfusion sets. This is known as a Hayes-Martin needle aspiration syringe and is manufactured with a special locking device to hold the barrel in position to facilitate negative pressure. If this type syringe is not available, an ordinary glass 30-mL syringe can be used. The needle with syringe under negative pressure is again moved back and forth a few times, and then the needle and syringe are briskly removed together. With this technique, the material in the needle is deposited on the end of the barrel of the syringe.
E The aspirate on the barrel of the syringe is spread on one or more slides as a thin film. Any material left in the needle is sprayed out over another slide. The material on the slides is spread thinly, using the same technique as that used in a blood smear. The slides may be either immediately fixed in alcohol and ether or air dried, according to the wishes of the pathologist. If any sizable particles are adherent to the inner wall of the syringe, these are removed with a "rake" or swab, placed on filter paper, and fixed in formalin for block paraffin section. If the pathologic process is malignant, the needle tract and site of puncture (which were marked with India ink) are excised at the time of definitive surgery. If there is any question regarding an inflammatory process, some of the material is sent for culture.
o
E
FIGURE 3-1 Continued
BASIC CONSIDERATIONS
Commonly Used Terminology Squamous Epithelium
for
9. TTF-I: Used to differentiate thyroid and lung tumor from other tumors.
Ashok Koul Metaplasia: Transformation of fully differentiated cells
of one kind into differentiated cells of another kind in response to abnormal stimuli (e.g., columnar epithelimn changing to squamous epithelium due to irritation such as smoking). Leukoplakia: White patch. There is no specific histologic connotation. Causes of leukoplakia in oral cavity are Candida infection, lichen planus (unknown etiology), irritation by dentures, and chewing tobacco or betel nuts. Keratosis: Thickening of squamous epithelium. Three types of keratosis include parakeratosis-thickened keratinized layer with presence of nuclei in the cells; hyperkeratosis-thickened keratinized layer without nuclei with prominent stratum granulosum underneath; and dyskeratosis-distinct alteration of the epidermal cells. Benign dyskeratosis is caused by viral changes from molluscum contagiosum, herpes simplex, and Oarier's disease. Malignant dyskeratosis appears as enlarged nuclei, hyperchromasia, loss of polarity, increased mitosis, and prominent nucleoli. Dysplasia: Change affecting the size, shape, and orientation of epithelial cells caused by chronic irritation of any type. Dysplasia can be mild, moderate, or severe. Atypia or atypism: Abnormal nuclei. They can be seen in inflammatory disease, can be reactive, for example, after repair following trauma or surgery, or can be associated with neoplasms.
Commonly Used Special Stains for Head and Neck Lesions 1. Cytokeratin: Used to stain epithelial cells and to differentiate between epithelial and nonepithelial cells. Also used to detect individual or small groups of metastatic cells in a lymph node that cannot be seen in routine hematoxylin and eosin stain. Helpful in sentinel node of breast. 2. Thyroglobulin: Stains thyroid follicular epithelial cells and can be used to differentiate between metastatic thyroid and nonthyroid carcinoma. 3. Calcitonin: Used to stain for medullary carcinoma. 4. Congo red: Used to stain amyloid in medullary carcinoma. 5. $-100: Used to stain neurogenic lesions and melanomas. 6. HMB-45: Used to stain melanoma. 7. LCA: Used to stain lymphoid cells, thus differentiating lymphoma from undifferentiated carcinoma. 8. Mucin: Used to look for mucin production by a tumor, thus helping in the diagnosis of mucoepidermoid carcinoma.
Mucosal Biopsy: Toluidine Blue Staining Technique Although not specific for invasive squamous cell carcinoma, toluidine blue staining may give some indication relative to the ideal site for biopsy of a clinically dysplastic lesion. False-positive results are common relative to an ulcerative inflammatory lesion. Any ulcerative lesion could stain positive regardless of the etiology. This technique consists of gently cleansing the suspected areas with I % to 2 % acetic acid, staining with topical application of the dye, and then gently cleaning with water and I % or 2 % acetic acid. The suspicious areas, for example, in erythroplasia or dysplasia may stain a very deep blue, indicating the ideal sites to biopsy. If there is negative uptake or minimal staining, the clinical diagnosis overrides the lack of a deep stain. Repeat biopsy or better yet total removal of the suspicious area is indicated.
Exfoliative Technique
Cytology
Biopsy
For the suspicious ulceration in an area where it may be difficult or hazardous to obtain a sufficient excised specimen (e.g., tracheoesophageal ulcerations overlying a pulsating vessel), a small piece of Gelfoam can be used. The Gelfoam is broken, and the broken edge is smeared over the suspicious area. Cytologic slides are made, and the Gelfoam itself can be sent for "cell block." This technique is also used during bronchoscopy (see Fig. 4-3).
Z-Plasty (Fig. 3-2) Definition A Z-plasty is the transposition of two opposing triangular skin flaps, thereby reversing the initial "Z" incision. The central arm of the initial Z is thus rotated, and the distance between points I and 2 is increased (AI and 01). The most useful angle formed by each lateral arm to the central arm is 60 degrees. The central arm corresponds to the scar contracture, which is to be changed in direction, lengthened, and tension released. The length of each lateral arm equals the length of the central arm. Variations in the angle will vary the direction of the resulting central arm and the length gained. An extended description of the Z-plasty follows, because it has wide application in reconstruction procedures in head and neck surgery.
BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2) Technique of Basic Z-Plasty
3.
Highpoints 1. Optimal flap angle is 60 degrees. This will rotate scar or incision 90 degrees (A and Al). 2. Be sure resultant rotated scar is in or in line with the natural skin crease. The base ends of the lateral arms should be in the line of the natural crease (A and Al). 3. Realize effect of changes of flap angle to gain in length of scar line and the degree of rotation of scar line. 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 tip necrosis (points X and Y of A); the larger the flap angle, the more tension on surrounding tissue. 5. Carefully place sutures to avoid strangulation of blood vessels. 6. Each lateral arm should be the same length as the central arm in the classic Z-plasty. 7. As a check for correct planning of the classic Zplasty with 60-degree flap angles, an imaginary line (natural skin crease) connecting the base ends (points XI and yl of Al) of both lateral arms should pass through the midpoint of the central arm. 8. It may be advantageous to have a set of dividers and protractor in the sterile field. Limitations and Complications 1. Dog-ears are likely to form near the base of the transposed flaps. If these require excision, they cannot be excised toward the base but rather away from the base (see Fig. 3-4A to C). 2. When an angle formed by a scar with a natural skin crease is progressively less than 50 degrees, the angle of the tip of the transposed flap of the Z-plasty
4.
5. 6.
becomes less than 30 degrees and hence reduces practicability of the Z-plasty. A word of caution regarding the use of an extensive Z-plasty in the primary closure of a wound for a malignant lesion: Margins must be free of disease for fear of implantation of tumor cells along the transposed flaps. Tip necrosis may occur. Wilkinson and Rybka (1971) have shown experimentally that glue or tapes prevent tip necrosis. Too much lateral tension occurs with larger flaps in tight surrounding tissue. Strangulation of blood supply with suture may occur.
A The scar, web, or linear contracture extends along the line X-V (central arm). An incision or excision of a small amount of skin is made along the line X-YoFrom points X and Y two other incisions (lateral arms), each of equal length to the line X-Yare made to Xl and V', respectively, at a 60-degree angle (flap angle) (range is 30 to 90 degrees). Points Xl and Y' are along the natural skin crease. B The flaps formed by X and Yare widely undermined with extreme care to preserve both arteries and veins. Small skin hooks or fine nylon sutures are used to handle the flaps. Trauma must be minimal. The transposition is begun by rotation of Y to Y'. C X is rotated to X'. Sutures of 5-0 or 6-0 nylon are usually used. These sutures are placed slightly obliquely to relieve tension along central arm after closure. D, D1 Rotation is completed. The scar line (central arm) has been rotated 90 degrees, and the distance between points 1 and 2 has been increased 75%. These geometric figures refer to a flap angle of 60 degrees.
Continued
BASIC CONSIDERATIONS
y'_. BASE END OF LATERAL ARM - LATERAL ARM y' .1
,
x·
",6(1'
,
A1
A
x'
2
~SKIN CREASE 60' ", BASE END OF Y • -X' LATERAL ARM LATERAL ARM
2
FIGURE 3-2
CENTRAL ARM (SCAR)
BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2) E TO G If a parallelogram is outlined around the corners of the Z-plasty, some interesting theoretical measurements are obtained: The short diagonal of the parallelogram before the Z-plasty (which is the length of the scar contracture) between points 1 and 2 in E becomes the long diagonal 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 gained in any classic Z-plasty between points 1 and 2 corresponds to the long diagonal minus the short diagonal (G). Expressed in another way, the total length desired between points 1 and 2 after the Z-plasty can be easily achieved by constructing parallelogram before the Z-plasty whose long diagonal is equal to the final desired length and the direction of the final or resultant central arm. The shaded triangle in E corresponds to one rotated 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.
a
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 rate of increase in the length of the release (McGregor, 1962): • 30-Degree angle yields 25% increase in length. • 45-Degree angle yields 50% increase in length. • 60-Degree angle yields 75% increase in length. H, I The smaller the flap angle, the lower the number of degrees the central arm or "scar" line is rotated. This is important in planning the resultant arm to lie in a natural skin crease (dotted line). Variations of flap angle end in various positions of the resultant central arm, which is the long diagonal of the parallelogram. This demonstrates how a Z-plasty is varied so that the resultant central arm can rest along a natural skin crease. This is further shown in the following steps. Continued
BASIC CONSIDERATIONS
60'
E
B ,< SCAR 2 TO BE EXCISED LENGTH TO BE INCREASED
SHORT DIAGONAL (CENTRAL ~RM)
NATURAL SKIN CREASE
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' G SCAR LINE
I FIGURE 3-2 Continued
...
BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2) J TO L
First select the length of the central arm that may equal the entire length of the scar or a part thereof. If the scar is long, multiple Z-plasties are necessary (see 5 and T). The midpoint of the central arm should lie on the natural skin crease (J), and the base end of each lateral arm must be located on the natural skin crease (K). Each lateral arm is equal in length to the central arm. A protractor can be of aid in the determination of these measurements. L demonstrates the final result. (To achieve a more pleasing result, the lateral arms can be slightly curved.)
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 the tension on the surrounding tissue, with too much borrowing from each side. These larger angles tend to result in larger dog-ears at the base of the triangle. Clinically, a GO-degree flap angle has been shown to be the largest angle that will allow transposition of triangular flaps while achieving the greatest increase of length along the central arm or line of contracture. With this angle the central arm is rotated 90 degrees. As the central arm length is increased, the greater is the percentage increase in length. Depending on the relative 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.
FIGURE 3-2 Continued
BASIC CONSIDERATIONS
o
FIGURE 3-2 Continued
M, N The direction of linear scars or webs or linear contractu res is changed from vertical to horizontal in scars of the neck. The size of the Z-plasty is large for clarity's sake. In actual practice multiple Z-plasties with a long scar are preferred (see Sand T) or a slight curvature of the lateral arms.
0, P Scar across nasolabial fold is converted to lie in and along the natural skin crease of the nasolabial fold.
Continued
BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2) Q I ncrease the length between the ends of the original scar contracture, for example, lengthening of the contracted tissue causing upward distortion of the upper lip. R Release and redistribution of tension along linear contracture breaks up unsightly scars of cheek and thus returns some elasticity, aiding in normal facial expression. This is accomplished either by multiple Zplasties (see Sand T), by opposing Z-plasties (see U and V), or by W-plasty (see X and V).
Types and Modifications Z-Plasty
of
1. Single Z-plasty (M and N). The single or basic Zplasty has multiple applications as previously described. By and large, however, it is limited to relatively short scars. It can be useful in longer scars only when the surrounding tissue is very loose, as, for example, in the neck. 2. Half Z-plasty (Q and R). This is actually a variant of the angles of a basic Z-plasty. It simply means that an increase is made at right angles to a wound into which is transposed one triangular flap (Q). This is useful in the elongation of a wound, especially the short side of a curved defect (R). 3. Multiple Z-plasties (5 and T, 51 and Tl) (Davis and Kitlowski, 1939; Limberg, 1963; Morestin, 1914). Multiple Z-plasties are two or more Z-plasties in either a continuous series or interrupted series, with a number of other modifications. Of necessity the
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 tight or has lost its elasticity. A single Z-plasty in a long scar would be impractical and almost devastating on the cheek. 4. S-plasty (see W) 5. W-plasty (Borges, 1959) (see X and Y)
Continuous Types (Entire Scar Excised) 5 Depicted is a series of continuous Z-plasties in which all the arms are equal, all the angles are 60 degrees, and all the lateral arms are parallel. The entire scar contracture is excised in a continuous line. The lengthening of the scar contracture is obvious. 51 Depicted is a similar type of continuous Z-plasties, except that the lateral arms are independent with a space between each Z. '
Interrupted Types (Portions of Scar Excised) T Depicted is a series of multiple Z-plasties of equal size similar to those in Sl except that intervening portions of the linear scar between each Z are not excised. The length of the remaining portion of the scar varies according to the desired result. T1 This series of interrupted multiple Z-plasties differs from those in T in that two are opposite. These are the so-called opposing Z-plasties. Continued
BASIC CONSIDERATIONS
Q
R
s
T
TI FIGURE 3-2 Continued
BASIC CONSIDERATIONS
Z-Plasty (Continued) (Fig. 3-2) Depicted in steps U and V is an example of the excision and reconstruction of a scar on the side of the cheek. This technique is very useful in upsetting the tension of contractu res, especially on the cheek (after Converse, 1964). U, V
W S-Plasty. The lateral arm of a basic Z-plasty may curve in a convex arc. This aids in preserving the blood supply, especially in burn scars in which the blood supply is compromised. The full application of this modification is in the neck, where a large S-plasty is performed. This is possible because of the laxity of the surrounding tissue.
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 removed. Collagen synthesis is increased in the papillary dermis secondary to fibroblast formation. Myofibroblasts develop. Hair follicles remain the same in structure and number and become separated. Adipose tissue is decreased in thickness, probably permanently. Muscle becomes thinner, but there is no loss of function. Blood vessels proliferate; increased vascularization of the skin with distention of capillaries and an increase in the number of arterioles becomes evident within several days. Because of the dense vascular pattern, viability and survival of expanded tissue is similar to that of delayed flaps. Effects of Tissue Expansion (Cherry et aI., 1983)
Tissue Expansion (See Fig. 3-2Wl) Versaci and Balkovich (1984) reviewed the history of tissue expansion dating back to 1905. The technique was revived by Neumann (1957), and important recent contributions have been made by Radovan (1982, 1984), Austad and associates, (1982), Sasaki and Pans (1984), Argenta and associates (1984), and Kabaker and colleagues (1986). Anatomic Physiology
Tissue expansion permits an increase in the length of a flap as compared with nondelayed random flaps (dermal and subdermal plexus) and improves random flap survival by increasing vascularity. Skin is not simply an elastic membrane but has dynamic properties responding to the tissue expander. This response allows many applications in terms of modifications in flap design, length, and overall size (Sasaki and Pans, 1984). After implantation a dense fibrous capsule develops on the 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
FIGURE 3-2 Continued
BASIC CONSIDERATIONS
A silicon balloon is inserted via a silicon tube to which is attached an injection port. As shown in the photograph (Wl), various sizes and shapes of balloons are available.
at a second stage or (2) utilize short-term expansion (Sasaki) intraoperatively by expanding tissue for reconstruction for a period of 15 to 30 minutes. This technique can facilitate closure of defects of up to 3 or 4 cm without long delay and can minimize the possible complications of infection and prolonged deformity at the donor site. Avoid resection of surplus skin over dead space; these areas usually contract eventually.
Technique
Applications
Anesthesia is usually local plus basal. The incision is made as small as possible, just large enough to insert the empty balloon, alongside or near the tissue to be expanded. Injection ports are kept away from the tissue to be expanded and are buried under the skin by blunt dissection so that they are easily accessible for injection of saline solution. For scalp expansion a 250-mL balloon is inserted in the subgaleal plane. The balloon is expanded using sterile saline with gentamicin. The balloon is partially filled immediately after the initial incision, and systemic antibiotics are given for 5 to 7 days. After 10 to 14 days additional injections of 10 to 30 mL, depending on the size of the balloon, are given at 3- to 5-day intervals (some surgeons inject every 7 to 10 days) usually over a period of 6 to 8 weeks. If pain does not subside within 5 to 10 minutes, the saline solution is withdrawn. Another technique is rapid injection over a period of 24 to 48 hours to blanching of the skin and then withdrawal of some of the sterile saline solution. Careful monitoring for pain and skin necrosis is most 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. Occasionally two or three balloons can be used simultaneously in two areas. If there is insufficient expansion of the skin when the balloon is removed, the process can be repeated. The diseased area is resected when the balloon is removed, and the defect is closed by advancement or rotation flaps of the expanded skin. If the lesion is malignant, the delay necessitated by the usual technique of tissue expansion is obviously not possible. TWooptions are available: (1) temporarily cover the defect with a split-thickness skin graft and then use tissue expansion
Tissue expansion can be used for defects secondary to trauma, congenital lesions, and resection for carcinoma. Sites include the scalp, forehead, and face. Tissue expansion can be used before random flaps and free flaps and in excision of cicatricial deformities with closure by advancement or transposition flaps. Other potential applications have been suggested by Argenta and associates (1984).
Z-Plasty (Continued) (Fig. 3-2) Device (After Radovan)
in Head and Neck Surgery
Complications and Potential Problems
• Infection, avoided by strict sterile technique • Skin necrosis • Patient reluctance due to swelling of the expander. Explain that this technique will usually result in a smaller number of surgical procedures for large defects that ordinarily would require several staged operations.
W-Plasty (See Fig. 3-2X and Y) x, Y The W-plasty is a method of excising a scar to break up a straight line by removing small interdigitating triangles on either side of the scar line. It is useful in depressed linear scars of the cheek when no lengthening of the line of contracture is necessary. The W-plasty, unlike the Z-plasty, does not gain length. A metal template or bent flap metal strip modeled to correspond to small equal triangles is useful to mark the area for the line of excision (X). McGregor (1962) has demonstrated modification of the W-plasty for the closure of an oval wound (Y).
BASIC CONSIDERATIONS
~2
x
y
FIGURE 3-2 Continued
BASIC CONSIDERATIONS
Rhombic Flap (After Limberg, 1963; Modified After Gunter, 1983; Bray, 1983) (Fig. 3-3) The rhombic flap is based on the mathematic shape of a rhombus, which is an equilateral parallelogram in which all sides are equal in length and the opposite sides are parallel. There are two equal obtuse angles opposite one another and two equal acute angles opposite one another. The basic Limberg rhombus has two 120-degree obtuse angles and two 60-degree acute angles. It is important to understand this basic mathematic calculation to utilize this flap as well as minor modifications of it. A rhomboid, on the other hand, is a parallelogram in which the pairs of opposite sides are either longer or shorter in length than the pairs of the other side. Highpoints
Basic geometry of the perfect or ideal rhombic flap: 1. All sides are equal. 2. Opposing angles are equal. 3. The ideal acute angle is 60 degrees; the ideal obtuse angle is 120 degrees. 4. The flap is exactly the same geometric size, shape, and angles as the defect, including the length of the short diagonal and the long diagonal of the parallelogram. 5. The long diagonal (B, line A-El) of the flap forms a 60-degree angle with the long diagonal (B, line A-C) of the defect in any of the four possible (A and B) donor sites of the flap. Both long diagonals are the same length and are represented as the line with dashes in A. 6. The short diagonal (B, line D1.F) of the flap equals the short diagonal (B to D) of the defect, and the two are represented by the dotted lines. 7. The pivot point, the point on which the flap turns, is A, whereas Dl, El, and F are the mobile or rotated points (el. Planning the Flap
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.
3. The short diagonal of the flap should parallel as closely as possible the lines of maximum extensibility (LME). These lines are at right angles (perpendicular) to the natural skin folds referred to by Borges (1959) as the relaxed skin tension lines (RSTL). This principle is demonstrated in Figure 6-21H and I, where the short diagonal of the flap is at right angles to the nasolabial fold. 4. Although the flap closes the defect, the donor site is closed by undermining and mobilizing the skin that forms the outer margin of the donor site, line E-F in C. Hence, the flap must be planned so that transposition of line E-F will not cause distortion. Otherwise, the vector of tension (VaT) (D) will be changed, and distortion of other structures will occur. At times, compromises may be necessary. This should all be calculated before the flap is actually incised. 5. Exact geometry is not always necessary if there is sufficient mobility of surrounding skin. 6. Modifications will be necessary if frozen sections indicate inadequate margins in the resection of a malignant lesion. A The shaded area is the ideal defect, planned primarily to resect all disease with adequate margins and four possible juxtaposed donor sites. The choice of the donor site should be such that the donor site short diagonal is parallel to the LME.The long diagonal of the defect equals the length of the long diagonal of the donor site, both represented by the dashed lines; the short diagonals are likewise equal, both represented by the dotted lines. Point A is the pivot point with a 60-degree angle formed by both long diagonals. The base of the flap is the line represented by dashes and dots and obviously left intact. This is the space between points A and F in Band C. B The donor site has been chosen, again emphasizing that both defect and donor site are geometrically identical. The short diagonal line B-D of the defect equals the length of the short diagonal of the donor flap as well as the side line Dl-E' of the flap. 0'E' is a straight line continuation of the short diagonal line B-D.
BASIC CONSIDERATIONS
A
c
B
A
F
B
E
A
o
C FIGURE 3-3
C Mobilization of the flap. Ideally, this is accomplished by rotating the flap on the fixed point A, with point F mobilized and being moved to point D, which is relatively fixed. This results in a vector of tension (VaT), as depicted in D. If, on the other hand, point D must be moved toward point F to effect closure of the donor site, then the vaT changes toward point B. This in turn lengthens the width of the defect B-D. This
then requires widening the flap along the line Dl_F, which can be accomplished if the skin of the donor site has sufficient elasticity, a factor that should be evaluated before the choice of the donor site. D The ideal closure demonstrates the ideal vaT. Examples of this type of flap with modifications are depicted in Figure 6-21 E to I.
BASIC CONSIDERATIONS
Excision of Dog-Ears (Fig. 3-4) Most dog-ears can be handled initially by flattening and lengthening the ellipse of skin to be excised. If this is impractical or dog-ears are present, one of the following techniques can be used. A The dog-ear has resulted from unequal lengths of each side of the repair.
B A dog-ear is excised by resection of a longer and flatter ellipse of skin. C A dog-ear is excised using the V (step 1) to Y (step 2) principle (see Fig. 9-7J and K). Dog-ears can also be prevented plasty, as depicted on 3-2X and y.
1. The dotted line is the back cut. 2. A back cut has been performed and the excess skin along the longer skin edge is excised on the dotted line. 3. Completed closure.
B
2
A
c
3
FIGURE 3--4
2
by a modified
W-
BASIC CONSIDERATIONS
Bone, Cartilage, and Nerve Grafts
(See Figs. 3-5 to 3-8) Basic Principles Relative to Bone and Cartilage Grafts and Implants (After Schuller, 1980) See also the discussion of osseous microvascular free grafts in Chapter 24. Bone Grafts
TYpesof bone grafts include autologous bone and homologous preserved bone (implant). Bone is a specialized type of connective tissue covered by periosteum, which in turn is a specialized form of connective tissue. The bone is made up of (I) cortical bone, an outside firm compact layer that provides rigidity, and (2) cancellous bone, an inside layer coupled with marrow and a spongy component that has the greatest osteogenic potential for growth and thus prevents reabsorption of the bone graft. Bone grafts in turn require two important items for success: (I) a good blood supply in the recipient bed and (2) mechanical stress (e.g., muscular contraction). Hence, the ideal bone graft should, if feasible, include both cortical and cancellous bone regardless of where' and how the graft is utilized. Donor Sites The choice of the donor site depends on the type of reconstruction intended and includes the following:
preserve perichondrium when possible and when curling is not a detriment. In an animal experiment preserving the perichondrium in free cartilage grafts Duncan and co-workers (1984) concluded: "The results obtained strongly suggest that perichondrium responds briskly to repair injury and that the breaking load is greater in the presence of perichondrium and increases with time. It is suggested that perichondrium be included with free cartilage grafts for optimal survival and intercartilaginous healing." The question has been raised whether the experiments should be repeated using costochondral cartilage, as this experiment was done with ear cartilage. Tardy (1985), however, does not believe that the perichondrium is necessary for cartilage graft survival. Gibson, in 1957, introduced the principle of "balanced cross sections of cartilage." This concept stems from the fact that the cartilage has a subperichondrial layer of flattened chondrocytes that maintains the inner zone of the cartilage taut. Interruption of the balance of these peripheral cells on one side will make the cartilage warp toward the opposite side. Strict adherence to the principles of balanced cartilage carving as stated by Gibson will result in implanted cartilage grafts that will not warp (e.g., Gibson selects cartilage and shapes the cartilage graft by trimming equal portions on each side). This, of course, means that the perichondrium will be sacrificed. When utilizing thin strips of peripheral cartilage, gentle morsulization or cross hatching of the subperichondrium will break the spring effect and prevent warping. Implants
• Rib
• Iliac crest • Septum-vomer and perpendicular ethmoid • Anterior wall of the maxilla
plate
of the
Cartilage Grafts
TYpes of cartilage grafts include autologous cartilage and homologous preserved cartilage (implant). Donor Sites • Costochondral • Nasal septum • Auricular concha (see Fig. 6-26A to L) The problem with cartilage grafts is that they tend to curl with the concavity toward the perichondrium, if it is preserved. Despite this problem the author prefers to
1. Alloplastic materials a. Problem of rejection b. Migration c. Infection 2. Homologous bone and cartilage grafts a. Problem of rejection b. Questionable vascularization c. Infection Rib, Iliac, and Costochondral Grafts (Fig. 3-5) Highpoints
1. Preserve periosteum with cortical bone graft or perichondrium on at least one surface. There is some difference of opinion regarding this suggestion, with more unanimity regarding the periosteum and the perichondrium in children.
BASIC CONSIDERATIONS
Bone, Cartilage, and Nerve Grafts
(see Figs. 3-5 to 3-8) 2. Excise a larger section of graft than is necessary. This will allow sufficient latitude for choice of best configuration of graft. The use of a template or model made from plastic or stiff paper is a great aid in shaping the graft. 3. Grafts must be firmly fixed and usually immobilized. 4. Recipient site should be free of contamination. Infection must be avoided. A Location of incisions for rib (1), iliac crest (2), and costochondral cartilage (3) grafts.
F With rib rongeurs, the rib is sectioned at either end. The periosteum on the anterior surface of the rib has been preserved intact with the rib graft. The wound is closed in layers approximating the sectioned muscles over the bed of the removed rib.
Iliac Graft See Figure 3-6 for additional technique. An incision (A [2)) is made inferior and posterior to the iliac crest. The anterior attachments of the external and internal oblique abdominal muscles are sectioned close to the bone. A portion of the tensor fasciae latae may also require transection. The periosteum is left intact with the graft if the cortex is used.
Rib Graft An inframammary incision (A [I)) is made extending toward the posterior axillary line. The greater the curve desired for the graft, the more posterior the incision. The pectoralis major and minor muscles are transected. Depending on the extent posteriorly, the latissimus dorsi muscle may be sectioned. The attachments of the serratus anterior muscle are separated from the selected rib, usually the sixth or seventh. The presenting periosteum is preserved intact. This graft is not used for mandibular construction except possibly when combined with other mandibular support. B With the periosteum of the rib exposed, an incision is made through the periosteum along the superior margin and another incision along the inferior margin of the rib. The periosteum is sectioned at either end.
C Cross section of rib graft with intact periosteum anterior surface is shown.
on
D With the use of an Alexander rib periosteal elevator, the periosteum along the superior and inferior surfaces of the rib is separated. The neurovascular bundle is included in the inferior periosteal flap and preserved at the donor site. E A Doyen elevator completes the periosteal separation posteriorly. If this is carefully performed, the pleural cavity is not entered. When the pleural cavity is inadvertently opened, it is necessary to use underwater drainage (see Fig. 2-5A to C) or to close the chest with the lung fully expanded.
G Depending on the length and width of the defect to be grafted, a somewhat larger section of iliac crest is removed with a Stryker saw. Suction type drainage is used if indicated. Bone hemostasis is achieved with electrocautery or bone wax. (A variation of this harvesting technique is depicted in Figure 3-6.) Refer to the microvascular section in Chapter 24 for a discussion of vascularized bone graft.
Costochondral
Graft
An oblique incision (A [3)) is made over the broadest expanse of the seventh, eighth, and ninth costochondral cartilages. The anterior rectus sheath and the rectus abdominis muscle are transected and separated, exposing the underlying perichondrium, which is left intact. The purpose of the retained perichondrium is to facilitate an adequate "take." This, however, is controversial. In addition, the perichondrium can cause curvature of the cartilage graft. To avoid this, a central core of cartilage is obtained. H An area is outlined representing a much larger graft than is required. This is cut to the desired depth, avoiding a through-and-through incision of the cartilage. I A rectangular block is then excised with the aid of a right-angle knife (Beaver Blade No. 64).
J
The excised block of cartilage with anterior layer of perichondrium intact is shown. The wound is closed in layers.
BASIC CONSIDERATIONS
Neurovascular hundle rletal pleura
FIGURE 3-5
BASIC CONSIDERATIONS
Bone, Cartilage, and Nerve Grafts (Continued) Not depicted is the technique for obtaining cancellous bone. This is procured from the iliac bone through either bur holes or plugs or sections of cortical bone first removed. The cancellous bone can then be obtained either with a curet or in strips or blocks, depending on its use. The use of curetted cancellous bone is shown in the reconstruction of the mandible, using a metal trough to hold the bone in place (see Fig. 14-lOH).
Iliac Bone Graft-"Trap Door Type" (After Laurie et aI., 1984) (Fig. 3-6) Highpoints 1. Avoid injury to the lateral femoral cutaneous nerve. Hence, the incision is made lateral and oblique to the iliac crest. 2. If the edge of the crest is not necessary for the reconstruction, utilize a segment beneath the crest, the so-called trap door technique. 3. Use a medial bone approach if possible. 4. Replace the crest. Complications • "Gluteal gate" • Pain at donor site A The skin incision is made lateral and oblique to the iliac crest. The lateral femoral cutaneous nerve passes deep to the lateral portion of the inguinal ligament and should, if possible, not be transected. Likewise, avoid trauma to the nerve by "over" retraction. If the rim of the crest is not required, it is preserved, as depicted, on a hinge of periosteum if possible.
B The hinged edge of the iliac crest is returned to its original position and wired in place. The knots on the wire suture are buried.
Auricular Cartilage Graft (Fig. 3-7) The cavum-between the anthelix and the crus helicis (see Fig. 12-2A)-is an ideal source of autogenous cartilage for graft purposes. This cartilage graft, with one side or both sides of perichondrium, can be used to augment the dorsum and lateral portions of the external nasal framework as well as to provide for support in blowout fractures of the orbit (see p. 436, Plastic Reconstructive Surgery, June 1982). A Depicted is the incision for harvesting the auricular cartilage. The incision is made along the inner edge of the anthelix (see Fig. 6-26), maintaining a broad base for the skin flap. The perichondrium is included (one or both sides) in adults, but at least one layer of perichondrium is left at the donor site in children. The skin flap is returned and approximated with 6-0 nylon sutures using cotton impregnated with antibiotics, or povidone-iodine (Betadine) as a gentle compression dressing over the donor site. B The removed auricular cartilage demonstrates the concave and convex contour of the cartilage. For nasal reconstruction, it is best not to attempt to reshape the configuration of the cartilage but rather to choose that portion with its natural shape that best meets the required shape and size. For orbital floor support, the cartilage can be cross hatched and shaped and thinned to 1 to 2 mm in thickness as required to close the defect. The scar at the donor site is barely visible, without any significant deformity.
BASIC CONSIDERATIONS
FIGURE 3-6
B FIGURE 3-7
BASIC CONSIDERATIONS
Sural Nerve Grafts (Fig. 3-8) The sural nerve, which is on the posterolateral aspect of the lower extremity, accompanies the lesser saphenous vein. It is formed by a junction of the medial cutaneous sural nerve and the anastomotic ramus of the common peroneal nerve. This is a sensory nerve that supplies the skin of the posterior surface of the lower leg and the region of the lateral malleolus.
Figure 3-8 depicts the anatomy of the sural nerve and its formation from the two nerves, as just mentioned. This nerve branches and may be used as a nerve graft either in its branched form or in its single trunk form. Its terminal portion, the lateral dorsal cutaneous branches, is preferred for facial nerve reconstruction. This nerve is distributed over the lateral portion of the foot. It can be obtained by two or more short horizontal incisions and can be carefully removed from its bed alongside the lesser saphenous vein.
Skin Incision All skin incisions in the neck, with few exceptions, should follow the natural skin creases. This is important 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 muscle. The superior-based cervical flap in neck dissection has the best blood supply, and the posterior flap has the poorest. After adequate skin flaps are elevated, the deeper fascial incision may be changed as the exposure dictates. Skin incisions for operations in the superior cervical regions should be 3 to 5 cm below the horizontal ramus of the mandible to avoid injury to the mandibular branch of the facial nerve. For operations in the inferior cervical region, the skin incision usually should be at least 2 to 3 cm above the clavicle, because incisions placed lower will tend to drop over the clavicle in time and become unsightly. An exception is the upper incision for a deltopectoral flap, which lies close to the level of the clavicle.
If a single horizontal incision following a natural skin crease does not give adequate exposure as, for example, in a thyroglossal cyst that lies at the level of the thyroid gland or in a branchial fistula, multiple horizontal incisions in stepladder fashion solve the problem admirably. A skin incision made along the anterior border of the sternocleidomastoid muscle is entirely unnecessary except in an extreme emergency. Even in an emergency tracheostomy, the horizontal incision is preferred. There are exceptions to any rule of thumb. The exposure for a radical neck dissection is the main exception. Although multiple horizontal incisions (MacFee) can be used in this operation, the exposure and time consumed raise some questions (see Fig. 16-6A to F). Another exception may be a total laryngectomy for malignant disease in an individual with a long, thin neck, in whom two horizontal incisions may extend too far laterally and thus enter an area of later metastatic spread. This exemplifies a basic principle in operations for malignant disease: avoid skin incisions for cosmetic 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 reconstructive procedures associated with neoplastic disease except in the rarest circumstances. Scars in such areas will delay an early detection of metastases and often make later radical surgery difficult.
Nonabsorbable Sutures for Mucosal Repair Although nylon and Prolene suture materials have been shown to result in minimal tissue reaction and are utilized in repairs of mucous membranes of the oral cavity, their use involving the mucosa in oropharyngeal, laryngeal, and hypo pharyngeal surgery has been found to be not as satisfactory. The problem is that loose loops, ends, and knots are sites for the collection of debris, mucus, and food and are very difficult if not impossible to remove. If the sutures are totally buried, nonabsorbable suture materials (nylon, prolene, or silk) are ideal; otherwise an absorbable material is recommended. Chromic gut is preferable, rather than Vicryl; the Vicryl appears to have a longer than necessary absorption rate on mucosal repair.
BASIC CONSIDERATIONS
PERONEAL ANASTOMOTIC
N.
LESSER SAPHENOUS V.
EDIAL SURAL CUTANEOUS N.
FIGURE 3-8
BASIC CONSIDERATIONS
Preoperative and Postoperative Care (See Figs. 3-9 to 3-12) William R. Nelson and R. Lee Jennings In this brief treatise, specific problems are mentioned and procedures are described that are somewhat different from those encountered and used in routine general surgical and ear, nose, and throat patient management. Adequate preoperative evaluation and preparation are of the utmost importance in these patients, who are often afflicted with disabling medical disease. After surgery, these individuals need unusual care. Wound healing may well depend on the surgeon's detailed knowledge of the complications that might arise and of specific peculiarities of tissues in the head and neck region.
Preoperative Care 1. The sine qua non of preoperative preparation is proper evaluation of the disease for which surgery is planned. For a patient with a tumor, radiographic and pathologic studies and a positive biopsy after radiographic studies are mandatory. In the event that an unusual neoplasm has been diagnosed (e.g., a soft-part sarcoma, lymphoma, or uncommon variety of salivary tumor), it is often wise to ask the attending pathologist to seek consultation on the tissue slides. Pathology consultation is certainly needed when the original tissue diagnosis was made in a hospital unfamiliar to the surgeon. A second opinion from an experienced tumor pathologist may alter the surgical approach. Chest radiographs are essential in the search for metastatic disease or concomitant bronchogenic carcinoma, the latter being a frequent second neoplasm in any patient with head and neck mucosal cancer. CT or MRI aids in the evaluation of the extent of the primary tumor and nodal status in conjunction with physical examination. Imaging at times may be misleading, especially of the oropharynx. Angiography is essential in blood vessel problems and can be helpful in neoplasms such as carotid body tumors, juvenile nasopharyngeal angiofibromas, and, possibly, secondary operations on parathyroid adenomas. On occasion, false-positive findings will be reported when there is marked edema and/or fibrosis around the tumor margins. Treatment planning can proceed when this staging process is completed. 2. The usual supportive and diagnostic measures must be instituted preoperatively in patients with surgical diseases of the head and neck. Careful medical evaluation and therapy are important because cardiovascular, pulmonary, or hepatic dysfunction commonly accompanies the surgical problem, particularly in the case of mucosal cancer. It is the
responsibility of the surgeon to identify medical problems and obtain medical consultation to reduce perioperative complications. 3. Cultures of infected lesions should be made well in advance of surgery, because these problems may require both local and systemic control measures. The irrigation or power spraying of the oral cavity (with half hydrogen peroxide and half saline solution) will often clear up necrotic tissues and exudate on the surface of a tumor. In patients with known preoperative infections, specific antibiotic coverage would be indicated before, during, and after the operation. Obviously, presurgical infection control is vital in these instances. 4. Stop cigarette smoking well ahead of scheduled procedures. Often, dramatic clearing of excessive secretions will occur and postoperative tracheobronchial difficulties will be less severe. Positivepressure breathing (with or without added medications for bronchodilatation and mucous liquefaction) and postural drainage may be a great aid to those individuals with pulmonary and tracheobronchial disease. Oral or transdermal nicotine products are helpful during withdrawal. Continued tobacco use is detrimental to flap success when flap or microvascular free-flap repair is planned. 5. The alcoholic patient should abstain from alcohol for at least a week before surgery because postoperative delirium tremens yields a high mortality. Most alcoholics will be evasive about their liquor consumption. The families of suspected alcoholics should be questioned before the final scheduling of surgery so that plans for adequate preoperative hospitalization can be made. High caloric feedings, vitamin therapy, and tranquilization will be of help during this "drying out" phase. Alcohol rehabilitation clinics are helpful and in some cases provide the only method to ensure preoperative abstinence. 6. It is vitally important for the surgeon to discuss frankly and honestly with patients the possibilities of loss of any function during an operative procedure. With total laryngectomy or extensive oropharyngeal procedures, the patient should be enlightened about the physiologic and anatomic changes to be incurred and must be encouraged about speech and swallowing therapy possibilities. In situations where there is some doubt as to the extent of surgery, the possibilities of postoperative functional loss must be outlined. It is always best to give each patient some hope that such losses will not be incurred. Any person awaiting surgery should be given a lucid description of planned tracheostomy, feeding tube, and drainage tube utilization. Simple explanations of planned procedures are helpful, but too detailed a discussion of the surgical technique
BASIC CONSIDERATIONS
may frighten an already apprehensive patient. Preoperative visits by previously operated patients mayor may not be wise, depending on the disfigurement or dysfunction present and the patient's own personality and state of anxiety. After surgery when the individual is recuperating, a visit by one of these veteran patients may be extremely helpful. The local chapter of the Lost Chord Club or the International Association of Laryngectomees should be contacted about each new laryngectomy case so that a visit by one of these laryngectomees can be scheduled. Speech therapy must be arranged through this organization or through a professional speech therapist. For those patients who are candidates for a Blom-Singer procedure, such surgery can be planned when indicated.
7. All apparently malnourished patients require nutritional evaluation pretreatment by the hospital nutrition team. Nasopharyngeal or nasogastric tube feedings may be advisable preoperatively in patients plagued with severe nutritional deficiencies and swallowing problems; however, this method has been replaced in many centers by percutaneous endoscopic gastrostomy (PEG) tube placement (Fig. 3-9) (see also Chapter 21). This method is better tolerated, may be continued postoperatively for as long as needed, and avoids having a tube across suture lines. Complication rates may be less and survival rates improved when the nutritional status is more nearly normal. Nutritional support is provided to patients undergoing preoperative chemotherapy or radiation therapy.
Gastrostomy tube
B
A
Moss type gastrostomy tube with jejunal extension for feeding placed at laparotomy
c FIGURE 3-9
A, B, and D show the PEG tube; C is the Moss type placed at laparoscopy.
BASIC CONSIDERATIONS
Total parenteral nutrition (TPN) is extremely helpful perioperatively in those few patients in whom tube feedings are not possible. Open gastrostomy or jejunostomy feedings are rarely necessary but are indicated when nasogastric and TPN approaches are impossible or when skull base procedures require harvesting gastric or jejunal flaps to separate the pharynx from central nervous system. Then placement of a gastrostomy tube for suction with jejunal extension for feeding is helpful. 8. Red cell transfusions may be required preoperatively, and generous amounts of blood should be held in readiness for any radical surgical procedure, even though blood administration is less often utilized today in the average major head and neck procedure. In selected cases, the patient can donate their own blood for autotransfusion or obtain directed donations from compatible family members. Coagulation studies should be ordered when bleeding tendencies are suspected, usually in alcoholic patients with hepatic dysfunction. 9. Consult with the anesthesiologist well in advance when airway, cardiac, alcoholic, hepatic, and other systemic problems are present. Also make detailed plans regarding type of intubation (orotracheal or nasotracheal), tracheostomy, cardiac monitoring, and optimum positioning of anesthesia equipment. In case of partial airway obstruction, a careful attempt to intubate the patient may be made transorally or transnasally by the anesthesiologist. If intubation is not immediately successful, a fiberoptic laryngoscope is passed into the trachea with the patient awake but sedated and then the endotracheal tube is positioned over the endoscope. Always prepare for emergency tracheostomy even though the procedure is rarely necessary. 10. Shave and prepare the skin with germicidal soap to widely encompass the area of surgery. Germicidal soap preparation in the operating room is sufficient. Some patients, particularly senile individuals, require careful skin cleaning daily for 3 to 4 days ahead of time. Cleanse the external ear canal with soap and a cotton-tipped applicator on two or more occasions before parotid surgery and other procedures in the ear area. Consultation with the microvascular plastic surgeon ensures adequate preparation and exposure when microvascular flaps are planned. Skin preparation in the operating room is carried out with the effective povidone-iodine (Betadine) scrub and paint or a similar product. Take care to protect the eyes with ophthalmic ointment and pads during skin preparation, draping, and surgery.
Bowel Prep
In the rare instance where bowel preparation is necessary, this method is both simple and effective: 1. The patient must be on a clear liquid diet for at least 1 to 2 days before the operation. 2. GoLYTELY (PEG-3350 plus electrolytes; Braintree Laboratories), 4 L, is administered orally beginning early in the afternoon I day before surgery. 3. Neomycin (1 g) and erythromycin base (1 g) are given orally at 1 PM, 2 PM, and again at 10 PM for surgery the next morning (adjust for later surgery). 4. Encourage clear liquid intake until midnight. 5. Give a cephalosporin, 1 g, and metronidazole (Flagyl), 500 mg, every 6 hours for 24 hours beginning preoperatively. Postoperative Care The postoperative orders for typical, all-inclusive care after head and neck surgery might be outlined as follows: 1. Careful monitoring of vital signs. The head should be elevated to 30 to 45 degrees when blood pressure has stabilized. Among the rare exceptions is ligation of the common or internal carotid artery. In this case, a flat or slightly head-down position would be imperative. The head-up position decreases postoperative edema and seems to improve respiratory function greatly. Ambulation is started when the erect position is tolerated without dizziness or syncope. 2. Tracheostomy care (Fig. 3-10). Give 40% oxygen through a loosely applied mist mask (not by catheter into tracheostomy tube), to maintain oxygen saturation above 90 %. Pulse oximetry is recommended. Suction the tracheostomy frequently in the early postoperative stage. Insert a sterile, open-ended catheter well below the inner tip of the tracheostomy tube. (The person performing this procedure must use sterile gloves or a sterile hemostaL) Deeper suctioning is occasionally necessary. At times counterclockwise rotation of the tracheostomy tube can facilitate the introduction of the suction catheter into the left mainstem bronchus. Ordinarily, with deep suctioning, the catheter passes into the right mainstem bronchus, since the right bronchus is in a more direct line with the trachea than the left bronchus. Use a V-tube attachment for brief, intermittent spells of suctioning. Each should last a few seconds (no longer than the person handling the catheter can comfortably hold his or her breath). Gently twist the
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 prevent trauma to anyone area of tracheal mucosa. The thumb should be repeatedly placed over the open end of the V-tube and removed during the procedure. Avoid prolonged and continuous suctioning to prevent dangerous oxygen desaturation. An oxygen saturation monitor should be in use during suctioning. Hyperventilation with 100% oxygen is recommended before suctioning, and brief oxygen inhalation while suctioning is used as needed. Instill sterile normal saline solution with an eyedropper or syringe without needle in 1- to 2-mL amounts every 2 to 4 hours and remove by suctioning to prevent dry tracheitis. Detergents or enzymes may be helpful locally in cases of severe dry tracheitis with crusting. Remove and clean the inner cannula of the tracheostomy at least every 4 hours. Remove, clean, and replace the entire tube every 1 or 2 days after the tracheostomy is well established (usually in 5 to 6 days). Large crusts may require removal by forceps (with the entire tube out if a solid tract is present). If large crusts or obstructing crusts occur in a laryngectomy tube and cannot quickly be removed from the tube, then remove the entire tube stat. Use extreme care when changing a tracheostomy tube in an infant. Carry out the first change in the operating
room or intensive care unit with a bronchoscope and an endotracheal tube available. A cuffed tracheostomy tube allows positive-pressure breathing when required. A low-leak technique will minimize injury to the trachea, thus preventing tracheal stenosis. Otherwise, the traditional noncuffed metal tube with inner cannula is desirable. The disposable, cuffed plastic tube (without inner cannula) has become popular with many thoracic surgeons in patients requiring very brief tracheostomies. This tube has not been generally satisfactory in our hands because of its large outer diameter and the lack of an inner cannula for cleaning purposes. The Shiley cuffed tube does have an inner cannula and is the preferred product in our hands but is also difficult to insert and prone to tearing of the cuff. Some surgeons (JML) prefer the Portex tubes with inner cannula. The cuffed tube-if needed-is easier to insert. The tube is made in various models, some of which are flexible. The low-pressure cuff is relatively atraumatic; and when it is inflated, only enough air should be injected to prevent leakage between the cuff and the wall of the trachea. When patients are learning to swallow after extensive procedures with preservation of the larynx, cuff inflation prevents aspiration but is ordinarily contraindicated, because this merely hides evidence of aspiration of swallowed liquid and pureed foods. When the patient returns from surgery to the recovery room and respiratory assistance is no longer needed, the cuff of the endo-
tracheal tube inserted at the end of the operation is normally deflated. Just before this, however, the nurse must be prepared to suction the remarkable quantity of secretion that gathers above the inflated cuff. This mucous material usually drops quickly into the trachea on deflation. Never discontinue a tracheostomy until it is certain that the patient has a satisfactory airway. Mirror or fiberoptic laryngoscopy allows evaluation of the subglottic, glottic, and supraglottic airway. In spite of some criticism of this method, half- and full-corking is a satisfactory technique of "weaning" the patient from a tracheostomy. However, one must be certain that the tracheostomy tube does not fill the lumen of the trachea when corking is attempted! By gradually decreasing the size of the tracheostomy tube (from the standard NO.7 for men to NO.6 or No.5), the surgeon can then cork with ease and finally remove the tube. Examine the larynx before corking or removing the tube. At times tube removal aids in deglutition. The patient must be able to pull the cork at any time if breathing becomes difficult. Of course, the corked, inner cannula must be removed and cleansed, just as previously described, until final discontinuance of the tracheostomy. When oral or laryngopharyngeal surgery with tracheostomy has been performed, remove the feeding tube when the patient is swallowing with ease. The tracheostomy tube must be left in place as a "safety valve" in case aspiration occurs. The surgeon must then carefully test the swallowing function to be certain that ingested liquid is not being aspirated before final termination of the tracheostomy. Here, food coloring added to liquid or puree diet aids in evaluating aspiration. After partial laryngostomy, removal of the tracheostomy tube may be necessary to initiate the act of swallowing. Close observation for aspiration is necessary, and, if significant, the tracheostomy tube should be reinserted.
3. Laryngectomy stomata need care similar to that for tracheostomies (see Fig. 3-10). The entire laryngectomy tube must be removed, carefully cleansed, and replaced at least twice daily by the surgeon, a member of the house staff, or other trained personnel. At this time the suture line is meticulously cleared of crusts with saline solution (if necessary with cautious application of diluted peroxide to loosen any dried material). Avoid the use of peroxide within the stoma. It can cause obstruction in both the tracheostomy or laryngectomy tube, as well as in the suction catheter. Antibiotic ointment is then applied to the skin/mucosal edge before tube reinsertion. If there is ulceration or persistent erythema, tincture of benzoin may be applied carefully to the edge of the stoma and to the surrounding skin. Most patients are allowed to go without the laryngectomy tubes for increasing periods
BASIC CONSIDERATIONS
during the waking hours after the first 2 to 3 days. The patient should be taught self care as convalescence continues, the goal being independence in care on hospital discharge. Many surgeons prefer to keep the tube in place at night until it is certain that a large rigid stoma has developed. In dry climates, prolonged laryngectomy tube use and home humidification are necessary to avoid dry tracheitis. Plastic "buttons" or stoma rings (especially the Helsper button) are helpful in preventing stenosis when stomata are small and in treating stenosis (by dilatation with larger and larger rings). A "bib" of porous gauze (without cotton filling), moistened frequently with water, should be placed loosely over the stoma at all times. If a plug becomes lodged at the distal end of the laryngectomy tube, the entire tube must be removed STAT by anyone! This is a life-saving procedure, since the author (JML) knows of one patient who died because of this incident. 4. Narcotic requirements are usually minimal after head and neck procedures compared with after abdominal and orthopedic procedures. Adequate pain control is to be ensured in the immediate postoperative period with intravenous narcotics provided via patientcontrolled analgesia (PCA) according to the protocol used in each hospital. Patients who have had procedures that require the harvest of microvascular flaps involving muscle and bone require longer use of PCA analgesia, whereas patients with neck dissection require minimal narcotic analgesia. Nonsteroidal antiinflammatory analgesics, such as ibuprofen 600 to 800 mg via feeding tube or orally every 6 hours, are usually adequate for minor pain as recovery continues. The use of tranquilizers for anxiety or rest1essness is important. Alcoholics who require large doses of tranquilizers should be cared for in the intensive care unit until stable. Oversedation with resultant respiratory depression should be avoided in any patient who might aspirate. Serious consequences have been observed in patients with partial airway obstruction, such as in a patient with a posterior nasal pack placed for nasal hemorrhage control who was oversedated. All postoperative head and neck procedure patients should receive prophylactic medication to avoid gastritis and gastric hemorrhage. Effective medications for gastric hemorrhage prevention include H2 receptor blockers such as ranitidine (Zantac), 50 mg intravenously every 8 hours or 150 mg via feeding tube every 12 hours. 5. Perioperative antibiotic use along with improved surgical techniques has resulted in very low postoperative infection rates. In clean surgical procedures (major salivary gland resection, thyroid and parathyroid resection, cyst removal, and radical neck dissection) there is no evidence that antibiotic administration decreases the already low infection rate. In longer, clean cases (free flap repair, combined parotidectomy
and neck dissection, or operation through radiated tissue), a cephalosporin is administered beginning preoperatively for 24 hours. Clean contaminated cases are those in which the surgical field is exposed to mucosal secretions (combined oral and neck procedures, pharyngeal, sinus, and laryngeal procedures). Here, the wound is exposed to both aerobic and anaerobic bacteria and higher wound infection rates are expected. Some procedures, such as skull base surgery, in which the central nervous system is exposed to pharyngeal secretions and in which abdominal flap harvest is utilized, would be impossible without perioperative antibiotic use. In these cases, antibiotic administration is started preoperatively in full dose and discontinued 24 to 48 hours postoperatively. In simpler clean-contaminated cases (radical neck dissection with oral or pharyngeal resection and free flap repair or laryngeal surgery), 24- to 48-hour cephalosporin coverage is used. Other surgeons use ampicillin sodium/sulbactam (Unasyn), 1.5 g, intramuscularly or intravenously every 6 hours unless the patient is allergic to penicillin. This is given as a single dose preoperatively and continued postoperatively for 24 to 48 hours. Some surgeons use clindamycin 1% as a mouthwash one to three rinses per day before the operation and continued 24 to 48 hours postoperatively. Ototoxicity and nephrotoxicity may occur. In more extensive procedures (skull base surgery or mandibular resection cases in which hardware is used), perioperative cephalosporin and aminoglycoside antibiotics are used for 48 hours. Still, there is little evidence to recommend anyone drug combination over another as long as the antibiotics are effective against oral gram-positive aerobic and anaerobic bacteria. In any cases, antibiotics will not prevent infection where poor surgical technique allows continued postoperative salivary wound contamination. Watertight closure of suture lines without tension is mandatory. 6. Irrigate the oral cavity at least four times daily when suture lines are present. (Tube feedings should replace oral intake during the postoperative healing phase in all except the smaller, intraoral resection cases.) Hydrogen peroxide/saline solution administered by power atomizer, Asepto syringe, or Water Pik, is useful in keeping the operative site clean. Aspiration of the irrigating solution is best managed by a tonsil tip attached to a portable or wall suction apparatus (Fig. 3-11A). The patient should be placed in a sitting position for this treatment to prevent the aspiration or the swallowing of the irrigating solution. As recovery progresses, the patient can be a valuable ally in wound care. Patients who become self sufficient in their care also have less anxiety and seem to have a more comfortable postdischarge recovery.
BASIC CONSIDERATIONS
the suction drains. Kling is the best material to secure the pressure gauze (see Fig. 3-11B) but there should be no pressure over any type of transposed flap. Vacuum apparatus of Hemovac or Jackson-Pratt types is generally satisfactory for wound drainage, the latter being preferred by this author (WRN) because less clotting is experienced. Avoid drainage sets with hard catheters. Large-sized catheters (10 mm) are best for larger cases and small (7 mm) for less extensive cases. Clotting will occur in any tubes inserted into wounds and must be evacuated. Tube stripping or "milking" is helpful in removing clots. Again, the patient can assist with this procedure. A word of caution regarding these tubes needs to be made.
7. Frequent wound cleansing with peroxide is advisable to reduce wound contamination by tracheal secretions and serum crusting. Stents over skin grafts are kept in place for periods varying from 4 to 5 days for mucosal defect skin grafts and up to 6 to 7 days for skin defect grafts. Pressure dressings are not required, because fluid accumulation can be prevented and skin flaps made to adhere nicely to deeper structures with the use of properly managed vacuum wound catheters. Some surgeons use pressure dressing over the parotid salivary gland after radical neck dissection to prevent edema and swelling of the parotid salivary gland, which can be permanent. Pressure dressings are also occasionally utilized along with
CARE OF INTRAORAL SURGICAL WOUNDS
POSTOPERATive
_ 1_
CARE
A
OWER SPRAY 0 SALINE & H202 (1/2 AND 1/2)
CONNECTIONS
TO POWER SPRAY-SUCTION
APPARATUS
ALWAYS PROTECT THE EAR!
B
FIGURE 3-11
ASEPTO SYRINGE OF SALINE & H202
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They must not cross the carotid vessels nor be located too closely to a microvascular anastomosis, because there is danger of pressure necrosis or microvascular anastomosis failure. One or two fine, absorbable, loosely placed sutures are used to keep the tubes in the desired location. Antibiotic ointment may be applied over exposed suture lines. Some physicians prefer a quick-drying liquid dressing administered by spray to these skin closures. It is acceptable to leave neck wounds uncovered postoperatively. This allows frequent inspection
by care personnel. Bulky dressings can hide the rare but dangerous postoperative hematoma and do little to protect the operative site. With pectoralis major flaps no pressure dressing is used. In microvascular free flap cases wound exposure is mandatory for observation and Doppler checks of vascular flow. Here, any pressure over the site of vascular anastomosis may result in flap loss (Fig. 3-12). All tubes and drains are possible sources of ascending infection, and appropriate precautions to prevent this should be taken. The neck wound should
, \,
\
Pectoralis major rotation
A
flap
B 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.)
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be carefully examined daily for any evidence of fluid accumulation. Prompt evacuation is imperative. Late accumulations often herald the development of pharyngeal suture line disruptions. (Foul-smelling, mucuscontaining material is diagnostic of such a complication.) If Proteus infection is suspected clinically or by laboratory tests, use the appropriate antibiotic. If necessary, dilute solutions of acetic acid used locally may resolve the problem. If infection persists, widely open the overlying skin flaps and .start irrigation and packing after adequate drainage of any pockets. Loosely and temporarily applied saline/hydrogen peroxide packs after each irrigation will clear up any anaerobic infections and stimulate formation of granulation tissue. These packs should be changed frequently. Antibiotic coverage is restarted when culture results are available. Carotid artery exposure (which is usually prevented during the operation by muscle flap coverage or dermal graft; see Figs. 22-35 and 22-36) necessitates extremely vigorous local wound care. Ligation may become necessary if granulation does not quickly cover the vessel. The appearance of a pale, avascular area in the arterial wall indicates an impending rupture. If the wound is clean proximally and distally an elective arterial bypass graft could be performed through clean surgical fields (see Chapter 22). 8. When needed, feeding tube placement can be by the preoperative PEG tube method or by a large bore nasogastric tube placed during surgery. The former method is preferred except where tube feeding requirements are only a few days and preoperative nutrition is adequate. If not placed preoperatively, the feeding tube must be inserted by the anesthesiologist, especially when the procedure is a laryngectomy. Here, the tube insertion must be completed before pharyngeal wall closure to prevent possible perforation of the suture line. Some surgeons prefer the PEG tube (see Fig. 3-10) in a laryngectomy in the hope of decreasing the incidence of fistula formation. In any event, do not reinsert an accidentally removed feeding tube after pharyngeal or esophageal closure before wound healing, because the reinserted tube can disrupt the suture line. Postoperative chest radiography confirms proper placement of the tube before use. Postoperative consultation with the nutrition team allows calculation of caloric requirements and method of product administration. Administer high-caloric liquid feedings by tube after nausea and gastric atony have subsided. Clear surgical liquids or DsW may be given by tube in the interim. Commercial products for tube feeding are now numerous, and specific recommendations are not possible because a hospital will usually have one product line available. Choose the appropriate product after consultation with the dietitian.
Your hospital may have an enteral feeding protocol, but a simple sample protocol follows: 1. Confirm accurate tube placement by radiography or air injection and auscultation. Small-bore tubes require radiographic confirmation of position. 2. Elevate the head of the bed or place the patient in a chair at the bedside. 3. Check gastric residual. If it is greater than 100 mL, withhold feeding and check hourly until less than 100mL. 4. Start feeding by pump with dilute (half-strength) product at 50 mL/hr. Check residual every 4 hours. Discontinue feeding if residual is more than 100 mL and restart when residual is less than 100 mL. 5. Advance to full strength after 12 hours if residual is less than 100 mL. 6. Advance rate of feeding 25 mL/hr every 12 hours when full-strength formula is tolerated until the desired rate is achieved (caloric requirement calculated by the nutritional team). 7. Convert to interval feedings in five divided doses when the desired rate is tolerated. 8. Discontinue feedings and check residual if patient complains of nausea or gastric discomfort. 9. Flush the tube with 30 mL of water before medication administration and with 60 mL of water after interval feedings. 10. Give supplemental water according to the osmolarity of the feeding formula. 11. Check electrolyte levels frequently until stable. 12. Diarrhea may be treated by tube-feeding adjustment or medication.
Complications Complications in nutritional support are related to the delivery method. Properly adjusted TPN solution seldom causes electrolyte imbalance, but central venous line infections are common, particularly when a tracheostomy is present. Central venous line placement complications should be rare and include pneumothorax and bleeding. Nasogastric feeding tube complications include the avoidable misadventures of lung placement, nasal cartilage necrosis, and esophageal perforation on tube placement, especially if a tube with wire stylet is used. PEG tube complications tend to occur at the time of tube placement and are rare. There have been two instances of postoperative implantation of squamous cell carcinoma at the PEG site reported. Any enteral feeding method may cause reflux and aspiration (more common with large-bore nasogastric tubes) and diarrhea due to the osmotic effect of the product. All methods of nutritional support can cause electrolyte imbalance and are more difficult to manage in patients with diabetes, congestive heart failure, and hepatic and renal failure.
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These brief preoperative and postoperative suggestions should serve as a guide in the management of patients undergoing head and neck surgery. Meticulous attention to details of patient care will help to decrease morbidity and mortality in these surgical cases involving complex anatomic areas.
better expressed in negative rather than posltlve terms-what should not be done or pitfalls to avoid. It would of course be impractical to attempt any kind of exhaustive listing of departures from sound practice; however, a few that stand out as perhaps too often seen 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 surgery or if necessary postoperatively. The patient's head should be flexed forward so that the best opportunity to insert the tube in the esophagus is achieved. Hyperextending the head and neck will tend to place the tube in the larynx and trachea, which can end up in a very serious aspiration and death. After the tube is inserted, the end is placed in a cup of water to be certain that there are no bubbles. If there are bubbles, then the tube is most likely in the trachea. Examination with a laryngoscopy is sometimes necessary to confirm mislocation of the tube.
Common Departures From Sound Management-"Pitfalls" (From Lore and Shedd, 1979)* Sound clinical management, as collectively developed over years of accumulated experience, is sometimes
• Open biopsy of a lump in the neck before performing a complete head and neck and general physical examinations • Inadequate incisional biopsy of an oral cavity lesion • Inadequate excisional biopsy of a suspicious oral cavity lesion • Failure to review previous histopathology slides • Permitting a single histopathologic benign diagnosis to override a clinical diagnosis of carcinoma • Biopsy of the larynx, hypopharynx, nasopharynx, esophagus, or trachea before radiologic studies and imaging when such studies are indicated to aid in the evaluation of the extent of disease • Lack of multidisciplinary approach, when indicated • Tailoring the scope of surgical resection to the ability of the surgeon rather than to the objective requirements imposed by the lesion • Compromise of the ablative phase of surgery to accommodate limited reconstructive skills
'From NIH publication #80-2037, September 1979.
PUTTING IN THE FEEDING TUBE (NASOESOPHAGEAL CATHETER FOR FEEDING)
CLAMP OR CORK MUST BE USED!
CATHETER ~EL.: SOPHAGUS BUT TEST TO BE SURE!
FIGURE 3-13
NOTE CATHETER WITH OPEN TIP!
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• Compromise of surgical margins because radiation therapy or chemotherapy was or is to be given and, conversely, giving less than an adequate tumor dose of radiation therapy with the intent of resorting to surgical excision of any residual disease • Performing the right operation on the wrong patient • Assessing the degree of success or failure of radiation therapy on the basis of the response of the lesion during or immediately on completion of treatment • Failure to realize the implications of the "condemned mucosa" or multiple primary syndrome • Failure to perform a complete general physical examination as well as a complete head and neck examination • Prolonged watch-and-wait attitude in the face of an asymptomatic mass • Inadequate search for an occult primary tumor • Abandonment of the patient with neck metastasis from an undetectable primary tumor • Enucleation of tumors of the major salivary glands and thyroid gland • Treating a patient with antibiotics for an extended period of time without a biopsy Open Biopsy of a lump in the Neck Before Performing a Complete Head and Neck General Examination Discussion An open biopsy will yield the histologic diagnosis but in carcinoma will usually: • Not indicate origin or extent of the primary tumor. • Encourage spread of tumor in the neck. • Make necessary the resection of a large area of overlying skin. • Interfere with the usual anatomic surgical planes relative to definitive therapy. Prevention. Complete an adequate head and neck examination, including optical nasal laryngoscopy, as indicated, direct endoscopy, plus x-ray and imaging evaluation of the mandible, sinuses, nasopharynx, larynx, and chest and a general physical examination. It is very important then when examining the oral cavity and oropharynx that palpation, especially of the base of the tongue, be performed. Rectal and pelvic examination should be done as indicated. When all of these fail to reveal the source of the primary tumor, then needle aspiration is recommended. For example, prostate, colon, and breast cancer can metastasize to head and neck (see pp. 780 to 787 for a discussion of metastasis to lymph nodes of the head and neck). If the needle aspiration fails, then open biopsy is justifiable and, depending on circumstances, may preferably be performed in the operating room with frozen section.
Inadequate Incisional Biopsy of an Oral Cavity lesion Discussion Punch biopsy of areas of leukoplakia or erythroplakia may well miss the site of carcinoma and lead the physician to a false sense of security. Prevention. The localized area of the leukoplakia or erythroplakia not responding to conservative management within 2 to 3 weeks is usually best totally excised. The specimen, properly marked as to orientation, is then submitted for serial histologic sectioning. Staining with toluidine blue may be of aid in selecting sites of biopsy. Inadequate Excisional Biopsy of a Suspicious Oral Cavity lesion Discussion By and large, highly suspicious lesions are best evaluated before excisional biopsy by the physician who will eventually make the decision as to the best course of management, whether it be surgery, radiation therapy, chemotherapy, or some combination of these. This evaluation is best achieved before any surgical intervention, so as to ascertain the size of the lesion as well as its local extension and the presence or absence of metastatic disease. For example, inadequate excisional biopsy of a lesion of the floor of the mouth may mask the actual extent of the tumor as well as cause obstruction of Wharton's duct, inducing enlargement of both submandibular salivary glands. This latter effect could be confused with possible metastatic spread to submandibular lymph nodes. Prevention. Initial evaluation before any type of surgical excision is best performed by a physician who will ultimately be responsible for the total management. Failure to Review Previous Histopathologic Slides Discussion At times, the physician responsible for the management of the patient with a head and neck neoplasm, which has been sampled elsewhere, will, in the face of expediency, rely solely on a written histopathologic report from an outside source. This occurs when a biopsy and histologic diagnosis have been performed at the time of original patient contact. Errors can occur when the personnel at the primary care facility simply have not had the exposure to some of the types of head and neck neoplasms. Evaluation of the degree of malignancy is most important; for example, in a mucoepidermoid carci-
BASIC CONSIDERATIONS
noma of a salivary gland, it is crucial to know whether it is low grade, intermediate grade, high grade, or very high grade. This grading not only influences prognosis but also is most important in the type of surgical management. Prevention. Request submission of all histologic slides and, if necessary, blocks for further evaluation. The results may even indicate that an additional biopsy should be performed. Permitting a Single Histopathologic Benign Diagnosis to Override a Clinical Diagnosis of Carcinoma
Discussion At times, the clinical diagnosis of a malignant neoplasm is not substantiated by biopsy and histologic evaluation. The problem may lie with the choice of the location of the biopsy site. For example, if the biopsy is taken in an inflammatory area surrounding a neoplasm, in the center of a necrotic area, or in the far periphery where only epithelial dysplasia is present, the specimen will lead to a histologic diagnosis of a nonmalignant lesion. Another problem may result from the paucity of histologic sections taken through the block of tissue, thus causing the malignant cells to be missed. An example of this pitfall is a single punch biopsy of a whitish patch involving, for example, the major portion of the vocal cord. It is better to strip the entire vocal cord. The specimen thus would include the entire suspicious area for serial histologic sections. Staining with toluidine blue may be of help in selecting sites of biopsy, for example, in the oral cavity, oropharynx, larynx, or hypopharynx. The whitish patch (leukoplakia, a term best discarded by the examining physician because it has implications of a malignant lesion) can be due to atypism, dysplasia, cancer in situ, invasive cancer, Candida, or lichen planus and may be related to smoking, irritation by a denture, or chewing tobacco or betel nuts with or without slacked lime. Prevention. A skilled clinician's impression on physical examination is more often right than wrong. The clinician, thus, must be wary of a benign diagnosis in the histologic evaluation for the previously mentioned reasons. Repeat biopsy or total excision of the lesion must be performed with explicit understanding by the pathologist that, if necessary, many serial sections should be performed. It may also be necessary to have recourse to one or several repeat biopsies. Then, should all biopsy specimens prove to be benign, such patients should be followed at close intervals until the diagnostic discrepancy is adequately resolved. Additional consultation may be advisable.
Biopsies of the larynx, Hypopharynx, Nasopharynx, Esophagus, or Trachea Before Radiologic Studies and Imaging Techniques
Discussion Biopsies of these organ sites will often cause edema and/or distortion of the neoplasm as far as its extent and size are concerned. Hence, radiologic studies, either in the form of plain soft tissue radiographs, CT, MRI, or contrast studies, can be erroneously interpreted, if performed after such biopsies. Prevention. If at all anticipated and practical, radiologic studies and imaging techniques are best performed before biopsy of the areas in question to avoid distortion in the interpretation. lack of Multidisciplinary Approach When Indicated
Discussion A primary care physician has the tremendous responsibility of the initial referral for definitive care of the patient with a head and neck neoplasm. At times these referrals are to other physicians who, although quite capable in their own disciplines, are not well versed in the multidisciplinary aspects of the management of head and neck malignant neoplasms. Prevention. Obviously, lesions frequently present with a choice of management that is clear cut, but in the patient's best interest even the slightest reservation should be subjected to a broader scrutiny. Use of multidisciplinary consultations or conferences should be stressed. The primary care physician must be cognizant of this multidisciplinary aspect and be sure that the physician chosen to manage the patient is also cognizant of this multidisciplinary approach. This latter physician in basic training may have sufficient knowledge of the disciplines involved or may in fact wish for an additional consultation. Tailoring the Scope of Surgical Resection to the Ability of the Surgeon Rather Than to the Objective Requirements Imposed by the lesion
Discussion When making a decision about the feasibility of surgical management of an extensive neoplasm it is a serious error to render a verdict of nonresectability because the physician or surgeon making the decision does not have the expertise or background to carry out the necessary operation.
BASIC CONSIDERATIONS
Furthermore, in surgery; tailoring the scope of excision to the ability of the surgeon, rather than to the objective requirements imposed by the character, location, and extent of the lesion, is inexcusable. Prevention. Although there is often a wide divergence of opinion regarding resectability, the physician making the decision must be well versed in the various options and fully aware of what can and cannot be resected with reasonably satisfactory results. Clear-cut knowledge of the natural history of the disease is as important as knowledge of the surgical technique in making this decision. A Compromise of the Ablative Phase of Surgery to Accommodate Limited Reconstructive Skills Discussion When the ablative surgery is modified to such an extent that adequate resection with reasonable free margins is jeopardized to accommodate wound closure, a surgical error is committed. The surgeon must be well versed in both the ablative phase and the reconstructive phase of surgical management. Otherwise, the likelihood of cure is compromised or the patient is disabled. The reconstructive phase must at times take somewhat of a "back seat" to the ablative phase but never vice versa. Prevention. Complete training of the head and neck surgeon in all phases of ablative and reconstructive surgery is necessary. Compromise of Surgical Margins Because Radiation Therapy or Chemotherapy Was or Is to Be Given Discussion It is a sore temptation to limit the area of surgical resection because of a false sense of security deriving from a favorable radiation therapy and/or chemotherapy result that has either already occurred preoperatively or is anticipated postoperatively. Prevention. If radiation therapy and/or chemotherapy are utilized in combination with surgery, it is important that the surgery encompass the same area that would have been resected had it been the sole treatment modality. Careful record keeping of the size and extent of the primary neoplasm (at times with the use of tattoo and photographs) as well as the metastatic disease is most important to prevent this error.
Performing the Right Operation on the Wrong Patient Discussion This pitfall is closely allied with earlier items mentioned in certain respects but primarily concerns itself with the definition of resectability versus operability. A neoplasm may be technically resectable utilizing a specific surgical technique, yet the operation is not suited to the patient or the patient may not be in such physical condition to tolerate the operation or the consequences of the operation (e.g., cardiac and pulmonary diseases). Actually, in head and neck surgery, there are very few general medical or general surgical problems that totally interdict surgical management, yet there are contingencies that influence the selection of a surgical procedure; for example, a supraglottic laryngectomy may well be suited to the carcinoma of the larynx but not suited to the patient who is elderly with chronic pulmonary insufficiency. The same principle may also well apply to the use of a nondelayed flap in a patient with diabetes and severe arteriosclerosis. Prevention. Careful evaluation of the total patient in regard to all vital functions being certain that the patient can tolerate not only the operation but also the anesthesia as well as the sequelae of both is essential. Assessing the Degree of Success or Failure of Radiation Therapy on the Basis of the Response of the lesion During or Immediately on the Completion of Treatment Discussion There is a tendency among some physicians to decide prematurely that radiation therapy has failed when disease is still present on completion of this modality. Along the same line is the error of deciding that the neoplasm under treatment will not eventually have a successful outcome when, early or midway through the treatment, the response has been slow. Conversely, a rapid response during radiation therapy is sometimes improperly used as a justification to reduce total dosage. A high rate of response of a neoplasm does not have implications for the dose needed to sterilize the tumors. Prevention. The physician must realize that response to radiation therapy is varied during the course of treatment and that this may not necessarily indicate the final outcome. On completion of the planned full course of treatment, a 4- to 6-week interval should lapse before biopsy is performed again.
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On completion of the planned full course of radiotherapy treatment, continued response may extend up to 3 months and even possibly 4 months. Early re-biopsy is indicated if there is clinical evidence of changes indicating either a regrowth of the tumor or increase of the size of the original mass. After radiation therapy or chemotherapy, the over· lying mucosa may be intact, giving a false impression of a complete response (see section on chemotherapy). There may be viable tumor cells deep to the intact mucosa. Deep biopsy through edematous mucosa after radiation therapy is challenging and may not be productive.
may be in the chest, breast, abdomen, pelvis, ovaries, urinary bladder, or elsewhere. Prevention. In addition to a complete head and neck examination, a complete physical examination is a sine qua non for diagnosis and must be performed before commencement of definitive management of a head and neck neoplasm. This examination should include digital rectal and pelvic examination as indicated. Prolonged Watch-and-Wait Attitude in the Face of an Asymptomatic Mass Discussion
Failure to Realize the Implication of the "Condemned Mucosa" or Multiple Primary Syndrome Discussion Especially in patients with multiple areas of leukoplakia and/or erythroplakia, multiple primary tumors are not only a possibility but are also actually a probability. Even in the absence of these possible precancerous lesions, multiple primary tumors are a distinct possibility in a patient who already has one squamous cell carcinoma of the head and neck. This clinical entity is more common in the heavy tobacco and/or alcohol user. These are the patients who demonstrate the condemned mucosa. A tendency to "zero in" on the site of the first or original lesion in follow-up examination is only natural, and often a follow-up and repeat complete head and neck examination is bypassed, thus causing other lesions to be all too frequently overlooked. Prevention. A complete head and neck examination must be performed at frequent intervals in all patients who have demonstrated a primary squamous cell carcinoma of the head and neck. A recommended regimen for follow-up is reexamination every month for the first year, every second month for the second year, and so on, up to 6 years. Beyond 6 years, follow-up is suggested every 6 months. Cell type and extent of the original lesion could modify this regimen. Failure to Perform a Complete General Physical Examination as Well as a Complete Head and Neck Examination Discussion Unfortunately, the division of human anatomy into various regions, for example, head and neck, chest, abdomen, and pelvis, is not respected by neoplastic disease or, for that matter, by infectious disease or trauma. A mass in the neck may not necessarily represent primary disease above the clavicle. The primary disease
All too often either the patient or the primary care physician may delay the evaluation of a mass in the head and neck that is causing no pain or interference with the patient's normal function. This delay could well be a disaster. Prevention. Any abnormal mass must be promptly and completely evaluated, and it is then usually removed, depending on the findings and diagnosis. Inadequate Search for an "Occult" Primary Tumor Discussion There are patients seen who have histologically proven involvement of cervical lymph nodes by squamous cell carcinoma without an apparent primary lesion. Such a patient should not be placed in this unknown primary category until after a completely adequate diagnostic work-up has been done. Prevention. The only admonition for this problem is to repeat complete head and neck and general physical examinations with diagnostic studies including radiographs of the paranasal sinuses, nasopharynx, esophagus, and chest. Depending on the histologic findings on aspiration of the metastasis, other radiologic studies should be performed as indicated. Areas to scrutinize extremely carefully if the metastases are squamous cell carcinoma are the nasopharynx (vault, lateral walls, and posterior choanae, including posterior edge of septum), tonsils, base of the tongue, pyriform sinuses, and inferior portion of the laryngeal surface of the epiglottis. If open biopsy is necessary after all else has failed, it may well be performed in the operating room with frozen sections, so that, depending on the circumstances and histologic diagnosis, a radical neck dissection can then be performed without delay. At times, the location of the cervical metastasis may give an indication of the location of the primary tumor (e.g., posterior triangle node, nasopharynx [vault], subdigastric node; floor of the mouth, tongue, oropharynx,
BASIC CONSIDERATIONS
hypopharynx, larynx, maxillary sinus, sphenoidal sinus, and posterior portion of nasal septum). Nevertheless, remember the possibility of skipped metastasis. Abandonment of the Patient With Neck Metastasis From an Undetectable Primary Tumor Such a patient should not be abandoned but should be given the benefit of definitive treatment. If the cancer in the neck node is well differentiated and if the node is situated in the midportion of the lateral neck, it may possibly represent a so-called bronchogenic carcinoma, although there has been uncertainty about the existence of this entity. In such an instance, radical neck dissection is indicated, with careful subsequent followup in a continued search for a hidden primary tumor. In some patients, the long-term repeat examinations will eventually disclose the primary tumor, it is hoped, at a treatable stage. If the node shows undifferentiated squamous carcinoma and if the node is at the periphery of the usual neck dissection, the management is more controversial. Some clinicians would advise neck dissections, whereas others would advocate radiation therapy. When the neck is irradiated in such circumstances, a judgment is necessary as to whether the ports should encompass the sites of a possible undisclosed primary tumor, for example, nasopharynx or base of the tongue (refer to the earlier discussion Failure to Perform a Complete General Physical Examination as Well as a Complete Head and Neck Examination for additional suggestions). Despite the ominous situation of the undiscovered primary tumor, a significant number of such patients do achieve cure by a combination of surgical and radiotherapeutic approaches. Enucleation of Tumors of the Major Salivary Glands and Thyroid Gland Discussion
The practice of enucleation of circumscribed tumors of the major salivary glands (usually the parotid) and of the thyroid gland existed in the past and continues in the present. This procedure is inadequate, can spread disease, and makes subsequent surgery difficult. After enucleation of a benign mixed tumor from a salivary gland, the tumor will most likely recur; and as it recurs, transformation to a malignant form can take place. Enucleation of a thyroid nodule can lead to several problems: (1) Although frozen sections may appear benign, final sections could be malignant. The secondary operation thereby necessitated is quite hazardous because of the possibilities of injury to the recurrent laryngeal nerve and/or external branch of the superior laryngeal
nerve and/or loss of the parathyroid glands. (2) A second nodule, which was not perceptible, may be left behind. This latter nodule has on occasion proved to be the carcinoma. Prevention. With all tumors of the salivary glands and thyroid gland, the operation of choice is total lobectomy. With the parotid salivary glands, exposure of the seventh nerve is important. With the thyroid gland, exposure and preservation of the recurrent laryngeal nerve and preservation of the parathyroid glands and external branch of the superior laryngeal nerve are important. In relation to thyroid lobectomy, the word "total" is stressed, because it is suspected that all too often the surgeon calls an operation a total lobectomy when in fact a subtotal lobectomy has been performed. A portion of the thyroid lobe is likely to be left behind the posterior suspensory ligament (Gruber, Henle, Berry) of the thyroid, if meticulous care is not exercised. Treating a Patient With Antibiotics for an Extended Period of Time Without a Biopsy Discussion
It is not at all uncommon to see patients with tumors of the head and neck in whom the initial physician assumed an inflammatory lesion was present and prescribed antibiotics for extended periods of time. Prevention. Often, in such circumstances, after a reasonable period of no response to antibiotics, a more careful examination of the lesion would mandate a biopsy and thereby avoid an unwarranted delay in beginning definitive treatment of cancer.
The Place for Chemotherapy in Management of Squamous Cell Carcinoma of the Head and Neck Monica B. Spaulding
Until about 20 years ago, chemotherapy was used in head and neck cancer as a last resort in those patients who had either presented with metastatic disease or failed other treatment modalities. Many of these patients were of poor performance status, had lost weight and had tumor-related problems with nutrition, suffered from obstructive pulmonary disease, and had other medical problems. In spite of these factors and in spite of having a limited choice of drugs, head and neck cancer was one of the first solid tumors found to be responsive to chemotherapy. The number of drugs with activity in head and neck cancer is now quite long.
BASIC CONSIDERATIONS
More recently, there has been a great deal of interest in utilizing chemotherapy as part of the initial treatment plan in patients who present with advanced stage III and IV disease. The rationale for chemotherapy use is to improve the overall treatment results of standard therapy. Chemotherapy can be given as a neoadjuvant treatment, to shrink the tumor before surgery and/or radiation therapy. Concurrent chemotherapy can be given with radiation therapy, so that the patient receives chemotherapy daily, weekly, or less often while receiving daily radiation. Chemotherapy can be administered as an adjuvant, after completion of standard treatment, or "sandwiched" as a treatment between surgery and irradiation. Finally, the utilization of chemotherapy as an initial treatment modality has led to a proliferation of "organ preservation" trials in which the standard surgical treatment is eliminated or modified in the face of a good response to chemotherapy. Recurrent or Metastatic Head and Neck Cancer Single-Agent
Therapy
The goal of chemotherapy in patients with locally recurrent disease or metastatic disease is palliation. Head and neck cancer may recur locally in the head and neck area and be associated with pain, bleeding, difficulty swallowing, or obstruction of the respiratory tract or may be widely disseminated involving lung, bone, and liver. The first chemotherapy demonstrated to have significant activity against head and neck cancer was the folate analogue methotrexate. Methotrexate remains the standard against which all other drugs need to be tested. It has a response rate varying between 10% and 30%, is relatively inexpensive, can be given in the outpatient department by a bolus injection, and has predictable toxicity consisting of mucositis and myelosuppression. The mucositis is self-limited, lasting only 2 to 3 days, and is dose dependent. Reducing the dose reduces the degree of mucositis so that even its toxicity is easy to manage. Methotrexate can be given in higher doses followed 24 hours later with leucovorin, a folate analogue, which protects normal cells from toxicity. In spite of the leucovorin rescue, the risk of toxicity is greater with the higher dose regimens, but there is no significant increase in the response rates or the duration of response with any of these studies. Other drugs shown to have significant activity in head and neck cancer over the next decade were bleomycin and S-fluorouracil (S-FU). Bleomycin, although having a measurable response rate of approximately 20 %, was limited by its toxicity. It is not myelosuppressive but does cause mucositis and
has a predictable dose-limiting side effect of irreversible pulmonary fibrosis. S-FU has been known to have activity in head and neck cancer since early studies as well. Both drugs (S-FU given by continuous infusion) have been utilized primarily in locally advanced disease as part of drug combination and combined modality programs. The biggest breakthrough in the management of head and neck cancer was the development of cisplatin (formerly cis-platinum) as a chemotherapeutic agent. The recognition that cisplatin was active in head and neck cancer has had a major impact on therapy of this tumor. As a single agent, it has higher response rates than methotrexate; however, it does require careful attention to hydration and has more side effects. Because its toxicity profile is different than other available chemotherapy, it is an ideal drug to include in drug combinations for treating head and neck cancer. Most active drugs cause myelosuppression and stomatitis, but the dose-limiting toxicity of cisplatin is renal impairment, a problem that can be overcome by administering large volumes of fluid and, if necessary, diuretics, to ensure good renal output. Carboplatin, a platinum analogue, also has activity in head and neck cancer and does not cause renal impairment, but dosing is limited by myelotoxicity, particularly a reduction in the platelet count. There are new drugs undergoing phase II trials that offer significant promise in head and neck cancer. Paclitaxel (Taxo!) was developed from the bark of the yew tree and has proved to be active in a variety of solid tumors. Its has a unique mechanism of action that also makes it a logical drug to include with others in combination. As a single agent, its response rate is as high as 40% in patients with recurrent or metastatic head and neck cancer, making it one of the most active drugs available for head and neck cancer (Cortes-Funes and Aisner, 1997). Its use can be limited by neurotoxicity, which can be severe and unpredictable, although also quickly reversible. Docetaxel has the same mechanism of drug action and seems to have the same degree of activity in head and neck cancer, although the studies are more limited. Both drugs can cause significant myelosuppression with neutropenia; however, the use of growth factors appears to ameliorate this problem. Sepsis and other forms of infection are uncommon. Mucositis has not been noted. Gemcitabine, an antimetabolite, has undergone evaluation in a number of tumors including head and neck cancer. The drug has a relatively low response rate but is well tolerated and may be useful in combination therapy. Like many of the other agents, it appears to have synergistic activity when used with radiation therapy, and studies of its use with radiation therapy are ongoing. Other drugs with significant activity in head and neck cancer are cyclophosphamide, hydroxyurea, and vinorelbine.
BASIC CONSIDERATIONS
Combination
Chemotherapy
In attempts to improve response rates, active drugs have been combined in a variety of ways. The active combinations invariably include cisplatin. When the combinations have been compared to a single agent such as methotrexate or cisplatin, the combinations have higher response rates, but frequently with more toxicity. Methotrexate, as a single agent, has been compared with the combination of cisplatin and 5-FU and of carboplatin and 5-FU. The response rate to methotrexate alone was only 10%, whereas the response rate to the combination was 32 %. There was no improvement in survival. In another trial, cisplatin as a single agent was compared with 5-FU as a single agent and to a combination of the two agents. Again, the combination resulted in a response rate of 32 % whereas the single agents, cisplatin and 5-FU, had response rates of 17% and 13%, respectively. Again, in spite of the higher response rate, there was no improvement in survival. Toxicity rates were higher in the combination of two drugs as well. Browman and Cronin (1994) did a meta-analysis of randomized trials in head and neck cancer and pointed out that the proportion of patients suffering severe nausea and vomiting can be far greater when patients are treated with a combination of drugs. Because new drugs are being developed, and because drug combinations are usually more effective in terms of response rates, there will always be an incentive to find an effective but well-tolerated combination of chemotherapeutic agents for patients with head and neck cancer. The treatment goal for patients with recurrent or metastatic head and neck cancer is palliation, and the toxicity of combination treatments is very important. Combined Modality Therapy For patients with local/regionally advanced but nonmetastatic disease, chemotherapy has been used to improve the results of surgery and radiation therapy. Patients with advanced but resectable disease have traditionally been treated by surgery with radiation therapy. The goal of induction chemotherapy, given before surgery, is to shrink the tumor so that it is more likely that it can be completely eradicated by the standard therapy that follows. Tumor responses during induction chemotherapy are much more impressive than the response seen when the same chemotherapy is given when there is metastatic disease. Overall response rates exceeding 85 % are common, and complete response rates (no clinical evidence of residual tumor) as high as 66% have been reported. The reason for the difference is probably better drug delivery to the tumor before there are surgical and radiation therapy effects on the blood supply. It is unclear, however, that such a high response rate, even when followed by the same surgery, translates
into improved survival. A large number of single arm, phase Tl trials have been reported, and most cite better disease control and improved survival in patients receiving chemotherapy when compared with a historical control. The few randomized phase III trials that have been reported have failed to show a survival benefit to the induction chemotherapy. Although one can object to the randomized trials as having inadequate chemotherapy regimens, modified surgical approaches when there has been a response to chemotherapy, or inappropriate selection of patients, no new large-scale trial designed to correct those deficiencies is even contemplated. The number of patients required for such a study, the need for quality controls, and enormous fiscal and manpower cost make such an endeavor unlikely in the future. Lore and colleagues (1995) have published a single-institution study in which a single surgeon performed all procedures, patients were carefully selected to have advanced but resectable disease, and effective chemotherapy with high response rates was given. Their results were compared with a matched control of patients included in the Head and Neck Contracts Program and clearly showed improved survival and disease control. Adjuvant Chemotherapy In many tumors, such as breast and colon cancer, chemotherapy is administered after surgery. This has the advantage of using pathology to select patients with bad prognostic features who are likely to relapse after the surgical procedure. Johnson and colleagues (1996) reported a lO-year study in which all patients undergoing head and neck surgery at the University of Pittsburgh, who were found to have extracapsular spread in their resected specimen, were offered postoperative chemotherapy in addition to radiation treatment. Of the 371 patients eligible for the chemotherapy, only 131 (35%) consented to receive it; however, their survival was significantly better than those who had refused the recommended chemotherapy. A randomized adjuvant trial has been done in patients with advanced head and neck cancer by the Radiation Therapy Oncology Group. In this large trial, patients with stage III and IV resectable head and neck cancer were randomized to receive immediate radiation therapy after surgery or three courses of chemotherapy with cisplatin and 5-FU followed by radiation therapy after surgery. There were 448 patients enrolled in the trial, and after 5 years of follow-up there was no significant difference in survival between those receiving chemotherapy and those not receiving it. Although this trial, like other randomized trials, showed no significant survival benefit to receiving chemotherapy, there was a decreased risk of metastatic disease. This suggests that there is some benefit to utilizing chemotherapy as part of the initial approach to advanced head and neck cancer.
BASIC CONSIDERATIONS
Organ Preservation When induction chemotherapy trials were first initiated, there were some patients who had "fantastic" responses to the chemotherapy and no visible tumor after two or three courses. In most cases, the patients still underwent standard surgery and radiation therapy. In some patients, there was no residual tumor identified in the resected specimen. In other cases, the patients refused the recommended surgical procedure and accepted radiation therapy only, and the tumor did not recur. These observations gave a justification for a trial comparing standard surgical and radiation treatment to chemotherapy followed by radiation therapy to responders. In 1984, the Veterans Administration Cooperative Trials Program began a study comparing those two treatment approaches in patients with advanced resectable, laryngeal cancer. The goal was to see if a laryngectomy could be avoided without compromising survival. Quality of life should be improved in patients who retained their own larynx and preserved intelligible speech. All patients were followed closely, and a salvage laryngectomy was offered for patients who did not respond to chemotherapy and for those whose cancer recurred after chemotherapy and radiation therapy. The end results were that the survival was the same in both study arms, and two thirds of the patients in the chemotherapy arm had laryngeal preservation. Distant metastases were also reduced in those receiving chemotherapy. A similar study has been done by the European Organization for Research in the Treatment of Cancer (EORTC) with identical result. A three-arm study comparing induction chemotherapy followed by radiation therapy, radiation therapy alone, and concurrent chemotherapy and radiation therapy is now in progress under the auspices of the Radiation Therapy Oncology Group (RTOG). Concurrent Chemotherapy and Radiation Therapy Chemotherapy and radiotherapy can be administered concurrently to enhance the local effect of the radiation and to simultaneously treat distant metastases. Early studies looked at adding single agents, such as methotrexate, bleomycin, and 5-FU, to standard doses of radiation therapy, 200 cGy/day for 5 days per week, to a total dose of 6500 to 7000 cGy. Each of these chemotherapeutic agents has mucositis as a toxic side effect; and, not surprisingly, mucosal toxicity was enhanced in patients receiving the concurrent treatments. This sometimes led to frequent treatment interruptions or even noncompletion of the total treatment. To reduce the severity of the mucosal toxicity, drug doses were reduced to the point that there was unlikely to be a systemic effect. Nevertheless, there were several randomized trials that did show a benefit to the combined therapy.
Radiation therapy works best in well-oxygenated tissue. Some patients present with tumor that is massive, fixed, and unresectable. Frequently, such a patient is referred for palliative radiation therapy. CT may even show areas of central necrosis, suggesting poorly oxygenated tissue and implying the radiation therapy is unlikely to sterilize the area. Investigators at Yale University have shown that mitomycin, an alkylating agent that is more effective in the absence of oxygen, does improve the results of radiation therapy. In a study of 117 patients with advanced head and neck cancer randomized to standard radiation therapy or the same radiation therapy plus mitomycin, those patients receiving the chemotherapy had a longer disease-free and overall survival. With this agent there was not an increased incidence of acute mucosal toxicity during the radiation treatment. Cisplatin also appears to be a radiosensitizing agent and is an active single agent for head and neck cancer. In a study of patients with advanced nasopharyngeal cancer, Al-Sarraf and co-workers (1998) reported a significant benefit to concomitant chemoradiotherapy. All patients received 7000 cGy doses of radiation therapy given over 6 to 7 weeks. Those patients randomized to the chemoradiotherapy arm also received cisplat in (100 mg/m2) on days 1, 22, and 43 of the radiation therapy. They were also to receive three courses of adjuvant cisplatin and 5-FU after completing the irradiation. Recurrence-free survival was 69% for those receiving the combined treatment and only 24% for those treated with radiation. The 3-year survival was 76% in those receiving the combined treatment, whereas only 46% of the patients treated by radiation alone were altve at 3 years. Other studies of combined chemoradiotherapy are in process. Vokes and associates from the University of Chicago (1992) reported beneficial effects of induction chemotherapy followed by concurrent chemoradiotherapy, particularly for organ preservation in patients with advanced head and neck cancer. Conclusion The role of chemotherapy in the management of advanced head and neck cancer has been studied extensively. In those patients with recurrent or metastatic disease, newer drugs have been shown to have exciting activity with manageable toxicity. The interest in combined modality therapy as a first approach to advanced head and neck cancer is expanding, and there are a number of new drugs, new combinations, and new ways in which treatments can be integrated to improve the management of these tumors. The area of research is changing rapidly, and one would anticipate even more advances as investigators continue their clinical studies.
BASIC CONSIDERATIONS
Preoperative Chemotherapy, Uncompromised Surgery, and Selective Radiotherapy in the Management of Advanced Squamous Cell Carcinoma of the Head and Neck John M. Lore, Jr., Sol Kaufman, Nan Sundquist, and Kandala Chary
In the management of advanced squamous cell carcinoma of the head and neck, there are a number of management possibilities: I. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Surgery plus radiotherapy Radiotherapy alone Surgery alone Chemotherapy plus radiotherapy-sequential or concurrent (organ sparing) -7 "salvage" surgery Brachytherapy Preoperative chemotherapy, limited surgery, and radiotherapy Preoperative chemotherapy, uncompromised aggressive surgery, and selective radiotherapy Post-treatment chemotherapy-palliation Intra-arterial chemotherapy lntratumoral chemotherapy
Of the 10 options, 6 include various forms of chemotherapy used in various techniques. The preference of one of us (JML) is. preoperative chemotherapy, uncompromised aggressive surgery, and selective radiotherapy. Highpoints
I. Preoperative chemotherapy: Two to three courses as tolerated are suggested based on response and toleration. Advance from two courses to three courses 2. Surgery un compromised by any response to the chemotherapy 3. Selective radiotherapy
After Chemotherapy
1. The primary tumor site is resected with classic radical neck dissection with adequate margins regardless of any favorable response to chemotherapy. With classic radical neck dissection and after response to chemotherapy, functional or selected neck dissection should be modified only in relation to preservation of the 11th cranial nerve when commensurable with adequate ablative surgical procedure. 2. Frozen sections of margins: re-resect if margins are positive or deemed too close. 3. Perform selective radiotherapy. This choice is based on an evaluation of a prospective protocol, originally reported in .1995 (Lore et aI., 1995), and a 5- to 20-year follow-up presented in 2000 involving 93 consecutive patients, 82 of whom have completed the protocol. There were two preoperative chemotherapeutic regimens: regimen A-cisplatinjbleomycin, 45 patients; regimen B-cisplatinj5-FU, 37 patients. The extent of the aggressive surgery was carefully documented before chemotherapy with tattoo, drawings, and anatomic stamps. This was the strict guide for the uncompromised surgery after the chemotherapy. The selective postoperative radiotherapy was based on previously published criteria (National Institutes of Health, 1979), with modifications. 1. Highest superior and lowest inferior neck dissection nodes positive 2. Margins positive on permanent section 3. Tumor extending through the lymph node capsule (extracapsular spread) 4. Extension of disease beyond the fascial planes of the neck 5. Invasion of the deep cervical musculature 6. Recurrence within 6 weeks 7. Inclusion of patients who had multiple cervicallymphadenopathy. This was later modified according to the extent and location of the multiple cervical lymphadenopathy. That is, all patients with multiple positive nodes did not receive postoperative radiotherapy.
Treatment Criteria Before Chemotherapy
1. A careful and complete evaluation of disease is based on clinical, CT, MRI, and, at times, PET examinations. 2. The extent of the disease is documented using tattoo, drawings, photographs, and description. 3. The planned operation is outlined in detail.
The protocol commenced in 1979, and the latest evaluation was done in 1999. The protocol is still used with modifications of the chemotherapy plan, increasing the number of courses to three whenever there was a favorable response and the first two courses were well tolerated. Also, other chemotherapeutic agents were used, mainly paclitaxel (Taxo!), when the response to the original protocol was not as favorable. The 5- to 20-year follow-up results of this protocol were presented at the
BASIC CONSIDERATIONS
5th International Conference on Head and Neck Cancer in August 2000. They were also presented in November 2000 at the Great Lakes Head and Neck Conference in Buffalo, New York, and in September 2001 at the 2nd World Congress of the World Federation of Surgical Oncology Societies in Naples, Italy. The latest data on this protocol have been reported in the Annals of Surgical Oncology (Lore et a!., 2003). The following is taken in part from that publication, with permission of the publisher. This protocol is not randomized, although randomized controlled trials have been in the medical/surgical literature. Nevertheless, lack of randomization in this current study and many other surgical studies is not necessarily an obstacle for validity. As said in the conclusion of an article by Fung and Lore (2002), "The nature of the RCTs is that they are difficult to use to evaluate the surgical techniques." Ideally, a randomized controlled trial of this current study would include one surgical oncologist, one medical oncologist, one radiation oncologist, and one pathologist. Together these physicians would either be native or move for 2 to 4 years to India, Egypt, or Puerto Rico. They would only see and treat patients with squamous cell carcinoma of the head and neck. This still would not lessen the problem of uniform surgical technique, which can change from time to time even with the same surgeon. These patients were untreated, consecutive, operable, and resectable for cure, with stage III to IV squamous cell carcinoma of the head and neck, including the sites listed in Table 3-1. The surgery was performed by a single surgeon (JML), including all the ablative surgery and 95 % of the reconstructive surgery (no significant portion was done by a resident, fellow, or any other attending surgeon). The T classification was based on ulceration and extent of the firm submucosal indurated mass. When there was significant edema and fullness surrounding the tumor
TABLE3-2
~
Distribution by Site, Stage, and 'Ireatment Regimen (N - 82) TABLE 3-1
Stage
Regimen
Site
No.
m
IV
A
B
Larynx Hypopharynx Oropharynx Oral cavity Total
21 10 36 15 82
6 2
15 8
12 8 20 5 45
2 16 10 37
9
7 24
"
,~
27 8 58
9
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.
these areas were included in the wide resection of the primary lesion but did not alter the T classification. The latest evaluation (1999) was based on a minimum follow-up of 5 years, extending to 20 years when possible. The survival data are given in Table 3-2. Figures 3-14 to 3-17 present the data in graphic form. Absolute survival is based on death from any cause, whereas relative survival is based on adjustments for normal age/gender mortality based on the National Center for Health Statistics 1997 Life Table (Anderson, 1999). The recurrence data and analysis for the primary sites are in Table 3-3. Data for distant metastases are in Table 3-4. Regimen A was 10/45 (22 %), and regimen B was 2/37 (5%), which yields a significant P value of .03, indicating improved outcome of regimen B. Patients with carcinoma of the hypopharynx had the highest incidence of distant metastases, 4/10 patients (40%). The P value, comparing the hypopharynx with all other sites, is .015.
Selected Survival Probabilities 5 Years
10 Years
Group
No.
Absolute (%)
Relative (%)
Absolute (%)
Relative (%)
Totalgroup RegimenA (bleomycin) RegimenB (5-fluorouracil) Comparison of regimens A and B (P value)
82 45 37
60 46 77 .004
66 50 83 .003
45 36 46 .5
58 44 64 .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 fo-
Percent Absolute Survival 40
:::> ....J
o (f) ell
« f0-
20
rD
20
()
o
a: o
5
10
15
UJ
c..
TIMEFROMENTRY(YEARS)
o
FIGURE 3-14 Estimated absolute survival for total study group (N = 82) with 95% confidence bounds. (Reprinted from Lore JM Jr, Kaufman S, Sundquist N, Chary KK: Carcinoma of the head and neck: A 5- to 20year experience with preoperative chemotherapy, uncompromised surgery, and selective radiotherapy. Ann Surg Oncol1 0:645-653, 2003, with permission.)
Estimated Survival
....J
«
:> a: :::>
:::>
> ~
uJ
a:
(/)
w
>
60
~ ....J W
a:
40
f-
z
w ~ 20 w
f0-
rD
FIGURE3-15 Estimated absolute survival in regimens A and B. (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.)
~
(f)
UJ
15
....J
Confidence Bands
2: 80 > a:
5 10 TIME FROM ENTRY (YEARS)
20
()
c..
a: UJ
c.. 0
o
o
5 10 TIME FROM ENTRY (YEARS)
15
FIGURE 3-16 Estimated relative survival for total study group (N = 82) with 95% confidence bounds. (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 Oncol1 0:645-653, 2003, with permission.)
o
5
10
15
TIMEFROMENTRY(YEARS)
FIGURE 3-17 Estimated relative survival in regimens A and B. (Figures 3-15 and 3-1 7 tend to show that survival rates in regimen A approach those of regimen B after 5 years. This may not be statistically significant, because after 5 years the number of patients in that group is not representative inasmuch as they have not been able to be followed long enough into the 5- to 10-year bracket.) (Reprinted from Lore JM Jr, Kaufman S, Sundquist N, Chary KK: Carcinoma of the head and neck: A 5- to 20year experience with preoperative chemotherapy, uncompromised surgery, and selective radiotherapy. Ann Surg Oncol 10:645-653, 2003, with permission.)
BASIC CONSIDERATIONS
TABLE 3-3
Primary Site Recurrences (N - 9) Regimen
Site
No.
A (N ~ 45)
B (N ~ 37)
Total
Oropharynx Larynx Hypopharynx Oral cavity Total
36 21 10 15
6 I I 0 8
1 (10)* 0 0 0 1 (2%)
7 (19%) 1 (5%) 1 (10%) 0(0%)
(15, 20, 27, 35, 50, 93) * (alive at 150 mol (52)* (18%)
v
*Duration of survival in months. 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.
TABLE 3-4
Distant Metastasis (N - 12)
TABLE 3-5 Comparison of Clinical and Histologic Data Relative to Neck Metastasis
(15%)
Origin Site
No.
No. in Protocol
Metastasis Rate (%)
Hypopharynx Larynx Oropharynx Oral cavity Total
4 2 5 1 12
10 21 36 15 82
40%* 10% 14% 7% 15%
Regimen A: 10/45 (22 %). Regimen B: 2/37 (5%). P ~ .03. *Comparison of hypopharynx with all other sites (P ~ .015). 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.
Note: Positive nodes are based on histologic examination of neck dissection specimens after response to chemotherapy. Hence, actual positive nodes would be high in number, because some nodes will not demonstrate malignant cells after chemotherapy. Of 17 necks judged clinically negative, 5 (29%) were found to be histologically positive (as shown in Table 3-5, which further evaluates the comparison of clinical and histologic data). A similarly calculated error in clinical versus histologic evaluation of lymphadenopathy was reported as 21 % by Sako and colleagues (1964). Myers and associates (1998) evaluated PET scans in NO necks, in 14 patients having radical neck dissections without any preoperative chemotherapy or radiotherapy, and in 7 patients (50%) having positive nodes histologically. Five of these patients had positive PET scans. Six recurrences in the neck occurred in regimen A (13 %) (Tables 3-6 and 3-7). The difference is significant
Clinical Histologic
Positive
Negative
Total
Positive Negative Total
36 24 60
5 12 17
41 36 77
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.
(P = .03). In regimen A, the overall incidence of neck recurrence in the patients with radical neck dissection is 7.8%. All of the six patients died of disease with survival ranging from 13 to 71 months, which emphasizes the seriousness of neck recurrence (Table 3-8). Five of these patients received radiotherapy; one refused. A hypopharyngeal primary tumor is more likely than other primary sites to lead to neck recurrence: 2/10 (20%) in regimen A. Seven of the 10 patients with hypopharyngeal carcinoma with T3 and T4 lesions had total hypopharyngectomies with total laryngectomies whenever there was any significant involvement of the hypopharynx. With carcinoma of the larynx, which required a total laryngectomy, a total hypopharyngectomy was also performed when there was any significant involvement of the hypopharynx. Reconstruction was usually performed with a pectoralis major flap or a posterior tongue flap, each combined with a posterior dermal graft (see Figs. 8-2G and 21-7). Preservation of a narrow strip of posterior mucosa to facilitate a conduit for swelling was not done.
BASIC CONSIDERATIONS
TABLE3-7 Neck Dissection and Recurrence in Neck (N - 6)
TABLE3-6 Neck Recurrences in Regimen A· (N - 6) According to Site
Sitet
No.
Recurrences
Oropharynx Larynx Hypopharynx Total
20 12 8 45t
2 2 2 6
-There were no neck recurrences tThere were no neck recurrences
(10%) (17%) (25%) (13%)
Duration of Survival (mo)
Neck Dissection Radical neck dissection" Regimen A Regimen B Suprahyoid (all regimen A) No node dissection
16,36 13, 71 16, 16
in regimen B. for oral cavity primary tumors.
No. of Patients
Positive Nodes
Recurrences
77
41
6 (7.8%)
43 34 2
27 14 0
6 (13%) 0(0%) 0
3
Hotal comprises43 radical neck dissections and 2 suprahyoid neck dissections.
From LoreJM Jr, KaufmanS, Sundquist N, Chary KK:Carcinomaof the head and neck: A 5- 10 20-yearexperience with preoperative chemotherapy,uncompromised surgery,and selective radiotherapy.Ann Surg Oncol 10:645-653,2003, with permission.
A total of 19 patients received the selective postoperative radiotherapy; 8 patients received it early (within 6 weeks post operation) (Table 3-9). Twelve patients received late postoperative radiotherapy (1 patient received early and late irradiation) (Table 3-10). All of these patients that received late postoperative radiotherapy died of the disease, although 3 patients survived more than 5 years. Major complications, which were life threatening, occurred as follows: one intraoperative death due to a myocardial infarction occurring shortly after the incisions were made; one carotid artery blowout, which occurred 7 months after completion of late postoperative radiotherapy after a contralateral neck dissection; one perforated gastric ulcer (outcome was good); and one respiratory failure (this patient had a long history of respiratory problems and died). Other non-life-threatening surgical complications are listed in Table 3-11.
TABLE3-8
No functional
neck dissection.
All six patients dead of disease. RegimenA, 6; RegimenB, 0; P ~ .03. "Includes three simultaneous contralateral suprahyoid dissections. Reprintedfrom LoreJM Jr, KaufmanS, Sundquist N, Chary KK: Carcinomaof the head and neck: A 5- to 20-yearexperiencewith preoperative chemotherapy,uncompromisedsurgery,and selective radiotherapy.Ann Surg Oncol 1O:645-6S3, 2003, with permission.
Only two patients had significant adhesions of the metastatic disease to the internal and common carotid arteries, which precluded safe dissection. The carotid artery's resection and reconstitution with a graft was not feasible because the area involved was not resectable. Resection of the carotid artery (common or internal carotids) was not necessary except for the 2 patients listed earlier. This indicated a favorable effect of the chemotherapy relative to clear surgical planes surrounding these vessels despite the proximity of tumor. Five hundred frozen sections were performed on all but 2 patients. Analysis of data on the frozen sections at the primary site suggested frozen section aided in the reduction of positive margins on permanent section.
Recurrences in the Neck (N - 6) (All in Ann A)
Primary Site
Details of Recurrence
Oropharynx Oropharynx" Hypopharynx Larynx Larynx Hypopharynx
Supraclavicular, infraclavicular, and mediastinal disease Recurrence at levels II, III, and IV Extracapsular spread Soft tissue involvement Recurrence at levels II and III Invasion of muscle (extracapsular spread)
Survival (mo)
Outcome
16
000 000 000 000 000 000
36 16 71 13 16
·Patient refused radiotherapy.
ODD,dead of disease. Reprintedfrom LoreJM Jr, KaufmanS, Sundquist N, Chary KK:Carcinomaof the head and neck: A S- to 20-yearexperiencewith preoperativechemotherapy,uncompromisedsurgery, and selective radiotherapy.Ann Surg Oncol 10:645-653,2003, with pennission.
BASIC CONSIDERATIONS
TABLE 3-9
Early Selective Postoperative
Radiotherapy
(N - 8)
Regimen A Primary Site
Regimen B Primary Site
Oropharynx
Hypopharynx
Oropharynx
Larynx
Hypopharynx
Indication
(N
(N
(N
(N
(N
Highest node positive Margins positive (on permanent section) Extracapsular spread Invasion of cervical musculature Early recurrence at primary site Highest node and margins positive
LFU at 3 mo
=
20)
=
8)
=
16)
DOC at 26 mo
=
9)
=
2)
DOC at 11 mo
DOD at 16 mo
DOD at 4 mo Alive at 82
IDO
DOD at 10 mo DOD at 8 mo
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 the primary site and underwent resection. Of these 4, only 1 had positive frozen sections on permanent section and only I patient died of disease. In a previous clinical trial (Lore et aI., 1989) evaluating the surgical complications after preoperative chemotherapy
TABLE 3-10
Late Postoperative Radiotherapy
(N
using a regimen similar to regimen A, it was reported that the surgical complications were no greater and actually less when compared with historical data of surgery alone than when combined with preoperative chemotherapy and selective radiotherapy. Evaluation of surgical complications were as follows:
= 12)
Regimen A Primary Site
Regimen B Primary Site
Oropharynx
Larynx
Hypopharynx
Oropharynx
Larynx
Indication
(N
(N
(N
(N = 16)
(N
Recurrence at primary site Recurrence in neck Second primary Metastasis to contralateral neck
3 DOD at 6, 15, 27 mo
=
20)
DOD at 35 mo DOD at 18 mo DOD at 45 mo
=
12)
=
8)
=
9)
DOD at 50 mo DOD at 71 mo
DOD at 16*, 16, 100 mo DOD at 75 mo
"'This patient also received early postoperative radiotherapy. DOD, dead of disease. 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, un compromised surgery, and selective radiotherapy. Ann Surg OncollO:645-653, 2003, with permission.
BASIC CONSIDERATIONS
TABLE3-11 Non-ute- Threatening Surgk:al Complications Complication
No. (%]
Pharyngoesophageal stricture Dysphagia (functional] Prolonged dysphagia Infection Fistula Tongue (tethered; limited mobility; anterior one third slough] Dehiscence (flap) Aspiration pleural effusion Poor wound healing Edema (left upper extremity] Intractable pain Narrowed cervical esophagus (beyond area of surgery] Exacerbation of cardiopulmonary problem Total patients
6 5 2 4 3 3
(7) (6) (2) (5] (4) (4)
1 1 I I I I
(1) (1) (I) (I) (1) (I)
1 (I)
24' (29)
'Some patients with multiple complications. Reprinted from Lore JM Jr, Kaufman S, Sundquist N, Chary KK: Carcinoma of the head and neck: A S- to 20-year experience with preoperative chemotherapy, uncompromised surgery, and selective radiotherapy. Ann Surg Oncol 1O:64S-6S3,2003, with permission.
• • • • •
• • •
Minimal to no flap necrosis Minimal incidence of oral cutaneous fistula Excellent wound healing Absence of carotid artery blowout after surgery (one blowout was following late postoperative radiotherapy) Good to excellent surgical anatomic planes especially around major vessels, thus aiding in preserving the major blood vessels Improved deglutition and hence improved nutritional status Improved airway when this has been compromised by the neoplasm Reduction in the necessity for pretreatment tracheostomy relative to airway compromise
Discussion Although there were no controls, per se, in the protocol, the use of two different regimens, A and B, demonstrated regimen B with 5-FU to be better. Regimen A, then, serves as an internal control, providing evidence that preoperative chemotherapy can make a difference since there is a significant difference between the two regimens (P = .004). Aggressive surgery is a sine qua non in the management of advanced head and neck squamous cell carcinoma. All else is complementary to the surgery.
Chemotherapy and radiotherapy are the adjuncts that require fine tuning. No compromise of the ablative surgery should be allowed, regardless of the response to the preoperative chemotherapy (Fig. 3-18). Regimen B is preferred. When preoperative chemotherapy is substituted for routine, postoperative radiotherapy, this allows the irradiation to be available for any recalcitrant recurrence. Once a complete therapeutic dose (e.g., 7000 cGy) is used as a routine, irradiation no longer should be used with the same ports or overlying ports. One recent report indicates that an overriding port is feasible. Radical neck dissection is preferred because speculation regarding the extent of the neck disease is thus no longer a worry or possibility. Remember neck recurrences are a serious event. Patients in regimen B had no neck recurrences. Functional neck dissection is not used in squamous cell carcinoma of the neck. A supraomohyoid neck dissection is not even considered. A suprahyoid neck dissection is used only in selected circumstances. The 11th cranial nerve is preserved if there is no disease at levels II or IV. As time goes by, modification of regimen B has been extended to three courses if the chemotherapy is well tolerated. Other agents, for example, paclitaxel, are included if the response has been poor to 5-FU. Preoperative chemotherapy may lessen the requirement for routine postoperative radiotherapy. Liberal use of frozen section with immediate re-resection could well be a contributing factor in the overall improved survival rate. Another important finding was the area in the clinical appraisal of the neck disease relative to both positive and negative lymph node evaluation. There was an error of 29% relative to clinical negative necks being histologically positive after neck dissection (see Table 3-5). This observation is similar to that (27%) reported by Sako and colleagues (1964) in an evaluation of neck metastases. There should be a reduction in this clinical error as imaging techniques improve with CT, MRI, and PET.
With chemotherapy and radiotherapy, either alone or combined, one never really knows whether the node was positive or negative, unless a pretreatment fine-needle aspiration or open biopsy was performed-the latter, one hopes, not done unless absolutely necessary. Fineneedle aspiration, if negative for malignant cells, may have missed the malignant cells. The same applies to the problem of preoperative chemotherapy as to whether a cervical node was negative or positive before treatment. Unless the pathologist is extremely adept, he or she may not recognize that a positive node favorably responded to the pretreatment chemotherapy. A finding in the lymph node with foreign body granulation reaction, keratin, but no true keratinization and fibrosis is an indication that a node was positive before the chemotherapy.
BASIC CONSIDERATIONS
centage of complete responders have persistent deep tumors or nodal involvement." (See Fig. 3-18.) Additional Comments As a corollary to the discussion, it appears that widespread use of radiotherapy as a routine postoperative modality is fraught with the misconception for the surgeon that margins are of little concern because the routine use of postoperative radiotherapy will adequately treat any residual disease. Although radiotherapy plays an important part in the management of head and neck squamous cell carcinoma, it is not to be used as a false sense of security for the surgeon; hence it is believed that it should not be routine. Another reason for substituting preoperative chemotherapy for the routine use of postoperative radiotherapy at the initial treatment phase is that the radiotherapy would then be available during the follow-up postoperative phase if indicated. It is very interesting to note data that were reported (January 2000) comparing mastectomyjlumpectomy in younger women and older women. The researcher on this article, Dr. Frank Vicini of the William Beaumont Hospital in Royal Oak, Michigan, states, "You have to do bigger surgeries to make sure you have all the cancer cells." Vicini concluded by saying, "The postsurgical radiation cannot compensate for a too-small cut." Other supports from the literature regarding surgery as the mainstay are: FIGURE 3-18 Photomicrograph of viable tumor cells (arrow) deep to regenerated mueous membrane in a patient who had 90% response to chemotherapy (hematoxylin and eosin, low power). This demonstrates the importance of tattoo so that the resection includes the area of the neoplasm before the response to chemotherapy; otherwise viable tumor cells would be left behind, leading to recurrence. (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 Oneol1 0:645-653, 2003, with permission.) Another factor in the evaluation of metastasis, which could be a problem, is a small positive node in a neck dissection, which may be missed in the evaluation of the gross specimen. Tracheostomy for obstructing lesions of the airway is seldom necessary with preoperative chemotherapy. Local recurrence at the primary site, neck, and distant metastasis is less. This same finding of viable tumor cells beneath healed, intact, normal mucosa has been reported in evaluation of preoperative chemotherapy in the treatment of rectal carcinoma. Hiotis and colleagues (2002) said, "A significant per-
1. Beauvillian and co-workers (1997) said, "This study indicates that a routine conservative approach should not be performed in patients with advanced squamous cell hypo pharyngeal carcinoma after neoadjuvant chemotherapy because surgery offers better results in terms of local control and survival." 2. Jones and associates (1996) stated, "The most satisfactory treatment is, of course, to completely excise the tumor at the first operation, and intraoperative frozen section histologic examination is helpful in achieving this end." This article was in reference to the management of head and neck squamous cell carcinoma. 3. The routine use of postoperative radiotherapy in the management of lung cancer has been in question, as reported by the PORT Meta-analysis Trialists Group (1998) . 4. Forastiere and co-workers (2002) stated, "Aggressive surgical resection is the cornerstone of therapy, with increasing roles for both radiation and chemotherapy, especially for organ preservation." 5. Bruce W. Pearson, of the Mayo Clinic at Jacksonville, Florida, said of one of the 82 patients in the protocol, "Mary is now 11.5 years post-right oropharyngectomy, partial mandibulectomy and right pectoral myocutaneous flap for squamous cell carcinoma of the right oropharynx. She had preoperative chemo-
BASIC CONSIDERATIONS
therapy but no radiation. In summary, Mary is an outstanding-outcome patient who has achieved, I am sure, a cure without the long-term indignities of radiotherapy effect." All these data, even though some are anecdotal, indicate that surgery, uncompromised, carefully planned, and all encompassing, is the important modality in the management of not all but most malignant lesions. Chemotherapy and radiotherapy require fine tuning, and each has a significant part in the overall planning of the treatment of squamous cell carcinoma of the head and neck. Organ Preservation
Most of the data regarding organ preservation are related to the larynx, with 5-year survival figures scarce. Failure of that treatment and the surgical salvage with its complications in the report of recurrent disease, which can be advanced, must be taken into account both in calculation of survival data, and in explanation to the patient, regarding this option. The focus of this alternative is on organ preservation to enhance quality of life while attempting minimal degradation along with survival. Whether the latter objective is realistic remains to be clarified. Review of a sampling from the recent literature (including sequential and concurrent modalities and covering the four major primary sites treated in the present paper) demonstrates three 5-year survivals in the range from 28% to 47%, a 4-year survival of 60% (larynx), and a 3-year survival of 51%. Direct comparison of these numbers with the present study outcomes would, of course, not be valid because of noncomparability in the distributions of patient and disease characteristics. On the other hand, the authors of the reviewed studies generally assert the need for significant improvements in control of the disease. One surgeon's (JML) experience indicates the more serious side effects relative to quality of life perspective is not from voice loss, which can be handled with tracheoesophageal device, electric larynx, or, in some patients, with true esophageal speech, but rather dysphagia, which all too often becomes a chronic disability and extremely difficult to manage long term. The following references provide valuable data on organ-preservation survival: Department of Veterans Affairs Laryngeal Cancer Study Group (1991); Urba and colleagues (2000); Kim and associates (2001); Suntharalingam and associates (2001); and Calais and co-workers (2000). Summary of Methodology
A summary of the methods that are favorable factors potentially contributing to improved survival are as follows:
1. Careful and complete evaluation of the extent of disease a. Primary tumor b. Neck metastasis c. Distant metastasis 2. Recording of the extent of disease (recording modalities: tattoo, written description, diagram, photographs) a. Primary tumor i. Size ii. Ulceration ili. Mass iv. Induration v. Edema b. Neck metastasis I. Levels/zones 11. Size lll. Multiplicity IV. Bilateral v. "Fixation"-presence and degree c. Outline of the planned surgical procedure 3. Chemotherapy-two courses/three courses a. Modification of dosages based on toxicity using standard criteria b. Regimen A is cisplatin and bleomycin c. Regimen B is cisplatin and 5-FU d. Addition of paclitaxel and possibility of other agents as per molecular biology 4. Surgery a. Area resected based on the pre-chemotherapy recorded extent of disease, not on any favorable response to chemotherapy b. Free use of frozen sections to assess possible involvement of margins (500 frozen sections on 80 of the 82 patients with 285 at the primary site and 215 of the neck-58 positive in 26 patients) c. Review of gross surgical specimen with pathologist at the time of surgery 5. Postoperative radiotherapy: selective, not routine; based on criteria published in National Institutes of Health report (1979) 6. Follow-up-for the lifetime of the patient a. First year: every month b. Second year: every second month c. Third year: every third month d. Fourth year: every fourth month e. Fifth year: every fifth month f. Sixth year and after: two times per year, or sooner depending on the postoperative course and histology; for example, sooner at any time there is recurrence, whether at the primary site, or the neck, or distant metastasis, or a second primary tumor 7. Extent of follow-up a. Complete head and neck examination
BASIC CONSIDERATIONS
b. Annual chest radiograph-preferably CT with mediastinum in search for metastasis and a second primary tumor c. Images-CT and/or MRI of the head and neck; frequency depends on the clinical history, findings, and final pathology, specifically in relation to number of nodes positive in the neck d. Complete head and neck examination to search for possible second primary tumors, even after 8 to 10 years' survival following first primary tumor Comments on the Previous Data by a Reviewer (Reviewer Unknown to the Authors) "This is a very thorough and complete study of the management of advanced stage III and IV squamous cell carcinoma of the head and neck. It has eliminated many of the criticisms of studies being at a single institution by a single surgeon with very standardized surgery including a standard management of the neck and primary site performed over a period of 20 years. The study is nonrandomized between the two arms with the majority of the cis-platinum/bleomycin patients being treated earlier in the study and the majority of the cisplatinum/5-FU patients who had a statistically definitely better survival, fewer distant metastases in the latter part of the study. "The major point of the paper is that preoperative chemotherapy does not change in any way the need for the previously-planned surgery. Radiotherapy is given for specific reasons. The conclusions reached by the author are far reaching: (1) that preoperative chemotherapy does not predict the need for less surgery or a potential better outcome (This, of course, is the mainstay for many of the current organ preservation regimens that believe that response to chemotherapy may predict patients with a potential improved survival or at least an option to preserve the larynx.); (2) that a standard neck dissection with preservation of the 11th nerve is required in all patients who initially had positive adenopathy in fear that residual malignancy may be missed in the neck; (3) that preoperative chemotherapy may lessen the requirement for postoperative radiotherapy; (4) that preoperative chemotherapy in select patients may reduce the incidence of distant metastases; and (5) that it is essential to document the initial extent of the primary and regardless of the response to the preoperative chemotherapy: the original area with a large margin must be resected. "It is for the reason above that I recommend publication of this article because of its value in substantiating the role of surgery as a primary modality not influenced by the effect of the chemotherapy. It provides specific survival information when the standard regimen is used consistently without any variation. It also reflects
the vast experience of a senior surgeon with expertise in the field of head and neck surgery." Conclusions • Improved survival: regimen B: absolute 76.7%, relative 83.4%
• • • •
Low incidence of distant metastasis: 5 % regimen B No neck recurrence: regimen B Recurrence at the primary site: 5% regimen B Surgery is a mainstay in the treatment of advanced squamous cell carcinoma of the head and neck. Chemotherapy and radiotherapy are important adjuncts that require fine tuning.
Acknowledgments The authors thank Ernesto Oiaz-Ordaz, MO, for his dedicated work in the review of the 93 patients relative to the initial review in the publication of the 1995 article (Lore et aI., 1995). We also thank the following Fellows in Advanced Oncologic Head and Neck Surgery: Frank Goldzer, Lawrence Teruel, Stoyan Kokocharov, Michael Medina, Robert Fowler, and Elbastar Mahmoud.
A Comprehensive, Interdisciplinary Head and Neck Service --------------
John M. Lore, ir., A. Charles Massaro, and Angela Bontempo
One solution to the problem of a joint cooperative effort in the complete management of the patient with carcinoma involving the head and neck can be achieved by the development of a head and neck oncology service. This service was formed at Sisters of Charity Hospital in Buffalo, New York, in the early 1990s. This endeavor requires the dedication and support from administration. When this latter aspect fails, then this concept of a patient care, academic, and educational facility no longer exists. In any event, below is the outline. This was successful for a period of approximately 8 years. Over the years, management of neoplastic disease, as well as other diseases, crosses time-honored established disciplines. In head and neck neoplasia, surgical, medical, and radiation oncology, as well as other supportive disciplines and services are involved. The input from these disciplines is usually achieved by multidiscipline conferences. To further develop this ecumenical approach, to avoid "turf battles," and to further enhance cooperative and closer exchange of ideas regarding diagnosis and management of head and neck neoplasia, a Head and Neck Oncology Service within the Head and Neck Center at Sisters Hospital, Buffalo, New York, was established in 1993. This service encompasses the above
BASIC CONSIDERATIONS
disciplines plus all other germane disciplines and services numbering over 20. The main purpose is to render the best possible patient care, to attract the best-qualified physicians and other professionals, thus sifting out the dabblers, and to promote an academic atmosphere. This oncology service functions as an autonomous service with the cooperation and support of the chairman of Surgery and Internal Medicine. The service, however, is not a separate department and has no representative on the executive committee of the hospital. The service is responsible for its own quality review data, which is supplied to the Continuous Quality Improvement Hospital Committee. Outpatient, inpatient, speech and swallowing clinic, and laboratory, physician's, fellow's, nurse clinician's offices, as well as oncologic dentistry and oral facial medicine, conference rooms, library and nutritionist's office and microsurgical laboratory are all contiguous on the same floor of the hospital. Also on the same floor is the pathology laboratory, where fineneedle aspirations can be analyzed and reported within 30 minutes to 1 hour. One floor above is the operating rooms and intensive care unit. One floor below is diagnostic and nuclear medicine. It appears that this approach to head and neck neoplasia, including thyroid and parathyroid tumors, truly improves patient care without the stigma of "treatment by committee" and avoiding the wasted time involved in "turf" conflicts. The Head and Neck Oncology Service is a complex system in which the sum of all the components is much greater for patient care than is any independent part.
Bone Imaging and Pathology Scott Cholewinski, John Asinvatham, Daniel Broderick, and John M. Lore, Jr.
Methods of Bone Involvement: Mandible 1. Direct gross extension of a juxtaposed malignant neoplasm through intact periosteum and cortex into the marrow cavity is not very common. 2. More often, the extension is through the site of a tooth socket, or the periodontal region, or retromolar trigone or related to an alveolar ridge with absent dentition. It is very important to have the patient remove all dentures and to scrutinize areas hidden by a denture. 3. Another route of bone invasion can be metastatic, usually the bloodstream. The concept of lymphatic spread has not been substantiated, although lymphatics may be demonstrated in periosteum accompanying the small arteries. 4. When periosteum is involved by tumor, the tumor cells can enter the cortical bone through Volkmann's canals and into the haversian system and then into the marrow (medulla).
5. Involvement foramina.
may occur
through
neurovascular
There is paramount concern regarding the mandible in the absence of direct gross invasion of the periosteum and cortex when there is a malignant juxtaposed neoplasm. This is an increased concern when there are varying degrees of fixation and extent of fixation to the mandible. Decisions regarding mandibular resection are based on the following: 1. Juxtaposed neoplasm fixed to the bone 2. Imaging a. Routine standard radiographs, as well as CT, will only demonstrate a grossly ulcerative lesion of the cortex. b. MRI, in the absence of grossly ulcerative cortical lesion, can be of help to the surgeon regarding a decision of mandibular resection-segmental or marginal with preservation of the mandible. An MRI can indicate a pathologic process if there is a change in the marrow. Normal marrow has a whitish color comparable to adipose tissue on Tl-weighted image due to marrow fat content. Abnormal marrow has a grayish discoloration. This could be caused by edema, neoplasia, inflammation, or other diseases. Thus, when there is a neoplasm juxtaposed to the mandible and there is abnormal 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 better to err on resection of a portion or margin of the mandible than assume the attitude of wait and see or use postoperative radiation therapy. Intraoperative smears of the marrow at the ends of a marginal resected area may be worthwhile to histologically evaluate the presence or absence of abnormal marrow cells. Figure 3-19 is a schematic sketch of an MRI cross section of mandible, demonstrating (I) juxtaposed neoplasm involving muscle; (2) periosteum (black line); (3) cortex (black line); (4) marrow; (5) cortex (black line); (6) periosteum (black line); and (7) juxtaposed neoplastic process. This drawing illustrates a muscle with evidence of invasion by neoplasm that is adherent to the periosteum (the narrow black line). The cortex appears intact, yet the marrow is grayish rather than its typical white appearance. This is a suggestion of infection or neoplasia or some other disease within the marrow when using a Tl-weighted image. This finding, plus the muscle with neoplasia adherent to the periosteum, is an indication to resect bone. In addition, an abnormality of the periosteum is suggested with a high signal on the T2-weighted image. The heavy black lines in the schematic represent 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 lines equates once again the cortex and the surrounding periosteum. Note that the marrow is not white but grayish. (Drawing courtesy of Daniel Broderick, MD.) Involvement of periosteum is an indication to remove the underlying cortex, because if adjacent cortex remains, the margin would then be a to 1.0 mm and hardly adequate. This would be the error if involved periosteum were stripped from the cortex with a periosteal elevator. One answer to this dilemma is treatment with ionizing radiation postoperatively. Some surgeons (e.g., JML) do not agree: it is better to remove the adjacent bone and the margin if possible or perform segmental resection of the mandible with reconstruction. This appears to be more valid in the younger patient, because the longterm effect of radiotherapy is questionable. Imaging evaluation with MRI is very valuable, because involvement of periosteum can at times be readily ascertained. Actual erosion of the cortex can occur but is not very common. The periosteum, which is juxtaposed to the tumor, may well be involved with the neoplasia. CT (using bone windows) is the basic imaging for cortical involvement, whereas MRI is ideal for evaluating marrow and periosteum. Dr. Broderick writes, "On routine Tl-weighted magnetic resonance (MR) images, the cortex and the marrow of the bone are easily distinguished with the decreased Tl signal intensity of the dense cortical bone and the increased Tl signal intensity of the fatty marrow. The periosteum is rarely evident as separate from the adjacent cortex. The increased Tl signal intensity of normal fat adjacent to the cortex/periosteum is readily visualized. When tumor extends to the cortex and obliterates the adjacent fat, invasion of the periosteum and bony cortex cannot be excluded. Altered signal intensity of the marrow (namely, decreased Tl and increased T2 signal intensity) may reflect marrow edema and/or neoplastic invasion."
Voice, Speech, and Swallowing Rehabilitation of the Head and Neck Patient Allen M. Richmond
The speech pathologist's role in working with the head and neck patient appears to grow out of real day-to-day clinical concerns. The head and neck surgeon may meet situations that demand time-consuming and comprehensive solutions. The problems that develop may need a model based on crisis intervention for solution, as proposed by Salazar-Sanchez and Stark (1972) for the laryngectomy patient. Other types of problems, even those involving extensive head and neck surgery, may involve less complicated, but appropriately timed intervention to maximize rehabilitation potential. Total Laryngectomy Evaluation, treatment, and rehabilitation of the laryngectomized patient involve a comprehensive approach that takes into account the psychosocial concerns as well as the physical limitations of the patient. Significant depressive reactions can occur as a result of surgery for cancer. Sutherland and Orbach (1953) relate postoperative depression to a sense of injury and often to important changes in the patient's functioning in the life situation. Conley (1985), in discussing the changes that occur as a result of surgical intervention in head and neck cancer, states that "It automatically generates fear, depression, and possible annihilation mixed with hope for cure, palliation programs, experiments, philosophies, calculations, emotions, and fantasies which the doctor and the patient can have regarding this confrontation." He further states that "regardless of the amount and quality of external support, [the patient] is singular and alone." Preoperative visitation by the speech pathologist with a focus on the method and timing of the visit may
BASIC CONSIDERATIONS
be helpful (Richmond, 1982). In addition, a visit by a laryngectomized patient can be arranged by the speech pathologist, who should find a suitable visitor that may share some common connection with the patient. Information on a wide variety of areas facilitates the informed consent of the patient. Discussion and description of types of alaryngeal communication, such as the artificial larynx and other augmentative communication devices, esophageal speech and the tracheoesophageal puncture (TEP), may be helpful. The AIdes and LowryRomero protocol (1982) includes a review of physical and lifestyle changes such as taste, smell, bathing, showering, coughing, throat clearing, lifting, dry nasal passages, hygiene, sex, smoking, drinking, first aid, humidity, cold air, and care of the stoma. Methods of Communication Artificial Larynx and Other Augmentative Communication Devices
Initial communication efforts can be facilitated through the use of an artificial larynx, either intraoral or transcervical, communication charts, and writing materials, such as a dry erase board and marker. Excellent lowcost word processing units are of help to some patients. Patients who are unable to acquire skills necessary to use the telephone can use e-mail, fax, prerecorded messages, answering machines, and special automated emergency call systems to provide some help. Illiterate patients may experience considerable frustration until they can be evaluated and fitted for an artificial larynx. Interpreters can assist patients whose primary language is different from that of the speech pathologist or physician. Bilingual family members can frequently be an asset in bridging the linguistic gap. They may be helpful throughout the therapy process in explaining therapy techniques, describing options, and defining therapy goals. Esophageal Speech
Esophageal speech continues to form a part of the communication rehabilitation process for some patients, although it is no longer the method of choice in the United States. Webster and Duguay (1990) reported on 1003 laryngectomy operations performed across the nation: the most prevalent type of post-laryngectomy speech used was "tracheoesophageal shunt speech," now commonly referred to as tracheoesophageal puncture (TEP), at 38.1%. Weinberg (1981) estimated that 25% to 50% of patients do not learn serviceable esophageal speech. Patients are not able to learn serviceable esophageal speech because of such factors as cranial nerve involvement, strictures, flaccid pharyngoesophageal segment, hiatal hernia, achalasia, poor diaphragmatic movement, stomach ulcers, and emphysema (Duguay,
1979). In a similar context Damste (1979) reports possible factors limiting the learning of esophageal speech, which include wound healing, diverticula, fistula, and amount of tissue in the pharyngeal wall. Tracheoesophageal Puncture
The TEP is a primary consideration for voice restoration with the post-laryngectomy patient. Considerable improvement and development of TEP methods have been effected, dating back to the early innovation of the externally placed valve, which can produce fingerfree fluent speech. Blom and colleagues (1982), 810m and Hamaker (1996), and Hilgers and associates (1995) have improved the technology, with the first handmade device introduced by Blom and Singer in 1978 to the most recent designs and equipment innovations. A preliminary insufflation test is effective to determine potential for cricopharyngeal spasm before surgery. This difficulty may preclude successful surgery unless myotomy or neurectomy is carried out to facilitate air flow through the neoglottis (see Chapter 20). Botox injection is now a method of choice for reducing spasm (BJom and Hamaker, 1996).
Conservation Surgery: Cancer of the Larynx Conservation surgery for cancer of the larynx may require voice refinement procedures (Doyle, 1997), special vocal treatment strategies focusing on specialized types of tracheotomy tubes, and augmentative communicative procedures (Mason, 1993) and/or special swallowing diagnostic and therapy procedures (Richmond, 1997). On occasion, patients may be placed on ventilators, both preoperatively and postoperatively. Doyle (1997) refers to improved diagnostic procedures for malignant lesions and more accurate identification of histologic character, loci, and spread of disease that result in an altered conceptual framework for treatment. Important goals of treatment can involve sphincteric and phonatory functions that include safe swallowing, adequate nutrition, and postoperative voice conservation (Bailey, 1985). Swallowing Swallowing Problems
Swallowing difficulties often accompany conservation surgery procedures. These swallowing difficulties may be amenable to special techniques of management. Logemann (1993) stresses the importance of relating the swallowing dysfunction to the exact extent of the patient's surgical resection to account for variations in surgical procedure. Richmond (1992) reviewed the swallow
BASIC CONSIDERATIONS
status of patients who had oropharyngeal dysphagia. He found that patients with posterior tongue and pharyngeal surgery had the poorest swallow rehabilitation results. Problems that mayor may not result in aspiration include delayed pharyngeal swallow reflex, delayed elevation of the larynx, inability to protect the larynx by vocal fold closure, cricopharyngeal dysfunction, incomplete or delayed velopharyngeal closure, limitations in pharyngeal motility, pharyngeal and esophageal pressure deviations, and general timing dysfunction. Pharyngeal and esophageal pressure deviations are often minimized in evaluation and treatment, but they are important facets of swallow function. In a study of pressure function, McConnel and co-workers (1988) report on manofluorographic analysis of swallowing. They studied the pharyngeal swallow with strain gauge pressure sensors that recorded pressure, anatomic events, and bolus transit on videotape, in coordination with lateral view fluoroscopic swallow study recorded on the left side of the video screen. They determined that an important factor for the pharyngeal swallow is the establishment of a pressure gradient for bolus passage. The oropharynx generates a propulsive pressure and the hypopharynx generates a negative pressure. The analysis of this twopump system facilitates a means for more precise quantification of swallow function. Multi-faceted swallowing difficulties are diagnosed through instrumental assessment. Instrumental assessments of swallow function include videofluoroscopy, flexible fiberoptic endoscopy, ultrasound, electromyography, electroglottography, and the measurement of temporal association between respiration and swallowing (Perlman, 1997). Additional instrumental imaging technologies may include scintigraphy, X-ray microbeam, MRI, real-time assessment of lateral pharyngeal wall movement, computer-assisted assessment of hyoid bone movement, three-dimensional ultrasound, image segmentation and volume determination, and quantification of echogenicity of the tongue (Watkin and Miller 1997). Fiberoptic endoscopic video examination, combined with a delivered air pulse, can aid in determining laryngopharyngeal sensory discrimination thresholds and provide a means for examining the sensory and motor aspects of swallow function (Aviv et aI., 1998). Some of the procedures are not used commonly for clinic examinations and are applicable to research at this time. Clinicians need to be aware of the scope of assessments to assist in development of therapeutic protocols. Medication Effects
Feinberg (1997) reviews medications that can have detrimental effects on swallowing function. The brain stem for swallow reflexive function, cortex for voluntary oral phase function, and sensory feedback mechanisms in
the oropharyngeal area act in a coordinated way for swallow function. Medications that affect these functions can impede the swallow mechanism. Each patient's medications should be reviewed because they may involve mental status changes, confusion, and/or sedation. Drugs may increase or decrease esophageal pressure, such as antacids (produce pH-dependent increase in lower esophageal pressure), alcohol (decreases lower esophageal pressure), drugs that increase or decrease skeletal muscle function (long-term use of corticosteroids can cause skeletal muscle wasting), and drugs that decrease food intake (antivirals or certain antibiotics that cause stomatitis). Some diseases and problems are treated with medications that cause or exacerbate oropharyngeal dysphagia (e.g., Parkinson's disease, hyper/hypothyroidism, steroid myopathy, alcoholic myopathy, diabetic neuropathy, inflammatory myopathies, and myasthenia gravis). Gastroesophageal reflux disease (GERD) may relate to excessive or prolonged or intermittent relaxation of the lower esophageal sphincter (LES). The LESprovides a barrier to the reflux of gastric contents. The elimination of irritating foods or drugs that lower LES pressure may be helpful. Additionally, inability to clear refluxed acid from the esophagus due to decreased esophageal motility and diminution of saliva may be contributory to GERD. Alcohol taken before lying down may also contribute to reflux disease. Odynophagia may be the result of esophageal injury, but it can also be caused by a tablet or capsule lodging in the mucosal wall of the esophagus. Xerostomia may cause food to stick in the throat or difficulty chewing. Videofluoroscopic swallow study (VFSS) is widely used and considered the gold standard to define pharyngeal physiology (Logemann, 1983, 1986, 1993; Perlman, 1997). The study begins with presentation of 1 mL of liquid barium and progresses to 3, S, and 10 mL. This study has been shown to be a safe and effective way of assessing oral and pharyngeal swallow function (Logemann, 1993). It is important to reestablish swallow function in as natural and timely a manner as possible with proper diet and without unduly stressing the patient. Dietary control is an important dimension of swallowing treatment. The rationale for dietary control appears to relate to the body being able to make natural accommodations or compensations for food intake, providing the food intake is properly controlled. Involuntary and voluntary compensatory movements are likely. The structures "affected less by the disease process work harder to avoid aspiration, excessive retention of bolus in the pharyngeal cavity or nasal regurgitation" (Donner, 1988 [po 2]). Decompensation may occur if the disease progresses or, possibly, if the system is not used for long periods of time and the musculature atrophies (Donner, 1988).
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According to Logemann and colleagues (1992), head and neck cancer patients accommodate small amounts of aspiration with pureed foods. [n studying outcome 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 clears the aspirated material from the tracheobronchial tree sometime later or may relate to the patient's mobility and general good health" (p. 185). The use of a staged diet, the Abbott Northwestern Staged Diet (Felt and Anderson, 1989), was reviewed for 36 head and neck surgical patients (Richmond, 1992). The diet controls for elasticity of, particulates in, and viscosity of foods. The treatment of dysphagia appeared most effective when specific dietary planning was incorporated. Temporary nonoral feeding may be particularly important in the management of head and neck surgery patients. Kirsch and Sanders (1988) report studies in patients undergoing abdominal surgery that indicate a IS % incidence of pneumonia as compared with a 1.5 % incidence in patients without a nasogastric tube. They further discuss a possible resultant incompetence of the upper and lower gastroesophageal sphincters, with regurgitation and aspiration of gastric and pharyngeal contents. An associated 32 % incidence of edema is reported with the nasogastric tube. The potential for postcricoid inflammation and resultant chondritis and laryngeal dysfunction is mentioned. The timely use of PEG can measurably improve the speech pathologist's ability to work with the dysphagia patient. Combined oral and nonoral feeding may be an initial step, because patients can have delayed pharyngeal onset owing to postoperative pharyngeal edema. They may have more difficulty in the controlled moving of very thin liquids through the pharynx into the esophagus, owing to delayed pharyngeal swallow onset. Thickening of liquids is advised for some patients, whereas others may react against "drinking" thickened liquids, which are changed into a puree. The potential for dehydration must be considered. Quality of life can be improved with improved swallow function, a byproduct of the combined oral and PEG feeding approach. A problem relative to swallowing management with the nasogastric feeding tube may result from the use of a tracheal cuff. Complications and hazards in use of a tracheal cuff include total occlusion of the airway, herniation of the tracheal mucosa, tracheal stenosis, granuloma formation, tracheal erosion, tracheal malacia, necrosis, erosion of the innominate artery, and tracheoesophageal fistula (Mason, 1993). Current tracheotomy tubes are manufactured with low-pressure high-volume devices that distribute the cuff seal over a larger area with lower pressure. Tracheostomy tube cuffs should not
exceed pressures of 25 mm Hg against the tracheal wall, and in some cases minimum pressures can be lower depending on the patient's trachea size (Mason, 1993).
Glossectomy Increased survival rates for glossectomy patients (Lauciello et a\., 1980) have led to increased need for speech-language intervention. Annually, 15,000 people are diagnosed with oral cancer and carcinoma of the tongue. This type of cancer is second only to lip cancer as the most frequent type of oral cancer. Recent advances in chemotherapy and irradiation may have made preoperative speech consultation and informed consent for total glossectomy more important than previously. The patient may want and needs to know the communicative implications involved after glossectomy. Discussion of implications of speech therapy and potential communication difficulties can facilitate patient understanding. Paulowski and colleagues (1993) emphasize the importance of effectively counseling patients with oral and oropharyngeal cancer before surgery as well as planning and assessing appropriate rehabilitation strategies. Further data on functional outcomes for specific surgical resections and reconstructions are needed. Sixteen patients with anterior oral cavity lesions, resection of the anterior tongue and mouth, distal flap reconstruction, and maintenance of the mandibular arch showed no improvement by 3 months post healing. The lack of improvement in speech and swallowing function in these severely impaired patients suggests that speechlanguage pathologists should be aggressive in the establishment and maintenance of a treatment program in the immediate postoperative period. The aggressive program is important or critical if the patient is receiving postoperative radiation therapy. Differences in prognosis for speech communication recovery can relate to the portion and amount of the tongue removed. Skelly (1972) described numerous compensatory procedures for improving speech intelligibility after glossectomy. When tongue tip, or a portion of the tongue tip, can be retained, speech intelligibility may be better. lmprovements in technology have facilitated communication through the use of fax machines, speech synthesizers, and TOO devices. Implications for swallowing post glossectomy also need to be discussed with the patient. Special dietary adaptations such as processing food in a blender or permanent nonoral feeding may be indicated. Preoperative visitation by a rehabilitated glossectomy patient may be helpful in providing a basis for improved or increased understanding of the pending surgery and its implications.
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Palatal Surgery Velopharyngeal
Function
Bzoch (1989) discusses an overall treatment protocol for optimal standards of care for cleft palate, cleft lip, and craniofacial anomalies: 1. Surgery to correct clefts of primary palate and lip, usually at 2 to 3 months; continued involvement of comprehensive evaluation team approach, in a complete care center, that includes genetic counseling, audiometric evaluation, language and speech stimulation, and dental evaluation and care 2. Complete closure of hard and soft palate by 12 months, if possible; assessment and monitoring of function and comprehensive team monitoring 3. Focus on motor speech and expressive language skill development and audiologic monitoring from 18 to 24 months 4. Continued team reevaluations; evaluation of velopharyngeal function with video fluoroscopy and/or video nasopharyngoscopy; possible referral to early educational setting (e.g., Head Start, pre-kindergarten, or day care in third year); possible speech and language therapy 5. In fourth year, if continued velopharyngeal insufficiency, for normal speech and language, consideration of secondary surgical or prosthetic correction; continued speech-language skill reevaluations and therapy; continued team care 6. In fifth year, team visit and reevaluation at 6-month intervals; pediatric health care review 7. In sixth year, necessary speech and language therapy; continued pediatric health care review; orthodontic and surgical treatment procedures necessary 8. In early adolescence, possibly lip revisions, rhinoplasties, and alveoloplasties with bone grafts; continued team care; psychosocial counseling recommended. Palatal Ablation, Compromise
Revision, or Velopharyngeal
Surgical procedures that involve palatal ablation or velopharyngeal compromise can predispose the patient to hypernasality and significant limitations in speech intelligibility. Additionally, intraoral pressure diminution can result in diminished swallow function. Videofluoroscopic examination of velopharyngeal function can be approached in a comprehensive way, as discussed by Witzel and Stringer (1989), with two or three views: a lateral view, an oblique Towne view, or a frontal Waters view. Video nasopharyngoscopy can give information on the anatomy of the velopharyngeal valve, closure patterns during speech, and the relative
size and location of velopharyngeal gaps. Assessment of consistency and specifics of movement and the function of the dorsum and posterior tongue during speech can be noted. Additionally, the anatomy and function of the laryngeal structures can be observed. The videotape is invaluable for further study and analysis. Aerodynamic measurements can provide additional information about velopharyngeaI function. Air pressure transducers can measure relative nasal and oral pressures with flow glottography. When questions of velopharyngeal function arise before adenoidectomy or tonsillectomy, instrumental procedures may be helpful in preoperative assessment and the prevention of significant hypernasality. If there are swallow problems, routine protocols are followed. Recommendations are made on the basis of clinical and instrumental findings.
Voice Voice disorders are common not only in patients after head and neck surgery but also in the general population. Ramig and Verdolini (1998) refer to studies showing estimates of voice disorders ranging from 3 % to 9 % of the total population. According to the National Center for Voice and Speech (1993), 24.49 % of the total population (or 28,269,000 people) are reported to have jobs that "critically require voice use"; 3.29% of the population (or 3,840,000 individuals) have occupations (e.g., air traffic controller, police, pilot) in which their voice is necessary for public safety. History taking and acoustic and perceptual assessment are critical aspects of voice evaluation. Morrison and Rammage (1994 [po 2]) state: "In our experience, for the majority of cases it seems advisable to have the otolaryngologist and speech pathologist see patients together, from the outset, each bringing their own professional skills to the evaluation process." Another area of evaluation was examined by Jacobsen and colleagues (1997 [po 69]). They studied the psychosocial consequences of voice disorders and developed the Voice Handicap Index (VHI). The test, according to the authors, demonstrates "strong internal consistency, reliability, and test retest stability." Some voice disorders may lend themselves to surgical intervention and careful preoperative and postoperative assessment. These disorders include, but are not limited to, laryngeal tumors (benign or malignant), papilloma, vocal nodules, vocal polyps, contact ulcer, granuloma, mucosal bridges, cysts, web, cricoarytenoid joint problems, and vocal fold paralysis. Preoperative and postoperative thyroidectomy voice evaluation and electromyography are important (Cernea et al., 1992). Women and professional singers are reported to demonstrate impaired production of high tones and
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altered speaking at fundamental frequency after thyroid surgery (Hirano, 1988). Voice evaluations were performed on patients who underwent thyroidectomy. Measures were derived from laryngeal stroboscopy, which included fundamental frequency, the lowest and highest frequency, vocal range, and a number of phonation time measurements. Deterioration in vocal performance was noted in patients with complete lesions of the external branch of the superior laryngeal nerve, subsequent to thyroid surgery. According to Morrison and Rammage (1994 [po 10]), "The comprehensive acoustic evaluation includes assessment of pitch, loudness, rate/duration and quality parameters of phonation and speech." Popular examination includes history taking and analysis, videostroboscopy, electroglottography, flow glottography, and, when vocal cord movement is of diagnostic importance, electromyography.
2.
3.
4.
5. Vocal Therapy and Vocal Management
Treatment efficacy in voice disorders is focused on databased research articles through group designs, singlesubject experimental designs, retrospective analyses, case studies, and program evaluation data (Ramig and Verdolini, 1998). Experimental and clinical data exist to support the effectiveness of voice treatment for voice disorders related to vocal misuse, hyperfunction, and muscular imbalance. Voice disorders include those with organic changes, special medical or physical conditions, and psychological causes. Pannbacker (1998) reviewed voice treatment techniques and outcomes and states that voice treatment depends on diagnostic category, client characteristics, and the preference of the clinician. Larson and Mueller (1992) surveyed speech pathologists for preferences in treatment approaches and ranked them in the following order: counseling, vocal abuse elimination, hard glottal attack, relaxation, changing loudness, pushing, yawn-sigh, ear training, establishment of new pitch, and digital manipulation of the larynx.
Hearing, Cochlear Implants, and Middle Ear Surgery Cochlear Implants and Rehabilitation
Less than 1 % of 15 million people in the United States with significant hearing impairment are candidates for cochlear implant (National Institutes of Health, 1988). Outcomes in children following cochlear implants are varied (Carney and Moeller, 1998): 1. Children receiving implants before 5 years of age using nucleus multielectrode cochlear aids and educated
6.
in a total communication environment that encouraged speech and signs to be used simultaneously had more accurate production of vowels and consonants than children who did not receive implants. With single-electrode and multielectrode cochlear implants, tactile aids, or hearing aids, better speech intelligibility was associated with earlier implant fitting (before adolescence) and better ability to perceive speech. Adult clients and patients who received various types of multi electrode cochlear implants achieved high levels of speech perception skill for sound and word recognition. Use of auditory information and feedback from a multi electrode cochlear implant alone did not sufficiently reduce deviant speech behaviors. Combined behavioral treatment program with a sensory aid was necessary to effect speech improvement. A cochlear implant promoted language development to a greater extent than would be predicted by maturation alone. Children using hearing aids who had severe to profound hearing loss, in the range of 90 to 100 dB, demonstrated speech perception and production skills superior to the best performers with cochlear implants. However, more recent research indicates the gap is closing faster, because this group of children with cochlear implants gain listening experience with their devices.
Middle Ear Surgery: Medical, Audio/ogic, and Speech Follow-up
Sullivan and Sullivan (1998) discussed surgical artifacts and iatrogenic anomalies in the context of demonstrating the utility of video otoscopy. They refer to postauricular mastoid bowl defects and scar after mastoidectomy, seborrheic residue, collapsing canal, extended and extruding pharyngoesophageal tubes, extruding wire stapedectomy prosthesis, fenestration cavity, and other problems. An important part of management of postoperative ear problems is a follow-up reassessment. The American Speech-Language-Hearing Association Guidelines for Identification Audiometry with children from 4 years of age to grade 3 indicate that children who have had a myringotomy and other surgical procedures involving the ear should be followed with periodic hearing examinations and communicative assessments. "Once people have been identified by the program, they should be followed regularly to ensure that their communication and medical needs are met. It is pointless to identify people who have hearing impairments unless there is a concurrent follow-up program to handle their habilitative educational and medical needs" (American Speech-Language-Hearing Association,
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1985 [po 50]). The audiologist and speech-language pathologist can assist the otolaryngologist in this regard with regular checkups and intervention as needed. Psychosocial Support
The speech pathologist, in addition to providing communicative assistance, can offer support and encouragement when appropriate or needed. A person or family in crisis becomes more susceptible to the influence of "significant others" in the environment. Significant depressive reactions can occur as a result of surgery for cancer. Sutherland and Orbach (1953) relate the postoperative depression to a sense of injury and often to important changes in the patient's functioning in his or her life situation. A person or family in crisis becomes more susceptible to the influence of "significant others" in the environment (Rapoport, 1971). Specific suggestions to assist the cancer patient in discussing feelings and thoughts appear applicable to patients with other types of disorders as well. Suggestions to staff and caregivers include, but are not limited to, the following: • To develop a caring and understanding relationship with the patient that can make communication easier for both patient and staff • To model expressive and open communication about feelings in a considerate way • To gently reflect some of the feelings that the patient may be expressing indirectly • To reinforce through words, gesture, and/or touch any appropriate expressiveness manifested by the patient • To openly state that there are things the patient may not be willing to discuss immediately and that the staff members and caregivers recognize and respect this need Summary
The head and neck surgery patient can be helped before and after surgery in many different ways, utilizing a number of different support systems, specialists, and methodologies. The author is familiar with the approaches and means of helping that the speech pathologist may offer these patients. It is hoped that the above discussion will assist in the recognition and understanding of these services. The review is not entirely inclusive but may provide a basis for improved communication and understanding between the physician, rehabilitation personnel, and speech pathologist, resulting in improved patient care.
Malignant Melanoma Constantine P Karakousis
There has been a considerable increase in the incidence of malignant melanoma over the past 3 to 4 decades. The lifetime incidence now is about 1 in 90. There are about 38,300 new cases of invasive melanoma and 30,000 to 50,000 cases of in situ melanoma diagnosed annually in the United States (Rigel, 1996). Therefore, this is no longer a rare neoplasm. The only known causal agent in the formation of malignant melanoma is exposure to ultraviolet light (290 to 320 nm UVB range) (Walter et aI., 1990). There is a higher incidence of malignant melanoma in latitudes closer to the equator. It is also more common in people with light skin color. The four major growth patterns of melanoma are superficially spreading melanoma (70% of cases), nodular melanoma (15 % to 30 %), acrallentiginous melanoma (2% to 8%), and lentigo maligna melanoma (4% to 10%). Nodular melanoma is characterized by a rapid vertical growth phase and has a high incidence of metastases and a worse prognosis. Lentigo maligna has a better prognosis, other factors being equal. Microstaging
of the Primary Melanoma
The previous morphologic description of the growth pattern of malignant melanoma has been superseded by the more accurate microstaging system provided by new methods of classification of the primary lesion. The method by Clark and colleagues (1969) classifies the primary melanoma according to the skin layer involved by the malignant process: levell-melanomas confined to the epidermis (in situ melanoma); level2-penetrating through the basement membrane to the papillary dermis; level 3-penetrating into the interphase between papillary and reticular dermis; level4-penetrating into the reticular dermis; level 5-penetrating into the subcutaneous fat. Breslow's method (1970) relies on the direct measurement of the thickest cross section of melanoma measuring the depth of the lesion in millimeters from the granular layer of the epidermis to the deepest extent of the tumor. Melanomas less than 0.76 mm thick have a 5-year survival and an overall cure rate in the range of approximately 98 %. Generally, melanomas are considered thin when they are less than 1 mm thick, of intermediate thickness when 1 to 4 mm thick, and thick when they are over 4 mrn in thickness (Balch et al., 1978). There is a correlation between Clark's method and Breslow's method of classification, and both of them correlate with recurrence rates and survival. However, of the two methods, Breslow's method correlates more closely with survival than Clark's method does (Balch et aI., 1978).
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5taging The staging of malignant melanoma depends on the micro staging of the primary lesion and the presence or absence of metastases to regional lymph nodes or distant sites. Thus, stage I melanoma (NO, MO) includes melanomas less than 0.75 mm (IA) and those 0.76 to 1.5 mm (IB) in thickness; stage II (NO, MO) includes melanomas 1.6 to 4 mm (IIA) and those thicker than 4 mm (lIB); stage III (any T, NI, MO) is that of any thickness with limited regional node metastases or fewer than five in-transit lesions; stage IV includes melanomas of any thickness with advanced regional or distant metastases (any T, N2, or M1) (Ketcham et aI., 1992).
uncommon manifestation of recurrence from malignant melanoma owing to trapping of melanocytes within the subcutaneous lymphatics and growth of a melanoma within this site. In-transit lesions are more common after node dissection due to stasis in the lymphatic flow occurring, with recurrences as high as 18 % in the same extremity after groin dissection for positive inguinal nodes. Local recurrence or satellite lesions around the primary site and in-transit lesions should be treated surgically whenever feasible (Karakousis et aI., 1980). In the extremities, hyperthermic perfusion is also another modality of treatment for the management of in-transit lesions. Regional Lymph Nodes
Treatment of the Primary Lesion Elective Dissection The surgical treatment of malignant melanoma depends on the microstaging of the primary lesion. Thus, for melanomas less than 1 mm thick, a I-em lateral margin is perfectly adequate in securing local control (Veronesi and Cascinelli, 1991). In a large prospective randomized study, comparing a 2-cm lateral margin with a 4-cm lateral margin, the local recurrence rate was the same in both groups (i.e., approximately 4%), and therefore a 2-cm margin is preferable by virtue of improved cosmesis and decreased morbidity (Karakousis et aI., 1996). Melanomas thicker than 4 mm are treated with 2- to 3-cm margins, the concern for local recurrence in these lesions being overshadowed by their high propensity for regional and distant metastases. In European reports, it has been recommended that a I-em lateral margin is adequate for lesions up to 2 mm (Veronesi and Cascinelli, 1991). Of course, in the head and neck area, particularly in the area of the face, traditionally narrower margins have been adopted. Local Recurrence and In- Transit Lesions Local recurrence is associated with a high rate of subsequent metastatic disease and the death of the patient. The mortality rate of local recurrence in one prospective randomized series was 80% (Karakousis et aI., 1996). However, there has been some evidence that the location of the local recurrence might be of prognostic importance. That is, recurrences occurring within the surgical scar may have a much better survival (i.e., about 80% with further wide excision) (Brown and Zetelli, 1995; Drzewiecki and Andersson, 1995). Melanomas that recur at a distance from the surgical scar of the first operation have a higher rate of recurrence and mortality. Local recurrence is considered a recurrence within 2 em from the previous surgical scar. Lesions appearing beyond 2 em from the surgical scar are classified as in-transit lesions when they occur between the primary lesion and the regional nodal basin. In-transit lesions are not an
In the case of a clinically localized melanoma after considering the margin of resection according to thickness, the other major consideration is the management of the . regional lymph nodes. In the past it was believed that, since about 20 % of the intermediate thickness melanomas and a higher rate of the thicker lesions present later with disease in the nodal basin, elective dissection might improve survival for some of these patients. Two prospective studies, however, failed to show any improvement in survival comparing the patients who had elective dissection with observation and lymphadenectomy only for those patients who later developed palpable nodes (Sim et aI., 1978; Veronesi et aI., 1977). The problem with the elective node dissection is of course that the majority (i.e., approximately 80% of the patients) do not have microscopic disease in the regional lymph nodes and, therefore, they have an unnecessary operation. The largest and most recent prospective randomized study showed no overall difference in survival in patients who had elective resection and those submitted to observation. However, there were some subgroups that seemed to benefit from elective dissection. These were patients with melanomas 1 to 2 mm thick and patients younger than 60 years of age (Balch et aI., 1996). A more recent update of this prospective randomized study confirmed, and actually provided, a significant difference in survival in favor of the elective dissection group, for nonulcerated melanoma. Intraoperative Lymphatic Mapping (5entinel Node Biopsy) The advent of a new method to identify the histologic status of the regional lymph nodes short of a complete lymphadenectomy has made largely irrelevant the issue of elective node dissection. In this method, reported by Morton and colleagues in 1992, it was shown that the lymphatic drainage from each particular skin site drains
BASIC CONSIDERATIONS
through the lymphatics to the regional nodal basin to a single (and infrequently to two) node(s), which may be called sentinel nodes. In this method of lymphatic mapping or sentinel node biopsy, one identifies and dissects the first lymph node that receives lymphatic drainage from the particular skin site involved by the melanoma (Morton et aI., 1992). This node should contain a focus of melanoma cells, if melanoma cells traveled through the lymphatics to the sentinel node. The sentinel node is identified by injection of a blue dye, isosulfan blue, which is injected near the site of the previous biopsy of the melanoma. Morton and colleagues initially suggested injection of 0.5 to 1 mL intradermally on either side of the biopsy incision. The site of injection is massaged gently for approximately 5 minutes, and then an incision is made over the nodal basin in the same direction that would be done for an elective node dissection. Of course the incision for sentinel node biopsy is shorter than that for the elective procedure. Morton and colleagues recommended the development of a flap at the nodal basin toward the primary site and identification of a blue-stained lymphatic channel within the subcutaneous tissue, which then should be traced to the sentinel node. If one cannot identify the blue-stained lymphatic channel or the sentinel node, repeat injections of the blue dye are performed at 20-minute intervals. In the author's experience, one actually may inject a larger amount of the dye, 2 to 3 mL, intradermally, because if an inadequate amount of dye is injected initially and the dissection in the nodal basin fails to reveal a blue-stained lymphatic channel and/or a sentinel node, further intradermal injections at the primary site may not help because the afferent lymphatics to the nodal basin from the primary melanoma site may have already been interrupted by the initial dissection. It therefore may be best to inject a larger bolus of the dye initially, hoping that there would be enough dye traveling along the lymphatics so that the lymphatic channels may be identified, as well as the sentinel node. The ability to detect the sentinel node varies with the experience of the surgeon in this procedure, and it tends to continually improve as the surgeon acquires more experience with this technique (Morton et aI., 1992). The success in identifying the sentinel node varies also according to the anatomic nodal basin, being highest in the groin and somewhat lower in the axilla. In the head and neck area, however, the identification of the sentinel node has been problematic. In our initial experience with sentinel node biopsy for melanomas draining to the cervical node basin, the success rate in identifying the sentinel node was only 56% (Karakousis and Grigoropoulos, 1999). These difficulties have led some authors to suggest that sentinel node biopsy is not applicable in the case of the head and neck melanomas because of the high rate of failure in identifying the sentinel node. Since the report by Morton of his technique of intraoperative lymphatic
mapping using the blue dye alone, identification of the sentinel node through the intradermal injection near the melanoma site of a radiocolloid has been reported with a high rate of success in identifying the sentinel node either by using this method alone or in combination with blue dye. The radiocolloid, usually 99mTc-labeled sulfur colloid, is injected intradermally on four sites around the biopsy site of the melanoma and then the scanning that is obtained serves to point out the nodal basin(s) to which the melanoma may be draining, being particularly useful for melanomas close to the midline of the trunk or head and neck; it also helps significantly in the localization of the sentinel node (exhibiting a radioactivity two to four times higher than the rest of the basin) through the use of an intraoperative probe. If one uses the combination of the two methods at the time of surgery, usually scheduled 3 hours after injection of the radiocolloid, one scans with the probe over the skin of the nodal basin, which has been shown to pick up radioactivity with the scan and identifies percutaneously the hottest spot over the nodal basin, which should be overlying the sentinel node. One can then make an incision centered over the hottest skin spot in the same direction as one would make for a cervical node dissection. The incision is then deepened through the subcutaneous tissue and platysma, and the probe is used again to further direct the course of the dissection. Scalpel or light cautery may be used in this process. If a blue-stained lymphatic channel is found, one may trace this channel with clamp and/or Metzenbaum scissors dissection toward the actual sentinel node. The sentinel node usually is stained blue in one pole at the point of entry of the blue-stained lymphatic channel. Occasionally, there are more than one lymphatic channels leading to the sentinel node. Infrequently, there are two sentinel nodes and, rarely, three sentinel nodes receiving direct lymphatic drainage from the primary site. The radioactivity of the sentinel node in vivo is recorded in counts per minute (CPM) by using the probe covered with a sterile sheath; and after the sentinel node is removed, this is recorded ex vivo and the radioactivity in the remaining nodal basin is also recorded. The last should be less than half of the ex vivo radioactivity of the sentinel node. If it is higher than that, this may indicate that there may be additional sentinel node(s) to be searched with the use of the probe because they may not be stained with the blue dye. With the combination of the blue dye technique, as well as the use of a radiocolloid with an intraoperative probe, the detection of the sentinel node in the cervical area should be close to 100% (Karakousis and Grigoropoulos, 1999). The radioactivity counts recorded over the site of injection around the primary lesion are about 30,000 CPM. In the case of a melanoma arising in the skin of the neck, the injection of the blue dye as well as radiocolloid near the primary skin site may seriously interfere with the
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identification of the sentinel node because of the close proximity of the primary skin site to the underlying lymph nodes. Therefore, for melanomas arising in the skin of the neck, although one may try to apply the technique just described, there may be serious interference from the primary site in identifying the sentinel node. In such cases, the decision can be made for elective node dissection on the basis of the prognostic parameters of the primary lesion and the likelihood of there being microscopic 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.
warrant attention regarding their prognostic factors and management. The two most common histologic types are liposarcomas and malignant fibrous histiocytomas (Morton et a!., 1997). Sarcomas metastasize primarily through the bloodstream but, infrequently, at an overall rate of approximately 5% (2.6% to 10.8%) (Brennan et a!., 1997) for all histologic subtypes, they may metastasize through the regional lymph nodes. Some of the
Therapeutic Node Dissection For patients who have palpable nodes in the cervical area, therapeutic lymphadenectomy should be performed if there is no evidence of metastatic disease at the distant sites. A thorough node dissection should be performed (usually a modified neck dissection) because one may thus avoid the complications of local recurrence within the nodal basin with its attendant risk also of further dissemination of the disease (Karakousis, 1998). For patients with positive nodes, interferon alfa-2b was reported to provide significant improvement in diseasefree and overall survival in the range of about 12 % over patients treated with surgery alone (Kirkwood et a!., 1996). The interim analysis of a follow-up study, however, showed again an improvement in disease-free survival but no significant difference in overall survival between the treated and control groups. At the present time, there is considerable interest in clinical research using vaccine therapy for stage III malignant melanomas.
Distant Disease For patients with hematogenous dissemination and a limited number of lesions involving one body cavity, resection of the metastases may improve survival particularly in patients with longer disease-free intervals CKarakousis et a!., 1994). Vaccine therapy is also being evaluated in patients who have resectable metastatic disease as an adjuvant modality for stage IV melanoma. Figure 3-20 shows a PET scan that confirms the presence of melanoma metastasis.
Soft Tissue Sarcoma Constantine P Karakousis There are about 6,000 new cases of soft tissue sarcoma diagnosed in the United States every year involving various anatomic locations. A little over 50% of patients ultimately die from progression of their disease (Brennan et a!., 1997). They represent an uncommon group of neoplasms; however, they occur frequently enough to
FIGURE 3-20 The whole body PET scan clearly confirms the findings on CT of the mediastinal lymph node in relation to the right innominate vein (brachiocephalic) in a patient with malignant melanoma. This verifies that the lesion seen on CT is most likely metastatic melanoma, with the primary lesion in the skin of the anterior chest wall. This patient also had a metastatic node in the supraclavicular area laterally that was removed by modified neck dissection. Remember that lesions less than 5 mm in size usually do not show up in a PET scan. 1, mediastinal lymph node; 2, cardiac silhouette; 3, urinary bladder. (Courtesy of Hani Nabi, MD.)
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histologic subtypes, however, such as malignant fibrous histiocytoma and synovial sarcoma, have a higher frequency of metastasis through the lymphatic system to the regional lymph nodes.
Sarcomas usually present as a mass associated with little or no pain, and, thus, they are often diagnosed when they are quite sizeable. The diagnosis is established via biopsy. Aspiration cytology does not usually provide a sufficient diagnosis. A core needle biopsy, such as with a Tru-Cut needle, often provides enough tissue to make a histologic diagnosis of soft tissue sarcoma and the histologic subtype involved. To obtain a core needle biopsy, the most prominent part of the skin around the tumor area is infiltrated with local anesthesia down to the surface of the tumor. A small nick with a No. 11 blade is made in the skin to allow passage of the rather thick needle through the skin and into the subcutaneous tissue. Through this small opening in the skin, three or four pieces from the tumor are obtained and sent for pathologic evaluation. The other alternative is open biopsy using an incision adequate enough to get to the site of the tumor and obtain a piece. The incision should be placed over the center of the tumor mass in the direction of what might later be the definitive incision. A number of these tumor masses, of course, may turn out to be lymphomas and be treated with means other than surgical resection. During open biopsy, as the tumor surface is approached and the incision is made through what may be the pseudocapsule of the tumor, a deeper cut into the tumor is done so as to have a representative piece of tumor tissue. Superficial biopsies are frequently not diagnostic when they are derived from the capsule of the tumor mass. If there is any doubt as to having a representative piece of tissue, frozen section may be obtained at the time of the incisional biopsy to ascertain that there is indeed representative tissue. One should not rely on frozen section to perform the definitive surgery unless the latter is not expected to cause a significant functional or cosmetic deficit. Frozen section is not as accurate as permanent section in determining that one is dealing with a soft tissue sarcoma or in defining the histologic subtype. Exuberant granulation tissue can be confused with malignant fibrous histiocytoma.
extent of the primary tumor. This is true for the head and neck area, as for other regions. In performing the resection, an elliptical incision is made around any previous biopsy incision. A decision has to be made preoperatively as to whether any substantial amount of skin should be removed, owing to close proximity to the tumor. If one can avoid a large resection of skin, then one may obviate the additional requirement of flap reconstruction. The dissection is carried around the tumor, trying to stay as far away from the tumor site as local anatomy permits. In situations in which underlying bone is in close proximity, one may have to remove a partial or the full thickness of the underlying bone. In soft tissue sarcomas of the supraclavicular area, because some tend to extend underneath the clavicle, it may be necessary to remove the clavicle to permit complete resection of the tumor, with simultaneous provision of adequate exposure of the brachial plexus and subclavian vessels. Claviculectomy in itself does not produce any significant morbidity or functional impairment for the patients, although for 3 to 4 weeks after the operation they may have to wear a sling until the healing is completed (Karakousis et aI., 1992). The objective is to obtain as much margin as anatomically possible around the palpable tumor mass. An adequate tumor margin of normal tissue should be 2 em or greater, but that is not always obtainable. However, in dissecting around the tumor mass, one should be able to obtain an adequate tumor margin in most directions around the mass and limit the margin only in the vicinity of critical anatomic structures that cannot be easily replaced or sacrificed. The goal is to eliminate or at least minimize microscopic residual tumor. It has been shown conclusively that adjuvant radiation (i.e., radiation given for potential microscopic disease) reduces significantly the rate of local recurrence (Brennan et aI., 1991). Radiation treatment may be given preoperatively, particularly in cases in which the tumor does not appear to be resectable without first shrinking down its size. More commonly, radiation is given postoperatively on the basis of the clinical-pathologic assessment of surgical margins and therefore the actual need for adjuvant radiation when the margins are considered inadequate. In a prospective randomized study, it was found that the preoperative (neoadjuvant) radiation is associated with a higher rate of wound complications compared with postoperative radiation (O'Sullivan et aI., 1999).
Treatment
Results and Prognostic Parameters
Node dissections can be fairly formal in terms of their extent, the incisions being used, and the dissection involved owing to the fairly constant anatomic location and the distribution of the regional lymph nodes. In contrast, surgical resection of the primary sarcoma has to be specifically designed for the anatomic location and
The rate of local recurrence with local excision alone has been reported in the literature to be 65% to 95% (Abbas et aI., 1981; Cadman et aI., 1965). When local excision is supplemented with irradiation postoperatively, the rate of local recurrence is about 25 %, so it is significantly decreased but still remains appreciable and
Presentation and Diagnosis
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higher than the 10% rate observed after wide excision alone (Karakousis et a!., 1995). Therefore, even when one intends to use the adjuvant modality of irradiation, it still is important to try to obtain as wide a margin as possible around the tumor in all directions that is clinically feasible. The 5-year disease-free survival depends primarily on the grade of the tumor, being for grade 1 tumors about 90%; grade 2, 65%; and grade 3, 45% (Karakousis et a!., 1995). The second prognostic parameter significantly affecting survival is the size of the tumor. Tumors less than 5 em in diameter have a better prognosis than those larger than 5 em. The third prognostic indicator is the location of the tumor: whether deep or superficial to the fascia or covering a muscular compartment. Sarcomas located in the subcutaneous tissue have a better prognosis than those located within muscle groups. Adjuvant chemotherapy of soft tissue sarcomas is still investigational, although there is a trend among medical oncologists to use adjuvant chemotherapy for high-grade soft tissue sarcomas. This is in contrast to sarcomas of childhood, especially rhabdomyosarcomas and bone sarcomas, in which the use of adjuvant chemotherapy is of proven efficacy in improving survival. Local Recurrence
Local recurrence should be resectable in the majority of instances (95 %). The overall 5-year survival rate is 65 % after resection of a local recurrence similar to that of primary sarcomas (Karakousis et a!., 1996). Distant Recurrence
Soft tissue sarcomas spread hematogenously predominantly to the lungs. Resection of pulmonary metastases is associated with a 5-year survival rate of about 20% (Lawrence et a!., 1987), varying with the number of metastases, the prior disease-free interval, the completeness of the resection, and control or lack of control of the primary site.
Thyroid-Related Orbitopathy Daniel P. Schaefer
Thyroid-related orbitopathy, also known as Graves' ophthalmopathy, is the most common cause of both unilateral and bilateral proptosis in adults. Synonymous terms include Graves' orbitopathy, dysthyroid ophthalmopathy, thyroid eye disease, thyroid-associated orbitopathy, infiltrative ophthalmopathy, congestive ophthalmopathy, endocrine exophthalmos, malignant exophthalmos, and von Basedow's disease (Werner, 1977). Graves' name can create confusion, because not all
patients with Graves' ophthalmopathy have systemic Graves' disease (hyperthyroidism). The systemic thyroid status may be hyperthyroid, hypothyroid, euthyroid, or even involved in a neoplastic process (Morris, 1988). Severity and duration of the disease are unpredictable. The proptosis is usually accompanied by other orbital signs, including eyelid retraction, orbital congestion, and motility disturbances, in isolation or in various combinations. Although orbital manifestations typically improve over several years, irreversible vision loss due to corneal exposure or optic nerve compression does occasionally occur (Grove, 1975, 1979). Careful observation and reassurance are helpful and often adequate, but medical and surgical intervention may be required and are beneficial when used judiciously. The disease may cause disfigurement, which may be psychologically devastating to the patient. Many patients state that they don't look like themselves anymore. They may have eyes that are protruding, with one eye looking in the wrong direction, they are uncomfortable, and they feel disfigured. Graves originally described a triad of hyperthyroidism, dermopathy, and eyelid retraction. Most patients with thyroid-related orbitopathy have preexisting or simultaneously diagnosed hyperthyroidism, but not all of them do. In at least 20 %, the diagnosis of a thyroid disorder follows (often by years) the initial orbital manifestations. Furthermore, 3% never develop a clinically apparent thyroid imbalance. Also, rather than being characteristically hyperactive, the thyroid is sometimes hypoactive. Thyroid-related orbitopathy is primarily a clinical diagnosis. The classic presentation is easily recognized. Atypical presentations such as marked asymmetry or purely unilateral disease, euthyroid status, acute severe inflammation, myositis, pain, or subtle non inflamed disease, unusual neurologic symptoms, unusual systemic disease, trauma, or paranasal sinus disease are not infrequent and may be difficult to differentiate, making the diagnosis suspect or raising the question of a second coexisting orbital process, especially if one fails to consider the diagnosis of thyroid-related orbitopathy. Orbital imaging studies will help in the diagnosis and management of these patients. Conversely, not all individuals with systemic Graves' disease demonstrate orbital involvement. Only 60% to 90% possess at least subclinical orbital involvement, such as enlargement of the extraocular muscles on CT. The prevalence of symptomatic and clinically apparent orbital involvement varies but is definitely less than 20 % of those with systemic thyroid disease.
Pathogenesis The immune system is attacking the thyroid and the orbital tissues. It is probably two different antigens that
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cause thyroid disease and thyroid-related orbitopathy but they are related and similar enough so that the immune system can attack both or may just attack one and not the other. The pathogenesis between systemic thyroid disease and orbitopathy remains a point of debate. Activation of the thyroid gland, as a result of inflammation, trauma, surgery, smoking, and irradiation, appears to prompt a release of a thyroid antigen that stimulates both the cellular and humoral cascades of the immune system. This combination of cell-mediated and humoral activation promotes inflammatory cell migration and production of edema in the orbit. Activated T lymphocytes invade the orbital connective tissue at the same time a local humoral immune reaction is initiated. Retrobulbar fibroblasts proliferate, resulting in increased synthesis and release of glycosaminoglycans. Locally produced lymphokines amplify the cascade. The result is thickening of the extraocular muscles and increase in orbital fat volume. The specifics of each step have been the subject of intense investigation (Volpe, 1974). A shared orbit-thyroid antigen(s) is then presented and released into the circulation (Heufelder, 1995). Therefore, the thyroid gland and the orbital content are probably a secondary responder to the immune system disorder rather than a primary etiologic factor. The histopathologic changes in thyroid-related orbitopathy may cause the retrobulbar fat and connective tissue stimulation with increased fibroblastic activity, glycosaminoglycan deposition, and edema. The extraocular myositis with edema, lymphocytic infiltration, and muscle necrosis may occur. The pathophysiology of thyroid-related orbitopathy is not well understood. There appears to be stimulation of orbital fibroblasts to produce hyaluronic acid. Doubling the hyaluronic acid content in orbital tissue increases the osmotic load fivefold. This may lead to passive swelling of orbital tissue (Kroll and Kuwabara, 1966; Sergott and Glaser, 1981). Epidemiology Thyroid-related orbitopathy most commonly occurs between the ages of 25 and 50. Graves' disease is five times more likely to affect women than men. The peak incidence is often earlier in women (fourth or fifth decade) than in men (sixth or seventh decade). Men have been reported to develop thyroid-related orbitopathy more severely than women. All races are affected, but whites are distinctly more commonly affected than blacks or Asians. Predominant clinical signs may also differ among races. Presentation in childhood is unusual but not rare (Bartley et aI., 1995). Genetic factors appear to have a role in the development of thyroid-related orbitopathy, with 20% to 60% of those affected reported to have a family history of thyroid disease. Human
leukocyte antigen typing varies by race, and no single marker has been shown to be universally common. Environmental factors are also important. Although the role of stress is disputed, cigarette smoking is clearly capable of aggravating and prolonging thyroid-associated orbital inflammation. Patients who have thyroid disease are seven times more likely to develop a more severe form of thyroid-related orbitopathy if they smoke. Surgical manipulation of the thyroid gland and radioactive iodine treatment have been reported to exacerbate preexisting orbital signs and symptoms, but this connection has not withstood careful scientific investigation. Clinical Course Thyroid-related orbitopathy is frequently a self-limited disease, but each of its associated orbital signs varies in prevalence and persistence. Soft tissue inflammation and congestion are common and nonspecific signs and typically resolve within 5 years. Eyelid retraction, either unilateral or bilateral, is common (90% prevalence) and the sign most likely to persist chronically. Extraocular muscle dysfunction occurs in 40% of patients, and intermittent diplopia will usually resolve over time. One third of the patients who develop constant, noncomitant diplopia will improve spontaneously. Unilateral or bilateral proptosis occurs in 60% of patients. Improvement is unusual in such cases, with fewer than 10% of patients demonstrating significant improvement within 5 years. Vision loss, the most feared complication, occurs in fewer than 5 % of those with orbital involvement. Sequelae that may cause irreversible vision loss if not managed appropriately include compressive optic neuropathy, corneal scarring, and secondary glaucoma. Corneal ulceration is rare. The clinical course of thyroid-related orbitopathy does not follow a linear progression of severity. It can have its onset over days to weeks. The acute phase may last from 3 months to more than 2 years. This phase is characterized clinically by inflammatory signs, including eyelid erythema, chemosis, injection, and edema and also by fluctuations that can occur daily or weekly. After resolution of the acute phase, proptosis, diplopia, and eyelid retraction may persist owing to the cicatricial changes that occur in the extraocular muscles and orbital soft tissue. The acute episodes may occur from one to three times during the course of the disease. The course of thyroid-related orbitopathy is unrelated to treatment of systemic hyperthyroidism. The thyroid and orbital manifestations act as two independent clinical processes, the treatment of either of which does not always affect the other. Many patients will have spontaneous improvement of their symptoms. The physician's goal is to prevent complications while we are waiting for the disease to "burn out."
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Ophthalmic signs and symptoms may worsen, improve, or remain the same in patients who undergo treatment of their hyperthyroidism with radioactive iodine-131 (without concomitant systemic corticosteroid treatment). Tallstadt reported in 1992 that thyroid-related orbitopathy might worsen in hyperthyroid patients aged 35 to 55 treated with iodine-13l. Orbital disease in these patients became worse compared with that in similar patients treated with methimazole or subtotal thyroidectomy. Mendlovic and Zafar suggested that this effect was more likely in patients treated with multiple doses of iodine-13l. Another study revealed that 15% of patients who were treated only with radioiodine developed or had worsening of their thyroid-related orbitopathy. In contrast, none of the patients who were treated with both radioiodine and prednisone had progression and two thirds showed an improvement. Only 3% of those treated with methimazole had any worsening of the condition (Bartalena et al., 1998). Patients should be maintained on corticosteroids throughout irradiation. Then the doses of the corticosteroids should be slowly tapered. Levels of serum and lymphatic thyroglobulin as well as of antithyroglobulin antibodies increase in the 6 weeks to 6 months after treatment with iodine-131 and also after thyroidectomy, which may provide a clue to the clinically observable flare-ups that sometimes occur after treatment. Advocates of thyroidectomy believe that removal of the inciting antigens in the thyroid gland with a total thyroidectomy reduces the incidences of thyroid-related orbitopathy. We have insufficient experience with this treatment option to comment. Differential Diagnosis Severe cases of nonspecific orbital inflammation, orbital infection, or cavernous sinus disease may cause congestion and proptosis that resemble the features of thyroidrelated orbitopathy. In addition to high-flow fistula of the cavernous sinus, infection and thrombosis may also cause injection, chemosis, ophthalmoplegia, and proptosis. Arterialization of conjunctival vessels and an orbital bruit are characteristics of cavernous sinus fistulas and do not occur in thyroid-related orbitopathy. Immunocompromise or signs of sepsis are typically present with cavernous sinus infection or thrombosis. Pseudo proptosis may be caused by an enlarged globe, extraocular muscle weakness or paralysis, contralateral enophthalmos, asymmetrical orbital size, or asymmetrical palpebral fissures (usually caused by ipsilateral lid retraction, facial nerve paralysis, or contralateral ptosis). Signs and Symptoms
There is no one universal answer as to how frequently these patients should be monitored in the acute and
chronic phases of the disease. Treatment should be individualized. Patients with active thyroid-related orbitopathy in whom optic neuropathy is present, or whose corneas are threatened by severe exophthalmos or eyelid retraction, must be examined very frequently. Patients who psychologically adapt poorly to the disfigurement that the disease may cause will require much more time and possibly psychiatric counseling. Symptoms and subtle signs of thyroid-related orbitopathy are often present for many months to years before diagnosis. A significant percentage of patients experience at least mild inflammatory changes at some point during the course of their disease. Common and nonspecific symptoms include tearing, irritation, grittiness, aching, and photophobia. Early signs include conjunctival injection, periorbital puffiness, abnormal tear break-up time, superficial punctate keratitis, and elevation of intraocular pressure. Most commonly, the conjunctiva is injected over the rectus muscle insertions. This may be accompanied by interpalpebral chemosis. The chemosis may appear hemorrhagic, and the conjunctiva may prolapse over the lower lids. Corneal exposure with keratitis, ulceration, or pannus formation may occur secondarily to the combination of proptosis, eyelid retraction and lagophthalmos, and restrictive myopathy that reduces the Bell's protective phenomenon. Periorbital skin may become puffy, and mild erythema may be present. In severe cases, the skin becomes lax and redundant with palpable subcutaneous edema. Eyelid retraction (upper and/or lower eyelids), inflammation, proptosis (unilateral or bilateral), lid lag, dry eyes, restrictive myopathy with diplopia, compressive optic neuropathy, and disfigurements are the primary signs. Increased orbital volume secondary to inflammation is believed to impede venous outflow, which further aggravates congestion and the resulting proptosis. Inflammation and congestion are two distinct processes, but they are intimately related. There may be resistance to retropulsion of the globe, but this is a nonspecific abnormality that may also result from a retrobulbar tumor or from diffuse inflammation. The signs may occur simultaneously or individually (Gorman et aI., 1984). Allergic conjunctivitis and dry eye symptoms are common misdiagnoses but eventually recognized to be thyroid-related orbitopathy. Tears are produced in normal quantity in this disease, at least as demonstrated by Schirmer testing. These tears, however, have been found to contain abnormal quantities of proteins and immunoglobulins, which, in conjunction with increased evaporation due to abnormal lid position, result in increased osmolarity. The lacrimal gland is often mildly enlarged and may be a target of immune interaction. The change in tear stability may cause symptoms and corneal changes identical to those seen in keratoconjunctivitis sicca. Ocular hypertension may be the initial manifestation. Orbital congestion and impaired venous outflow may
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contribute to the increased frequency of ocular hypertension. The examination should include a measurement of the intraocular pressure in primary and upward gaze, which may further elevate the pressure. Although intraocular pressure may fluctuate between 25 and 30 mm Hg, development of glaucoma damage is occasional. Patients with a preexisting diagnosis of glaucoma or active thyroid-related orbitopathy of more than 5 years' duration are at increased risk for glaucomatous optic nerve damage. Secondary ocular hypertension usually resolves as the orbitopathy improves, only rarely progressing to true glaucoma. Visual acuity and color vision are not affected until very late in glaucoma. Glaucomatous field loss (e.g., arcuate or nasal step defects) differs from the pattern of loss seen in compressive neuropathy or thyroid-related orbitopathy (e.g., central or centro cecal defects). The optic disc may initially be normal or edematous, but diffuse pallor develops over time. Tests Useful for Early Detection
The baseline examination includes assessment and documentation of visual acuity, color vision, pupillary function, intraocular pressure in primary and upward gaze, lid position, globe position (as quantified by Hertel exophthalmometer), motility (versions and ductions), and dilated fundus examination. If intraocular pressure is elevated or any component of afferent function is abnormal, visual field examination is also performed. Visual fields and color vision testing help in early detection. Pseudoisochromatic plates and red desaturation are complementary tests to establish the status of color vision. Patients need to be alerted about the possibility of a change in vision and need to arrange to see an ophthalmologist if this happens (Henderson, 1958). Examination of eyes with optic neuropathy includes careful evaluation and documentation of visual acuity, color vision, and pupil function at the initial examination and each subsequent visit to highlight subtle changes that will prompt further evaluation. Humphrey or Goldmann visual field examinations are performed, as well as CT (both axial and coronal views) to clarify optic nerve position with respect to the enlarged muscles. Contrast medium enhancement is not necessary. Examination of the pupils should include the swinging flashlight test to evaluate for an afferent pupillary defect (Marcus Gunn pupil). In addition, anisocoria should be documented and observation should be made as to whether the difference is greater in the light (parasympathetic defect) or dark (sympathetic defect). Retrodisplace the globe gently in various directions. Orbital tumors cause directional resistance to retrodisplacement of the globe according to their location. Thyroid-related orbitopathy causes a diffuse increase in resistance to ocular retrodisplacement.
Hertel exophthalmometry continues to be the standard method of measurement, despite its limited accuracy. If possible, the same practitioner should repeat the Hertel measurements with a similar width setting on the exophthalmometer at each evaluation. The Hertel exophthalmometer is useful to follow patients, but different observers often arrive at different measurements, especially if the base dimensions are not kept constant. However, careful measurements taken by a single examiner over a period of time may accurately reflect changes in globe position. More than 2 mm of asymmetrical proptosis raises the possibility of an orbital mass mimicking thyroid-related orbitopathy. Orbital ultrasound is an effective method of demonstrating increased muscle size but lacks specificity and does not rule out other disorders. Neuroimaging studies are often required when the diagnosis is in doubt. CT will aid with the differential diagnosis in atypical cases, help to evaluate the optic nerve in cases of compressive optic neuropathy, serve as a method to document progression in association with clinical signs and symptoms, or serve as a planning tool for possible orbital decompression surgery. Imaging studies permit the surgeon to evaluate the sinus anatomy and the degree of orbital congestion when orbital decompression is being considered, especially in patients suspected of having chronic sinusitis, because the finding of sinus opacification allows for preoperative antibiotics or sinus drainage. Nonenhanced CT (axial and coronal views with thin sections) is the best method to define anatomy. Contrast medium enhancement usually is not required because the orbital fat provides intrinsic contrast for many solid or cystic lesions and vascular anomalies frequently manifest radiographically as asymmetrical enlargement of the superior ophthalmic vein and a dilated cavernous sinus. Another reason to avoid contrast material is that iodine-containing agents preclude the immediate use of radioactive iodine in the treatment of hyperthyroidism. CT with contrast enhancement is helpful in patients who have more than the typical amount of pain on extraocular movement. Scleral enhancement and inflammatory infiltrates may differentiate an inflammatory pseudotumor from thyroid-related orbitopathy in these patients. CT is helpful in diagnosing and monitoring patients with optic neuropathy. These patients have enlarged extraocular muscles compressing the optic nerve at the apex. This finding will differentiate between thyroidrelated orbitopathy and other causes of neuropathy, such as anterior ischemic optic neuropathy. Imaging studies will typical show fusiform expansion of one or more of the extraocular muscles, generally with thin tendons. Large muscles, greater than 9 mm in width, or a crowded orbital apex indicates patients at risk for compressive optic neuropathy, as does restrictive myopathy.
BASIC CONSIDERATIONS
MRI is not necessary in evaluating thyroid-related orbitopathy; it offers little additional information and is more expensive than CT. Eyelid Retraction A common early finding of hyperthyroidism is eyelid retraction. Like other findings in thyroid-related orbitopathy, this can also be seen in euthyroid or hypothyroid patients. The classic presentation is a bilaterally symmetrical retraction of the upper and lower eyelids, the stare of thyroid-related orbitopathy. This generally improves as the thyroid function stabilizes, but it rarely resolves entirely. Involvement of Muller's muscle is often found in these patients, and hypertrophy of the levator palpebrae is not uncommon. Lagophthalmos (retraction of the upper lid with passive eyelid closure and in downgaze) and lid lag (a slowing of the descent of the eyelid with downgaze) are a result of the infiltration of Muller's muscle and the levator palpebrae. Forced ductions of the lid are usually positive in these cases. The involvement of the lids is usually asymmetrical, especially in chronic cases, but rarely may be unilateral. A number of patients develop an unacceptable amount of retraction, which causes not only cosmetic problems but also enhances tear evaporation and aggravates dry eye symptoms. Topical eyedrops, such as the a-adrenergic antagonists, have been used to counteract the sympathetic tone of Muller's muscle, but sustained improvement is rare, and topical toxicity frequently develops. When the lid retraction has been stable for at least 6 months in a noninflamed eye, then surgical intervention can be entertained. The differential diagnosis of eyelid retraction should include lesions that involve the midbrain, such as ischemia or tumors, hydrocephalus, or even contralateral ptosis. Neurogenic lid retraction will have a limitation of upward gaze, but lagophthalmos is absent; and results of forced duction testing of the lid and globe are normal. Other signs of neurogenic causes include convergence-retraction nystagmus and light-near dissociation of pupillary response. Contralateral ptosis may result in lid retraction on the intact side due to Hering's law of equal innervation. To test for this, elevation of the ptotic lid will result in an improvement of the contralateral lid retraction, demonstrating that the excessive innervation, or Hering's law, is the cause of the lid retraction. Also forced duction testing is normal and lagophthalmos and lid lag are absent. The various surgical techniques for the correction of lid retraction involve Muller's muscle and the levator aponeurosis in the upper lid and the capsulopalpebral fascia in the lower lid. Excising or recessing Muller's muscle and/or the levator aponeurosis, performing a
myotomy of the levator muscle, or inserting a spacer (fascia, donor sclera, or ear cartilage) between the distal end of the aponeurosis and tarsus via a cutaneous or conjunctival approach can lower the resting position of the upper lid. Lower eyelid retraction can be managed with recession of the retractors of the lower eyelids. Severe retraction requires grafting of spacer materials (fascia, donor sclera, ear cartilage, and also hard palate mucosa) between the lower eyelid retractors and the inferior tarsal border. A lateral tarsorrhaphy is a useful technique for protecting the cornea, decreasing ocular exposure, but, aesthetically, the appearance of the horizontal shortened palpebral fissure and the interference with the eyelashes and peripheral vision is displeasing to many patients. Upper and lower eyelid retractor repairs are much more satisfactory. A tarsorrhaphy may be a helpful adjunct to lower lid retractor repair in some cases. In individuals who have mild upper and lower eyelid retraction, particularly with temporal flare of the upper lid, a conservative tarsorrhaphy may be helpful in improving eyelid malposition, when performed in combination with Muller muscle recession in the upper lid and with recession of the retractors in the lower lid. When Hertel measurements are greater than 23 mm, lower lid retractor recession is difficult, and an orbital decompression should be considered before eyelid retractor repair in these patients. Lateral tarsorrhaphy is probably best reserved for patients with Hertel measurements greater than 23 mm who are not candidates for decompression surgery owing to their medical condition, a poor risk for anesthesia, or refusal to undergo the procedure. Proptosis The orbital apex has no room for expansion. Muscle enlargement posteriorly results in compression of the optic nerve just anterior to the optic canal. Proptosis serves as a protective function by expanding the total orbital volume. Muscle enlargement in the absence of significant proptosis is most likely to promote optic nerve compression. It is essential to check for signs of afferent dysfunction, (e.g., decreased visual acuity, abnormal color vision, afferent pupillary defect, and abnormal visual fields), even in apparently asymptomatic patients. Proptosis is less prevalent than eyelid retraction. It is caused by infiltration of the eye muscles with inflammatory cells and/or an increase in fat volume, resulting in forward displacement of the globe. Proptosis is usually axial and associated with increased resistance to retropulsion of the globe. In general, bilateral and asymmetrical proptosis is not uncommon. Nonspecific orbital inflammatory syndrome, orbital tumors (primary or secondary), orbital infections, and
BASIC CONSIDERATIONS
cavernous sinus processes may cause proptosis. Orbital inflammatory syndrome (orbital pseudotumor, myositis) or rare cases of orbital amyloidosis with muscle involvement are generally unilateral, accompanied by severe pain. The inflammation of the muscles involves the tendinous insertions and may simulate thyroid-related orbitopathy. The fat will appear infiltrated, and scleral thickening is not uncommon on CT. Orbital tumors (primary or secondary), on the other hand, cause unilateral and often nonaxial proptosis, without significant pain or inflammation. Orbital infections are also usually unilateral, but they tend to be accompanied by mild to moderate pain, inflammation, and sinus involvement. The proptosis secondary to cavernous sinus fistulas or dural fistulas is usually unilateral, accompanied by conjunctival chemosis, arterialization of the conjunctival vessels, and mild pain. There may be an orbital bruit or a history of trauma, or the proptosis may be idiopathic. Motility Abnormality Transient or intermittent diplopia is common but can progress gradually or rapidly to a constant diplopia. Patients generally have difficulty with fusion in the morning, owing to fluid accumulation in the muscles that occurs with a prolonged prone position. Initially, the extraocular muscles are infiltrated with inflammatory cells and edema, which then progress to a fibrosis that may create a permanent motility restriction. Ocular movements may be limited in a specific direction of gaze by the inflammation that involves a single or multiple extraocular muscles. The inferior rectus and then the medial rectus are the most commonly involved, which can result in a noncomitant esotropia and/or hypotropia. Thyroid-related orbitopathy most commonly involves the inferior rectus muscle with fibrosis, which restricts elevation of the affected eye and can even cause it to be hypotropic in primary gaze. On attempted upward gaze, the intraocular pressure may rise in the affected eye. Forced duction testing is the simplest and fastest test to evaluate restricted motility and is usually positive in these patients owing to the restrictive myopathy. This is important because approximately one third of the time the ophthalmologist is the first to recognize the diagnosis of thyroid disease. CT often reveals bilateral involvement of all muscles but sparing of the tendons. When orbital findings have remained stable for at least 6 months, then strabismus surgery may be entertained. Recession of the levator aponeurosis or inferior retractor muscles will reduce corneal exposure. The aim of extraocular motility surgery is to minimize diplopia in the primary position and in downward gaze but rarely will correct diplopia in all gazes. Adjustable suture techniques may be helpful to achieve optimum alignment, and optical prisms are a useful adjunct to motility surgery.
Botulinum toxin has been utilized in the treatment of strabismus and can actually achieve a permanent cure, obviating the need for surgery in approximately 30% of the patients in whom it is used. It is a great temporizing measure in about another 30 % of patients. Acquired diplopia may also be secondary to cranial nerve paralyses, myasthenia gravis, trauma, tumors, and orbital inflammatory syndromes. Cranial nerve paralysis and myasthenia are not restrictive, and therefore the forced duction test is normal. In myasthenia gravis, the patient's symptoms will worsen with fatigue and at the end of the day, with ptosis rather than an eyelid retraction. If a patient with thyroid-related orbitbpathy has motility disturbances and/or ptosis, he or she should be evaluated for myasthenia, because 5 % of patients with myasthenia gravis have thyroid disease and I % of individuals with thyroid disease have myasthenia gravis. Trauma to the floor or medial wall may result in a restrictive myopathy, with positive forced ductions. CT with coronal sections should be obtained in any patient with a history of prior trauma. Orbital inflammatory syndrome may mimic thyroid-related orbitopathy but is usually unilateral and accompanied by pain. CT often demonstrates the characteristic diagnostic tendon involvement and changes in the orbital fat and sclera. Optic Neuropathy Compressive optic neuropathy is a vision-threatening complication of thyroid-related orbitopathy that requires very careful evaluation and management. It can occur in inflamed orbits early in the course of the disease or late, in the postinflammatory stage, and in proptotic or nonproptotic orbits. CT or MRI of the orbit with coronal sections is required to demonstrate the enlargement of the muscles and their relations to the optic nerve. Sometimes the orbits are congested and inflamed, and sometimes they are not. The patients that have minimal proptosis, but moderate to marked limitation of extraocular motility and tight orbits show a warning that they are at greater risk for the development of thyroid optic neuropathy, owing to mechanical crowding phenomenon. The risk of developing thyroid optic neuropathy and loss of vision is relatively low (1 % to 5 %). Therefore, these patients should be monitored and followed closely, with evaluation of visual acuity, color vision, visual fields, and optic nerve examinations. The absence of disc edema or pallor does not exclude the diagnosis of thyroid optic neuropathy. Orbital decompression surgery is an effective treatment for compressive optic neuropathy. The medial orbital wall, especially the posterior ethmoids, along with the orbital floor is removed to allow expansion of the orbital contents into the ethmoidal and maxillary sinuses. Preservation of the bony strut between the
BASIC CONSIDERATIONS
ethmoidal and maxillary sinuses may reduce the adverse effects on ocular motility caused by a medial and inferior shift in the globe's position. Removal of the lateral wall and orbital roof sometimes is needed as an adjunctive decompressive measure. Treatment Plan Graves' disease is a complex, multisymptom disorder with a chronic, unpredictable course. These patients must be monitored and treated with a staged and compassionate approach that includes educational and emotional support. The course of the thyroid-related orbitopathy is generally independent of thyroid function. The disorder in a hyperthyroid patient is not managed differently ophthalmologically from that in a patient who is hypothyroid or euthyroid. However, treatment of the systemic thyroid condition often has a beneficial effect on the thyroid-related orbitopathy. Treatment may be divided into localized ophthalmic protective measures, medical anti-inflammatory treatment, surgical treatment, and radiation therapy. Cosmetic surgery should be avoided during the active phase of thyroid-related orbitopathy. Occasionally, low-dose irradiation (20 to 2S Gy) or surgical decompression is required to preserve visual function. Corticosteroids and irradiation are the most effective during the active inflammation, whereas surgical decompression relieves true congestion. After identification of early symptoms and signs of thyroid-related orbitopathy, observation and patient education are indicated. It can be reassuring to the patient to be given a description of the natural course of the disease and suggestions on conservative measures that help to control symptoms. When orbital inflammation is mild to moderate, as in most cases, conservative treatment, such as artificial tears and reassurance, is all that is necessary. Artificial tears and the use of sunglasses are helpful during the day, whereas elevating the head of the bed and taping the lids for sleeping are useful at night. In cases of mild to moderate proptosis and/or eyelid retraction, topical lubrication with solutions or ointment may suffice to provide adequate corneal protection. Moisture chambers or patching the eyes closed at night may also be helpful. External treatment with tears, humidifier, and topical nonsteroidal antiinflammatory drugs may be employed. These patients have exposure because of eyelid retraction, and its treatment is different than that for standard dry eye syndrome. Proptosis due to active inflammation may be improved by oral corticosteroids, whereas proptosis due to chronic inflammatory changes and fibrosis will not respond to corticosteroids. During the active orbital inflammation, and particularly during the acute phase of extraocular myositis, systemic corticosteroids or immunosuppressive
agents may limit damage to the extraocular muscles, decrease orbital edema, and decrease compressive optic neuropathy. High doses in the range of 80 to 120 mg of prednisone daily for adults usually are required for suppression of orbital inflammation. I generally reserve irradiation for the few patients who require additional treatment after decompression. One treatment plan is to initiate a 2-month tapering course of corticosteroids, and if there is a rebound when the corticosteroids are tapered, then radiotherapy, 20 Gy, given in ten fractions, is offered along with another course of corticosteroids. Care and judgment must be used because long-term corticosteroid treatment may be worse than the disease itself. It is better to defer surgery until the disease stabilizes into the postinflammatory or chronic phase. There can still be a waxing and waning of the smoldering inflammation in the postinflammatory phase, which is generally characterized by stability and lack of active inflammation. Staged reconstructive surgery is often performed at this time. The postinflammatory phase is often characterized by considerable orbital congestion related to venous stasis in a compressed orbit and manifested clinically by edema, chemosis, and commonly a painful pressure sensation. These congestive symptoms and findings must be differentiated from frank inflammation, because congestive disease in the postinflammatory stage responds poorly to medications and irradiation but often responds well to orbital apical decompression surgery, which restores venous outflow. Inflammation that is severe or associated with visual loss is treated immediately with high-dose oral prednisone; the doses are tapered slowly and tailored to the patient's clinical response. Pulsed corticosteroid therapy can be used in the more severe cases. High-dose corticosteroids are usually only temporarily effective in treating optic neuropathy, and their significant side effects preclude long-term use. Most of these patients will require irradiation or surgery. The role of radiation remains in dispute, and some orbital surgeons proceed directly to surgical decompression. Orbital radiotherapy (20 to 25 Gy) is believed to reduce the acute inflammatory signs and symptoms of thyroid-related orbitopathy. The chronic sequelae, such as restrictive strabismus and eyelid retraction from muscle and connective tissue fibrosis, are unlikely to be relieved. Irradiation is also an adjunctive therapy for patients with compressive optic neuropathy that does not adequately resolve with surgical decompression alone. It takes 1 or more months for maximal effect. Surgical decompression is more effective than radiation therapy for both correction of globe placement and relief of compressive neuropathy. Only a few patients require both treatments. Radiation therapy may be used in place of decompression in patients who are poor anesthetic risks or who refuse surgery.
BASIC CONSIDERATIONS
In the presence of corneal compromise or optic nerve compression, corticosteroids are used in a temporizing fashion in conjunction with low-dose radiation therapy (20 to 25 Gy). If vision deteriorates despite corticosteroid and radiation treatment, surgical decompression is warranted. Removal of bone from the posterior medial orbit is essential to decompress the optic nerve and can be accomplished by direct or endoscopic techniques. Contraindications to radiation therapy include concurrent chemotherapy or preexisting diabetes, because these patients are at risk for postirradiation necrosis of the retina and blindness. A relative contraindication to radiation therapy are patients younger than the age of 40, owing to the increased risk of late-developing sarcomas or other neoplasms of the orbital bones and soft tissues. Orbital decompression is indicated in patients with significant exophthalmos, with severe cosmetic disfigurement, or visual loss or severe exposure of the corneas. It is also indicated when corticosteroids are ineffective or contraindicated or the patient is intolerant or if irradiation fails or vision deteriorates rapidly. Removal or restructuring of the orbital fat may be performed in conjunction with the decompression. The number of orbital walls removed should be proportionate to the severity of the proptosis. In mild cases, the floor and medial wall may be removed through an external or endoscopic approach. When the operation is performed because of optic neuropathy, it is necessary to remove the bone in the region of the posterior medial wall, the posterior ethmoids, to relieve tissue crowding at the orbital apex. Lateral wall removal requires an orbital approach, whereas the roof is best approached intracranially. Indications for Orbital Decompression
• • • •
Progressive proptosis Optic neuropathy Optic nerve compression Orbital inflammation or pain refractory to medical management • Exposure keratopathy • Cosmetic deformity
Optic neuropathy at any time can change the order of this plan, forcing orbital decompression earlier than planned (Fatourechi, 1994). The potential complications of orbital decompression include diplopia, ocular dystopia, cerebrospinal fluid leakage, meningitis, infraorbital nerve paresthesia, blindness, nasal lacrimal duct obstruction, infections, and death (Garrity et aI., 1993). In patients with muscle enlargement and preexisting muscle restriction, postoperative diplopia is common after decompression but is rare in those who had normal motility before the
surgery. Adequate exposure, especially of the ethmoidal vessels and posterior medial wall of the orbit, and adequate experience are required to avoid these serious complications. The surgical assistants should be reminded about the risk of excessive retraction of the globe and orbital apex. The ethmoidal arteries must be isolated before bony wall removal. These patients should be advised that extraocular muscle and eyelid surgery will often be required after decompression and is part of the normal order of the treatment plan. Any or all of the just discussed treatments may be necessary in an individual patient with thyroid-related orbitopathy. When multiple modalities are indicated, the most commonly recommended order of therapy is topical lubrication, trial of corticosteroids, radiation therapy, orbital decompression, extraocular muscle adjustment, and eyelid recession. This order of therapy allows extraocular muscle surgery to be performed after rather than before orbital decompression, because decompression may alter the ocular motility alignment. Eyelid recession is performed after extraocular muscle surgery, which allows repositioning of the lower eyelid retractors, which may be further retracted as a normal sequela of the inferior rectus muscle recession (Wall and How, 1990). Endocrine co-management is essential in the treatment of thyroid-related orbitopathy. Once this has been established then orbital decompression, Botox (botulinum toxin type A, Allergan) and prisms, strabismus surgery, and finally lid repairs are administered and performed in this order as needed. Overall, patients are psychologically devastated by thyroid-related orbitopathy, and counseling and support should be requested when indicated. Until we are able to identify the orbital target tissues and their interactions with the thyroid, immunoregulator, and so on, therapeutic intervention will remain reactive and limited to palliation. In the future the treatment for thyroid-related orbitopathy will involve selective immune suppression that it is hoped will prevent many of the ocular problems that we encounter.
Dental and Prosthetic Considerations in Head and Neck Surgery (Fig. 3-21) David
M. Casey
In the surgical management of cancer of the head and neck, the patient's teeth cannot be disregarded. If ignored or improperly managed, they may become sources of acute or chronic complications for the patient, the head and neck surgeon, and, ultimately, the dental oncologist or maxillofacial prosthodontist who treats the patient's dental and prosthetic needs.
BASIC CONSIDERATIONS
The dental oncologist is a dentist with specialized training and expertise in handling the dental needs of the oncology patient. The maxillofacial prosthodontist is a prosthodontist with additional training and expertise in the oral and facial prosthetic needs of the postsurgical patient. Both of these dental specialists are integral members of the head and neck oncology team and should be involved in virtually all head and neck cancer patients' treatments, starting in the treatment plan stage. Their own particular expertise makes them best able to provide input into what degree of involvement by them is necessary and at what point in the patient's overall treatment.
A A preoperative consultation and examination of the dental/oral needs of the patient and a close working relationship between the head and neck surgeon can only have a positive influence on the patient's overall care by the head and neck team. Teeth that are foci of infection or unrestorable or unusable should be removed before or at the time of surgery to prevent acute dental crises postoperatively. Preoperative (B1, arrow) and postoperative (B2, arrow) radiographs are shown of strategic dental extractions done before primary surgery. 81, 82
Sectioning through a dentulous arch should be through the center of the socket of an extracted tooth (C1), except in instances when missing teeth, or large spaces between teeth, already exist where the surgeon plans to cut. (Dotted lines in C1 outline the area to be resected.) This will prevent situations from arising in which adjacent teeth are damaged or have insufficient bony support to survive (C2, arrow delineates damaged tooth).
C1, C2
Highpoints 1. Preoperative consultation and examination of head and neck cancer patients by a maxillofacial prosthodontist and dental oncologist contributes greatly to total patient care. 2. Controversy exists whether to remove or save remaining soft palatal segments after partial soft palatectomy, included with or separate from partial maxillectomy.
A FIGURE 3-21
Continued
BASIC CONSIDERATIONS
FIGURE 3-21 Continued
BASIC CONSIDERATIONS
Dental and Prosthetic Considerations in Head and Neck Surgery (Continued) (Fig. 3-21) 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 remaining soft palatal segment. It is hoped that the following brief guideline will give direction when the surgeon is faced with this conundrum. Whether to remove the remainder of the soft palate is based on the fact that the sling of the levator veli palatini muscles occupy the bulk of the middle third of the soft palate, moving the soft palate posterosuperiorly during speech and swallowing to contribute to palatopharyngeal closure. Thus, when only the anterior one third of the soft palate is removed, the remaining two thirds will be functional and should be retained. Conversely, when the anterior two thirds is removed, the remaining posterior third will be a useless, adynamic strand that should be routinely removed. The decision-making problem arises when the anterior third is removed, along with part of the middle third. How much of the middle third must be removed before the remaining part becomes nonfunctional and is best totally removed? The answer is probably somewhere in the mid-middle third, keeping in mind that individual variation is great, and this decision is totally in the hands of the surgeon intraoperatively. The shorter the
soft palate is in overall length, the more difficult this decision becomes. To err on the conservative side may make prosthetic reconstruction with a speech-aid prosthesis very difficult.
Dl, D2 When oncologically possible, the saving of a tuberosity (D1, arrow) or premaxilla will greatly improve stability of a maxillary prosthesis. D2 shows the tissue surface of the resulting stable prosthesis, with obturator part and tuberosity-supported section (arrow). E Small posterior strands of nonfunctional tissue after partial soft palatectomy (arrows) are best removed at the time of primary surgery. They prevent direct access to the palatopharyngeal defect by the speech-aid prosthesis and make insertion and removal difficult. Removal of the uvula is also advised in these situations, because a long uvula on an adynamic strand of soft palate will give a foreign object sensation on the posterior tongue. F Rounding over of bone cuts may prevent delays in healing, especially if radiation therapy is anticipated. This bone remains exposed 2 years after orbital exenteration and removal of inferior orbital rim, followed by radiation therapy.
BASIC CONSIDERATIONS
E
F FIGURE 3-21 Continued
BASIC CONSIDERATIONS
Maxillofacial Prostheses* (Fig. 3-22) David
Highpoints
M. Casey
Maxillofacial prosthetics is that subspecialty of prosthodontics that restores defects of the head and neck with artificial materials. Those defects may be secondary to oncologic surgery, trauma, or congenital defects. Prosthodontic rehabilitation is carried out when surgical reconstruction is not the preferred option or in some cases in conjunction with surgical reconstruction. Oral defects most commonly treated are those of hard and soft palate or of mandible or tongue or, more commonly, a combination of the above. Extraoral defects include orbital, nasal, and auricular structures. To lend stability and retention to prostheses, end osseous implants may be placed in supporting bone, with attachments such as magnets or clips to hold the prostheses in place.
* Endosseous implant cases presented here are courtesy of Norman Schaaf, DDS. For further reading, refer to Beumer J Ill, Curtis T, Marunick M: Maxillofacial Rehabilitation: Prosthodontic and Surgical Considerations. 51. Louis, Ishiyaku EuroAmerica, 1996.
1. Surgical reconstruction, when possible, is nearly always preferable to prosthetic reconstruction, when comparable aesthetic and functional results can be achieved. 2. Prostheses are sometimes used as interim treatment, until a sufficient disease-free period has elapsed. 3. Prosthetic results can be enhanced by preoperative planning and a close working relationship between the maxillofacial prosthodontist and the surgeon. A 1 TO A3 Surgical obturator. This prosthesis replaces hard palate (A1) and alveolar ridges and is placed during surgery (A2, arrow) being sutured or wired to place for 5 to 7 days (A3). Its advantages include more rapid return to oral feeding, helping to secure packing in place, and psychological aspects. 81 TO 83 Definitive obturator. This prosthesis is fabricated after healing is completed, usuallya minimum of 3 months. It is made of more permanent materials and rehabilitates the patient to near normal function, in terms of speech, mastication, and swallowing.A partial anterior maxillary resection is shown (B1) restored by a definitive obturator (B2, B3, arrow).
FIGURE 3-22
Continued
BASIC CONSIDERATIONS
FIGURE 3-22 Continued
BASIC CONSIDERATIONS
Maxillofacial Prostheses (Continued) (Fig. 3-22) C Mandibular reconstruction with implants. After partial segmental mandibulectomy, the ideal functional reconstruction is the prosthetic replacement of teeth, supported by endosseous dental implants, which are placed in a vascularized bone graft. Preoperative planning for implant position is key to a successful reconstruction. C shows such a case with implants (arrow) and superstructure to which a dental prosthesis is attached. Dl TO D3 Orbital prosthesis. Because the orbit is not amenable to surgical reconstruction, the ideal prosthetic result is attained by an endosseous implant-retained
prosthesis (01, right orbit). The prosthesis shown here is retained by magnets attached to the implants (02, arrow), with "keepers" embedded in the back of the prosthesis (03, arrow). "Reconstructing" the orbital defect by obliterating it with a flap obscures detection of early recurrence and eliminates the possibility of an aesthetic prosthetic reconstruction. El, E2 Nasal prosthesis. Adequate bone support for endosseous implants is often not present for support of nasal prostheses. The prosthesis (E1) is retained by magnets attached to the superior surface of an obturator prosthesis that replaces the premaxilla (at arrows, E2).
c FIGURE 3-22 Continued
Continued
BASIC CONSIDERATIONS
FIGURE 3-22 Continued
BASIC CONSIDERATIONS
Maxillofacial Prostheses (Continued) (Fig. 3-22)
prosthesis (F2, arrow), and endosseous implants (F2, arrow) have served the aesthetic requirements of this patient for 10 years as of this writing.
Auricular prosthesis. An ear prosthesis (Fl), retained by magnets embedded in the back of the
F1 TO F3
FIGURE 3-22 Continued
BASIC CONSIDERATIONS
Osseointegrated Implants in Head and Neck Reconstruction Maureen Sullivan
Mandibular reconstruction with fibula-free flap has allowed for a more predictable outcome in replacing the mandible. The use of osseointegrated implants in the fibula is required as a means of replacing lost dentition. Significant bulk of overlying soft tissue may prevent adequate crown to root ratio for optimal restoration of the implants. Because removable maxillofacial prosthetics are not possible in the grafted bone without osseointegrated implants, close communication between the surgeon and the prosthodontist is required to prevent overbulking of the overlying tissue. Maxillary reconstruction with free flaps in both the hard and soft palate have significant advantages. The ability for closure of the oroantral defects immediately postsurgically is an advantage for the recovery of the patient who is thus able to speak and eat. However, the disadvantages that must be considered are (1) the inability to inspect the surgical site for recurrent disease and (2) the fact that the significant bulk of the flap may prevent maxillofacial reconstruction with a removable prosthetic appliance. If the flap has considerable bulk overlying the surgical defect, there may be no means of maxillofacial prosthetic reconstruction. For maxillectomy patients who are edentulous, the use of osseointegrated implants secured to the remaining maxillary tuberosity should be considered at the presurgical treatment-planning phase. If the defect is to be left open, lining the defect with a keratinized skin graft will provide a more stable surface to engage the prosthesis. Osseo integrated implants have provided a more reliable means of retention for extraoral maxillofacial prosthetics as well. Historically, the auricular, ocular, and midface prostheses were retained by adhesive and soft tissue undercuts. With the placement of implants at the time of the initial surgery or at a subsequent procedure, magnets, bars, and clips to help retain large prostheses can be used. Close communication between the surgeon and the maxillofacial team during the presurgical treatment phase enables implant placement during the ablative surgery. BIBLIOGRAPHY Abbas JS, Holyoke ED, Moore R. Karakousis CP: The surgical treatment and outcome of soft-tissue sarcoma. Arch Surg 116:765-769. 1981. Acres Jc, Kryger MH: Upper airway obstruction. Chest 80:207-211,1981. Aguilar NV: Communication
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Obstet
118:989-990, 1964. Sako K, Razack MS, Kalnins 1:Chemotherapy for advanced and recurrent squamous cell carcinoma of the head and neck with high- and lowdose cis-diamminedichloroplatinum. Am J Surg 136:529-533, 1978.
BASIC CONSIDERATIONS
Salazar-Sanchez V, Stark A: The use of crisis intervention in the rehabilitation of laryngectomees. J Speech Hear Disord 37:323-328, 1972. Sasaki GH, Pans CY:Pathophysiology of skin flaps raised on expanded pig skin. Plast Reconstr Surg 74:59-67, 1984. Scanlon EF: The process of metastasis. Cancer 55:1163-1166,1985. Schorlemmer GR, Battaglini JW: An unusual complication of nasoenteral feeding with small diameter feeding tubes. Ann Surg 199: 104-106, 1984. Schuller DE: Onlay bone grafts in head and neck reconstruction. Am J Otolaryngol 1:344-351, 1980. Schuman BM: Thbe feeding as part of the supportive care of the surgical patient. Henry Ford Hosp Med J 19:35-37, 1971, Selden R, Sasahara AA: Central nervous system toxicity induced by lidocaine. JAMA 202:908-909, 1967. Sergott RC, Glaser JS: Graves' ophthalmopathy: A clinical and immunologic review. Surv OphthalmoI26:1-21, 1981. Sessions DG: Functional results following partial laryngectomy. In Myers EN, Barofsky I, Yates JW (eds): Rehabilitation and Treatment of Head and Neck Cancer. Washington, DC, V.S. Department of Health and Human Services, 1986, section III. Shafir M, Tiegenbrun J: Simultaneous placement of two permanent central venous catheters. Surg Gynecol Obstet 156:369-370, 1983. Shanks JC: Treatment of resonance disorders. In Perkins WH (ed): Current Therapy
of Communication
Disorders:
Voice Disorders.
New York, Thieme-Stratton, 1983, chap 5. Shanta W, Krishnamurthi S: Combined bleomycin and radiotherapy in oral cancer. Clin Radiol 31:617-620, 1980. Shipp T: Treatment of spastic dysphonia following surgery. In Perkins WH (ed): Current Therapy of Communication Disorders: Voice Disorders. New York, Thieme-Stratton, 1983, chap 4. Shoemaker WC, Mohr PA, Printen KJ, et al: Vse of sequential physiologic measurements for evaluation and therapy of uncomplicated septic shock. Surg Gynecol Obstet 131:245-254, 1970. Sim FH, Taylor WF, Ivins JC, et al: A prospective randomized study of the efficacy of routine elective lymphadenectomy in management of malignant melanoma. Cancer 41:948-956, 1978. Singer M, Blom E: An endoscopic technique for restoration of voice after laryngectomy. Ann Otol Rhinol Laryngol 89:529-533, 1980. Singer M, Blom E: Selective myotomy for voice restoration after total laryngectomy. Arch Otolaryngol 107:670-673, 1981. Sisson GA: Problems and complications in head and neck surgery. Laryngoscope 70:1142-1155,1960. Skelly M: Glossectomy speech rehabilitation. Springfield, IL, Charles C Thomas, 1972. Smith RO Jr, Dickinson JT, Cipcic JA: Composite grafts in facial reconstructive surgery. Arch Otolaryngol 95:252-264, 1972. Snow JB Jr: The classification of respiratory viruses and their clinical manifestations. Laryngoscope 79:1485-1493, 1969. Snow JB, Kramer S, Marcial VA, et al: Evaluation of randomized preoperative and postoperative radiation therapy of supraglottic carcinoma. Am Otol Rhinol Laryngol 87:686-691, 1978. Soroff HS, et al: Metabolism of burned patients. In Artz CP (ed]: Research in Burns. Philadelphia, FA Davis, 1962. Spaulding MB, Kahn A, De Los Santos R, et al: Adjuvant chemotherapy in advanced head and neck cancer. Am J Surg 144:432, 1982. Spaulding MB, Kahn A, Sundquist N, Lore JM Jr: Preoperative chemotherapy for hypo pharyngeal carcinoma. Laryngoscope 93:346-349, 1983. Stallings JO, Huffman WC, Bernstein L: Skin grafts on bare bone. Plast Reconstr Surg 43:152-156, 1969. Stephenson
HE: An
increasing
role
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in
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Sullivan RF, Sullivan CA: Video Otoscopy: 35,000 Sessions in Two Plus Years. Garden City, NY, 1998. Suntharalingam M, Haas ML, Van Echo DA, et al: Predictors for response
and
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concurrent
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and
radiation for locally advanced squamous cell carcinomas of the head and neck. Cancer 91:548-554, 2001. Sutherland AM, Orbach CE: Depressive reactions associated with surgery for cancer. Paper presented at Sixth Annual Cancer Symposium of James Ewing Society, 1953. Szymula N, Lore JM Jr: Neuroblastoma of the head and neck. Arch Otolaryngol 104:395-398, 1978. Tallstedt L, Lundell G, Torring 0, et al: Occurrence of ophthalmopathy after treatment for Graves' hyperthyroidism. N Engl J Med 326:1733-1738, 1992. Tapazoglou E, Kish J, Ensley J, et al: The activity of a single agent 5fluorouracil
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BASIC CONSIDERATIONS
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squamous head and neck cancers: Dose response evaluation. 8M] 282:600-602, 1981. Wynder EL: Etiological aspects of squamous cancers of the head and neck. JAMA 215:4S2-453, 1971, Young JEM, Archibald SO; Shier KJ: Needle aspiration cytology in head and neck masses. Am J Surg 142:484-489, 1981. Zavala DC: Complications following fiberoptic bronchoscopy. Chest 73:783-785, 1978.
4
DIAGNOSTIC ENDOSCOPY
PERORAL ENDOSCOPY OF THE HEAD AND NECK Indirect Mirror Laryngoscopy and Nasopharyngoscopy and Cervical Esophagoscopy Probably the most important overall diagnostic measure, indirect mirror laryngoscopy utilizes inexpensive equipment, and, when able to be performed, it facilitates a wide view of most of the structures that need examination. Its biggest drawback is a tendency to cause gagging in some patients, despite topical anesthesia. It
may also not adequately allow for visualization of the anterior commissure and the petiolus of the epiglottis as well as portions of the wall of the pyriform sinus and ventricle and lateral border of tongue base. Highpoints
1. Indirect mirror laryngoscopy (see Fig. 20-2) facilitates a view of the larynx, hypopharynx, base of the tongue, and inferior tonsillar poles. 2. Indirect mirror nasopharyngoscopy (see Fig. 4-8A to C) facilitates a view of the nasopharynx and nasal surface of the palate.
179
DIAGNOSTIC ENDOSCOPY
Direct Optical Laryngoscopy and Nasopharyngoscopy (Fig. 4-')
base of tongue, inferior tonsillar poles, nasopharynx, and the nasal surface of the palate.
A Nonflexible (rigid) Berci-Ward instrument (manufactured by Karl Storz) utilizes the Hopkins rod principle of optics and affords a complete magnified view with a good depth of field of the structures examined. In these respects, it is superior to the indirect mirror technique and can be adapted to photography, can be used as an observation tube, and can be connected to closed circuit television, with videotape recordings made, and used for stroboscopy. It facilitates visualization of the larynx, hypopharynx,
B The Lore telescopic biopsy forceps (Karl Storz) is another nonflexible optical instrument that can be used to visualize and to biopsy lesions of the nasopharynx and hypopharynx. C, D The Lore rigid optical instrument (Karl Storz) can be used for visualization, biopsy, and stripping of a vocal cord. It is also excellent for mediastinoscopy biopsy (see Fig. 19-8). D is a close-up view of the forceps.
A
B
c
D FIGURE 4-1
DIAGNOSTIC ENDOSCOPY
The flexible scope (see Fig. 4-9E) can be connected to an observer's attachment (see Fig. 4-9G) for photography as well as to closed circuit television. It facilitates visualization of the entire nasal cavity, nasopharynx (see Fig. 4-9F) , nasal surface of soft palate, posterior and lateral walls of the oropharynx, base of the tongue, hypopharynx, and larynx. Its main drawback is the smaller, less magnified view of the hypopharynx and larynx. Small lesions could be missed. It is excellent for evaluating the motion of the vocal cords in the recovery room, especially after thyroidectomy. It is inserted through a naris, seldom through the oral cavity. When passed through the oral cavity, the nasal cavity cannot be visualized. The scope can be passed through a tracheostoma or tracheostomy tube for visualization of the trachea and bronchi inferiorly and the larynx superiorly. Cervical
Evaluation of the medial wall of the pyriform sinus is most important in all moderate and advanced carcinomas of the larynx. Complete examination of the postcricoid area and esophagus is likewise important. All peroral direct rigid endoscopic procedures, that is, laryngoscopy, hypopharyngoscopy, bronchoscopy, and esophagoscopy, involve the same initial technique. In each case the "scope" is introduced into the mouth and hypopharynx using the same positioning of the head and neck. Hence, the details of laryngoscopy, which will be seen in detail (see Figs. 4-2 to 4-5), apply to each phase of peroral endoscopy. The supine position is routine; however, the sitting and semi sitting positions (Rose) have merit, especially in tense, unrelaxed patients and in those patients who cannot tolerate a reclined position. Some of the various types of rigid laryngoscopes available are:
Esophagoscopy
Direct Rigid Laryngoscopy and Nasopharyngoscopy
Abramson-Dedo: for Venturi type ventilation Dedo: anterior commissure scope Ossoff: posterior commissure scope Jackson: anterior commissure scope Holinger: "hour glass" anterior commissure scope Dedo: double-action anterior commissure scope Feder: single-action laser scope, bivalve scopes, micro laryngoscopy scopes Jako: laser scope Zeitels: wide-angle scope Kleinsasser: scope
The Holinger hourglass anterior commissure speculum is an excellent scope. Another instrument, interestingly enough, is the Jesberg short adult esophagoscope. Both of these can be inserted well into the intrinsic structures of the larynx for careful visualization of the walls of the ventricle as well as the pyriform sinus of the hypopharynx and the petiolus of the epiglottis.
While the patient is under general anesthesia it is a good time to palpate the base of tongue, entire tongue, floor of mouth, lateral oropharyngeal walls, and, if feasible at times, the lower portion of the nasopharynx, midline, and lateral walls plus perform a bimanual examination with a finger inside the mouth and the opposite hand on the neck.
The flexible scope with suction tract can be used to examine the cervical esophagus and the reconstructed pharyngoesophagus after total laryngectomy and total hypopharyngectomy. Air can be fed through the injection port with a hand-operated rubber bulb, which can dilate the lumen of the esophagus and the reconstructed area.
DIAGNOSTIC ENDOSCOPY
Direct Rigid Laryngoscopy and Hypopharyngoscopy (Fig. 4-2) Highpoints (for All Direct Rigid Peroral Endoscopy)
1. Proper positioning of patient is mandatory-flexion of the neck with head in the neutral position in the first stages and then extension. Shoulders are at the free end of the operating table. 2. Head and neck must be in the midline and not rotated to one side or other at the onset. 3. Do not insert the instrument in midline of mouth over incisor teeth. A lateral approach in the region of the premolars is ideal. 4. A contralateral approach is used when applicable to known disease. 5. Never use the teeth as a fulcrum when exposing the larynx; protect the teeth with a plastic guard. 6. Carefully examine teeth, both upper and lower, beforehand for any "caps," defects, or loose teeth. 7. Expose and identify basic landmarks: (a) base of tongue, (b) epiglottis, and (c) arytenoids. 8. The assistant holding the patient's head should be on the left side, leaving the right side clear for reception of instruments and suctioning. 9. When an instrument or suction tip is passed to the operator for insertion into endoscope, the passing nurse places the tip of the instrument or suction tip into the lumen of the endoscope while the operator grasps the handle or proximal end (see Fig.4-3C). 10. The patient is assisted in relaxing all muscles and reassured that no obstruction to the airway will occur when using only topical anesthesia. 11. Instruments in immediate use are placed on the "overhead" table (see Fig. 4-2A). 12. For teaching purposes-observation, a split field T adaptor is used. 13. Instruments are reviewed with the nurse before the procedure. 14. Any instrument that touches or passes by the vocal cords can cause laryngospasm and cardiac arrhythmias! The exception to the lateral approach is microlaryngoscopy, during which the laryngoscope is usually but not always inserted in the midline. An assistant to hold the head is not utilized. Anesthesia
Topical anesthesia is the anesthesia of choice for examination, evaluation, and simple biopsy for most adults, children, and some infants. The agents of choice are 4 % lidocaine, 10% cocaine, or 2 % tetracaine, in varying
amounts (on cotton) in adults to correspondingly less in children and infants. The application of the topical anesthetic is started with the patient in the reclining position. After the lips, oral cavity, and supraglottic regions are anesthetized, the patient is seated upright. The application of the agent to the vocal cords is first performed with cotton on a laryngeal applicating cross action forceps (Jackson) with teeth to secure the cotton under vision using a laryngeal mirror. The agent is then applied with a laryngeal syringe in drop fashion between the vocal cords, also under mirror vision. The dosage depends on the agent utilized as well as on the strength of the agent. During this maneuver the vital signsblood pressure, pulse, and respiration-of the patient are monitored and an electrocardiogram (ECG) is obtained. Reaction to the topical anesthetic must always be recognized early. Agitation and central nervous system (CNS) excitement are the early signs, which proceed to convulsions, after which follows marked CNS depression, apnea, hypotension, and cardiovascular collapse. Treatment with oxygen, diazepam, or an intravenous barbiturate is then urgent, with monitoring of the pulse and blood pressure. There are various opinions regarding the type of topical anesthetic agent and dosage of each agent relative to safety and adequacy and purpose of anesthesia. Topical anesthesia refers to the application of the anesthetic agent on the mucous membrane, whereas local anesthesia refers to the injection of the anesthetic agent. Nevertheless, several points should be emphasized in the use of topical anesthetic agents: 1. Cotton is the preferred material in the method of application. Cotton is just moistened; hence the dose is minimal. A possible criticism of this method is the fact that the exact amount of agent absorbed by the patient is relatively unknown, because a significant amount of the agent is still retained in the cotton. Yet, it is emphasized that the dosage absorbed is minimal, because, as mentioned, a significant amount of the agent remains on the cotton. In some 48 years of experience (JML), this has proved very satisfactory. For example, a total dose of 10% cocaine would be only 1 mL if all were absorbed. Yet, by using cotton in an unhurried manner, 3 mL has proved safe. Anaphylactic reaction and idiosyncrasy can occur; hence, time must be taken in applying the agent along with monitoring vital signs. 2. Cocaine, rarely used today, is restricted to those patients in whom vasoconstriction is desirable (e.g., in biopsy or endolaryngeal surgery). Cocaine crystals are not utilized. 3. Cocaine colored red and tetracaine colored bluegreen are never injected. Hence the coloring is an adequate warning sign.
DIAGNOSTIC ENDOSCOPY
4. Epinephrine is seldom utilized either with a topical anesthetic agent or with a local (injected) anesthetic agent. Epinephrine is not used, because it is believed that many of the so-called reactions to these anesthetic agents are in fact caused by the epinephrine itself. If vasoconstriction is required with topical anesthesia, oxymetazoline (Afrin) or phenylephrine hydrochloride (Neo-Synephrine 0.1 %) is utilized. The concomitant use of a vasoconstrictor allegedly decreases the amount of the anesthetic agent absorbed. No vasoconstrictor is used with local anesthesia. S. As a standby precaution the patient is always monitored by an anesthesiologist. 6. The application of the agent should not be hurried, with several minutes given for each application to take effect. This also allows time to evaluate the patient's tolerance to the agent. The total safe dosages of the agents vary. The rule of thumb to calculate the amount administered is that a 1 % solution contains 1 g in 100 mL or 10 mg in 1.0 mL. The estimated safe topical dosages absorbed vary from agent to agent. For an average adult, the estimated dosages (Snow, 1972) are as follows: 1. Lidocaine (Xylocaine) 2 % to 4 % -200 mg 2. Cocaine 4% to 10%-200 mg 3. Tetracaine (Pontocaine) 0.5 % to 2 %-80 mg
Other references indicate a wide dosage range, for example, cocaine 10% (1 mL equals 100 mg). Fatal overdose is 1.2 g, yet severe toxic effects have been reported with as little as 20 mg. Cocaine must be used with caution in patients with severely traumatized mucosa and sepsis. General anesthesia plus topical anesthesia is used for stripping of a vocal cord or other detailed endolaryngeal procedures. A small endotracheal tube can be
used, thus allowing for an unhurried procedure. This is routine with all microlaryngeal procedures. Topical anesthesia is always used as a supplement to the superior surface of the vocal cords. This is also routine with all micro laryngeal procedures. This allows repeat, indirect mirror laryngoscopy and reduces laryngospasm and the amount of general anesthesia used. Muscle relaxants should either not be used or used only in very small doses when stripping a vocal cord; otherwise, a bowed vocal cord will result. If a muscle relaxant is used, its effect must be terminated before the stripping. Discussion If an examination of the larynx has not been performed before the direct rigid laryngoscopy, an indirect mirror laryngoscopy immediately preceding the direct examination in the operating room is performed. The patient is now under preoperative medication and is more relaxed than when he or she was examined in the office. Indirect laryngoscopy affords a "bird's eye" view as well as the evaluation of function, which is hardly possible under general anesthesia. This same view is better achieved with the optical instruments under topical anesthesia. Areas in which "hidden" primary tumors may occur should be very carefully evaluated: base of tongue, wall of vallecula, pyriform sinuses, base of epiglottis, and ventricular and subglottic space. While the patient is under general anesthesia, it is a good time to palpate the base of the tongue, entire tongue, floor of the mouth, and the lateral oropharyngeal walls, and, if feasible, at times, the lower portion of the nasopharynx, midline, and lateral walls. Bimanual examination with the finger inside and the opposite hand on the area on the neck should also be done. Refer to Figures 20-2 and 20-3 for details of indirect laryngoscopy.
DIAGNOSTIC ENDOSCOPY
Direct Rigid Laryngoscopy and Hypopharyngoscopy (Continued) (Fig. 4-2) Stage I (See Fig. 4-2A to D)
A Depicted is the "overhead" peroral endoscopic procedures.
table used in all
This diagram outlines the operating arrangement utilizing the overhead table. B
room
C, D The assistant who holds the head is located on the left or right side of the patient, while the anesthesiologist (if general anesthesia is used) is located on the left side alongside the overhead table. If required, another instrument table is located on the right side opposite the patient's head, with the instrument nurse just above or slightly behind this table. In the recumbent position, the patient's shoulders are free of the table with the neck flexed (i.e., above the level of the
shoulders). The head starts in the neutral position and is then extended. The assistant sits on a stool with feet on a raft or footstool. The assistant's knees are used as support for his or her elbows. The head pad from the operating table may be used between the kneesand the elbows. Thus, the assistant does not tire when changing the position of the patient's head at the instruction of the operator. The operator uses the left hand to hold and insert the instrument and the right hand (D) to steady the jaw and retract the lips. The instrument is not inserted in the midline but off to one side. This is most important because the angle of insertion is greatest in the midline, owing to the longer and more anteriorly located incisor teeth and the bulk of the mid portion of the baseof the tongue. Injury is also more likely to occur to the incisors than to the premolars. Both upper and lower teeth are in jeopardy. A 4 x 4-inch piece of gauze or a plastic tooth guard aids in the protection of teeth and lips. If surgery is to be performed on the right vocal cord, the introduction of the gauze is on the left side of the mouth, and vice versa.
Continued
DIAGNOSTIC ENDOSCOPY
MAYO TABLE
OPERATING TABLE
I I OVERHEAD
ANESTHESIOLOGIS~
o
I TABLE I I I
I
I I
I I
BASIC I INSTRUMENTS:
I
I
I
ENDOSCOPISTD
FIGURE4-2
I I
I I
EXTRA INSTRUMENT TABLE
U B
FOR TOPICAL ANESTHESIA
FOOT STOOL
~NURSE
DIAGNOSTIC ENDOSCOPY
Stage III (See Fig. 4-2G to I)
Direct Rigid Laryngoscopy and Hypopharyngoscopy (Continued) (Fig. 4-2)
G The tip of the instrument is dipped slightly backward to lift the tip of the epiglottis.
Stage /I (See Fig. 4-2E and F) E, F The instrument, well lubricated, is advanced to the base of the tongue exposing the epiglottis and vallecula (the space between the base of the tongue and the epiglottis). E shows the cross-sectional anatomy, whereas F represents the view through the laryngoscope. As the instrument is advanced, the head is extended as depicted by the arrow. The laryngoscope tip is now in the midline, having eased into,this position from the side of the posterior third of the tongue while the body of the instrument still lies to the side of the mouth. This is most important. (For clarity the tooth guard is not depicted.)
H This is termed engagement of the epiglottis. The posterior commissure of the vocal cords, arytenoids, aryepiglottic folds, hypopharynx, and medial portions of both pyriform sinusesare visualized. If the instrument is swung from side to side, complete visualization of the pyriform fossae is achieved. G shows a cross section,_ whereas H depicts the view through the laryngoscope. As the instrument is advanced, the head is further extended. The neck, however, is still flexed so that the occiput is 10 to 15 em above the shoulder level. I With the head further extended, the tip of the laryngoscope is advanced slightly farther to the base
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 laryngoscope as a lever, but not the teeth as a fulcrum, the base of the epiglottis is raised and a full view of the larynx is obtained. The base of the epiglottis is now carefully scrutinized as well as the ventricle and subglottic space. Device to Hold Endotracheal Tube at Anterior Commissure
J
When operating on lesions at the posterior commissure or posterior one third of the vocal cords,
the endotracheal tube can be displaced anteriorly and held in position as follows: 1. The end of the plastic tooth guard is cut off the guard. 2. This end is sutured with heavy silk to the anterior portion of the laryngoscope. 3. The endotracheal tube fits into the concavity of the tooth guard and is thus held at the anterior commissure. Ossoff has designed a special scope for visualization of the anterior commissure (Weed et aI., 1994).
DIAGNOSTIC ENDOSCOPY
Rigid Bronchoscopy
(Fig. 4-3)
Highpoints 1. The right hand is used to introduce the bronchoscope; this differs from introduction of the laryngoscope. Care must be taken not to injure upper or lower teeth. 2. The total time of instrumentation usually should be no longer than 20 minutes. 3. Avoid indiscriminate and blind punch biopsies, especially of any carina or a bulge with intact mucosa and, of course, over pulsating areas. 4. Do not force the bronchoscope through the larynx. The vocal cords must be abducted; otherwise, damage may result. Gentle rotation of the tip may aid insertion. 5. When a foreign body is suggested and granulation tissue encountered, gently advance the bronchoscope beyond the granulation tissue. Granulation tissue may hide the foreign body. 6. Only the Holinger or similar type ventilation bronchoscope should be used. 7. Indirect laryngoscopy (see Fig. 20-2) with topical anesthesia is usually a routine done before bronchoscopy. Direct laryngoscopy and hypopharyngoscopy should also be performed. Lesions of the larynx and hypopharynx have been missed by surgeons who pass the bronchoscope (rigid or flexible or for that matter an esophagoscope) immediately into the trachea. Anesthesia Either general or topical anesthesia may be used in adults and cooperative older children. General anesthesia supplemented with topical anesthesia to the vocal cords is used for foreign body removal in infants and uncooperative children. After the bronchoscope is inserted in the lumen of the trachea, the anesthetic gas and oxygen are introduced through the anesthesia adaptor on the Holinger ventilation bronchoscope. The bronchoscopic lumen is then closed with a glass-capped adaptor or glass cover on a pivot, thus providing a semiclosed system. If tracheal toilet is the purpose, topical anesthesia may be preferred.
Sanders (1967) has designed a ventilating attachment for bronchoscopes utilizing the Venturi effect (Duvall et a!., 1969). There are two methods of introduction of the bronchoscope. One method relies on a laryngoscope with a removable slide; the other method is direct insertion of the bronchoscope. The direct insertion is the usual procedure and follows the steps of laryngoscopy exactly except that the bronchoscope is held with the right hand. The method of using a laryngoscope is depicted in A. After the vocal cords are exposed, the' bronchoscope is passed through the laryngoscope. Vision is then transferred from the laryngoscope to the bronchoscope, which is passed through the larynx into the lumen of the trachea. In either method, the bronchoscope must not be forced between the vocal cords. The vocal cords must be abducted; otherwise, injury to the cords will ensue. The slide of the laryngoscope is removed and the laryngoscope is backed off and gently pulled out, leaving the bronchoscope in place. A, B
Bronchoscopy using the laryngoscope for introduction should be familiar to all endoscopists. It is specifically useful in infants and children because identification of the laryngeal landmarks may be obscured through the smaller-lumen bronchoscopes. In adults with short necks and bulky tongues, the laryngoscopic introduction is also advantageous. It affords a view of the larynx and hypopharynx and protects the bronchoscope from oral contamination, although granted this point may have more theoretical than real value.
C The instrument nurse is shown placing the tip of the suction cannula in the lumen of the bronchoscope while the operator grasps the proximal end. The same technique is employed in the introduction of any bronchoscopic or esophagoscopic forceps or telescope. In the background is a pegboard on which all the endoscopic instruments are kept for easy selection by the operator. These instruments should be kept sterile in plastic transparent wrappers for immediate use. Continued
DIAGNOSTIC ENDOSCOPY
c
B FIGURE 4-3
DIAGNOSTIC
ENDOSCOPY
Rigid Bronchoscopy (Fig. 4-3)
(Continued)
D As the bronchoscope is advanced in the trachea, the following routine checkpoints are noted: patency, configuration, and deviation of the trachea and position, axis, degree of sharpness, and transmitted pulsation of the main carina. The orifices of the right and left bronchi are then examined, and the bronchoscope is inserted in the direction of the bronchus to be examined with the head and neck deviated to the opposite side. The Right Bronchus. Just at or beyond the level of the main carina, on the lateral wall of the rig\1t bronchus, is the lumen of the right upper lobe bronchus. Its carina is somewhat broader than the main carina. Only about 0.5 em of this upper lobe bronchus can be seen. A right-angled telescope usually enables visualization of two or three of the segmental bronchi, that is, the apical, posterior, and anterior segments. As the bronchoscope is passed along, the lumen of the right middle lobe is encountered on the anterior wall of the main bronchus. Its carina is almost horizontal and usually quite sharp. About 0.5 to 1 em of the middle lobe bronchus is easily seen. This bronchus divides into lateral and medial segments. This division is often visualized. Just at or slightly below this level, the superior segmental bronchus of the right lower lobe is encountered posteriorly. Beyond this point, the remaining terminal divisions are identifiable as the medial, lateral, anterior, and posterior basal segments. The Left Bronchus. Several centimeters beyond the main carina, on the lateral wall, the orifice of the upper lobe bronchus is seen. Its carina is slightly off the
vertical and is usually sharp. With a right-angled or retrograde telescope, the divisions into upper and lower (lingual) branches are easily seen. Just at or slightly below this level on the posterior wall of the left mainstem bronchus is the superior segmental bronchus of the left lower lobe. Beyond are the terminal divisions identifiable as the anteromedial, lateral, and posterior basal segments. As the bronchoscope is withdrawn, careful retrograde examination of all suspicious areas is made. The previously described telescopes, although still used by some endoscopists, have given way to the flexible bronchoscope, which achieves more distal visualization. E In all bronchoscopies in which a malignant lesion is suspected but no actual lesion is seen, Gelfoam smears are made in the region of suspicion. A 12-mm piece is broken off a sterile Gelfoam sponge (No. 7853-20 x 60 x 7 mm), folded, and grasped securely in a forward grasping forceps with serrated and slightly cupped jaws. "Peanut" foreign body forceps are ideal. The slightly irregular end of the broken Gelfoam is then rubbed over the area of suspicion and withdrawn. The end of Gelfoam that was in contact with the suspicious area is immediately rubbed on a glass slide, which is plated in alcohol and ether for fixation and Papanicolaou or hematoxylin and eosin staining. This technique is used in addition to the collection of aspiration specimens with or without saline irri.gation. A Lukens collection tube is utilized along with an open-ended suction tube. Extreme care is taken not to lose a part or all of the Gelfoam. A firm but not excessively firm grip on the alligator forceps is utilized.
DIAGNOSTIC ENDOSCOPY
E Left lower lobe superior ant. medial basal lateral basal post. basal
Lower lobe superior medial basal ant. basal lateral basal post. basal
Middle lobe carina lateral medial
Upper Division apical post. anterior
Upper lobe apical posterior anterior
Lower Division (Lingular) superior inferior Upper lobe carina
FIGURE 4-3 Continued
DIAGNOSTIC ENDOSCOPY
Flexible Bronchoscopy The great advantage of flexible bronchoscopy over rigid bronchoscopy is primarily in the visualization of the sub segmental divisions of the bronchi. Coupled with this advantage is the ability of the bronchoscopist to obtain selective biopsy samples, including the brush type from these subsegmental bronchi. Biplane fluoroscopy can also be combined with the flexible instrument to obtain brush biopsy samples beyond the range of the visualization of the scope. However, Gelfoam smears cannot be obtained. Flexible bronchoscopy can be performed under either topical or general anesthesia. Under topical anesthesia the instrument can be inserted either via the oral cavity with a bite block or a pharyngeal airway with a midline slot for the instrument or less commonly via the nasal cavity. A slide-type laryngoscope (Jackson) can be used to aid in the insertion of the flexible scope, if needed. If the flexible scope is introduced via the nasal cavity, the diameter of the scope may cause a problem, possibly resulting in epistaxis, if there is any significant nasal obstruction. Obviously, topical anesthesia must likewise be applied to the nasal mucosa, and cocaine can be used for this purpose because it is a vasoconstrictor. Otherwise 4 % lidocaine is used with oxymetazoline. Precautions in the use of cocaine are discussed on page 182. Under general anesthesia the flexible scope is introduced through the lumen of an endotracheal tube. A special adaptor to the endotracheal tube is utilized to continue the anesthesia along with oxygen administration. The drawback of this method is that the hypopharynx and larynx are not visualized unless they are independently examined. This is most important. As a matter of fact, too many times even without an endotracheal tube, the endoscopist does not take enough time to visualize the hypopharynx and larynx, thus possibly missing a neoplastic lesion in one of these structures. Thus, if an endotracheal tube is utilized, the hypopharynx and larynx must be scrutinized by laryngoscopy. Regardless of the method of insertion of the flexible bronchoscope, it should be lubricated and introduced so all structures can be visualized as it is moved along. Additional topical anesthesia can be inserted through the scope, and suction specimens can also be obtained in the same manner.
The C-arm can be used for purpose of concomitant bronchoscopy with fluoroscopy. Complications
• Hemorrhage, especially from blind biopsies. This can result in death when the biopsy is in either the trachea or the bronchi. • Hypoxia, anoxia, and respiratory arrest • Laryngospasm. Always use topical anesthesia on the larynx when general anesthesia is utilized. • Cardiac arrhythmia • Dental injury
Tracheal Lengths (Fig. 4-4) The length of the trachea in both adults and children is of importance in relation to the following: 1. Length of endotracheal tubes 2. Length of tracheostomy tubes 3. Feasibility of tracheal resection with end-to-end anastomoses 4. Evaluation of dead space. The number of tracheal rings will vary from 16 to 20. It is interesting to compare tracheal lengths in the cadaver (Table 4-1) with the living patient. The latter is a dynamic measurement and somewhat longer. In Figure 4-4 a comparison is made between measurements in the living infant and cadaver. Although the bases for measurements are not the same-Fearon and Whalen (1967) measuring from the vocal cords to the main carina and Hall (1955) from the lower edge of the cricoid cartilage-there apparently is a longer length in the living, and an indication of the dynamic nature of the trachea is the possible influence by the action of the diaphragm. Another point of interest is that the trachea is not a true cylinder but somewhat flattened posteriorly. This is one of the reasons for the complication of tracheal stenosis with the use of high-pressure cuffs on tracheostomy tubes and endotracheal tubes. Table 4-2 gives a guide for selection of appropriate tracheotomy tubes and bronchoscopes for use in children.
DIAGNOSTIC
TRACHEAL LENGTHS IN INFANTS 10
_
FEARON & WHALEN-(L1VING)
o
HALL & ENGEL-(CADAVER)
TABLE4-1 Average Cadaveric Lengths of 1\'achea (After Jackson. 1950) Patient
Length
6
Adult
4
Child infant
i2 cm (maie) 10 cm (female) 6cm 4cm
8
ENDOSCOPY
7.2
2
o
3
6
12
18
AGE IN MONTHS
FIGURE 4--4
TABLE4-2
Guide for Selection of Suitable 1\'acheotomy 1\1bes and Bronchoscopes
instrument
Child's Age
Size of Instrument
Holinger tracheotomy tube
Premature
No. 000 x 26 mm
( 41b) o to 6 mo 6 to 12 mo 12 to 18 mo 18 mo to 4 to 5 yr 4 to 5 yr to 10 yr 10 yr+
No. 00 x 26 to 33 mm
< 5 lb
3
o
3.5 mm
No. 0 NO.1 No.1 No.1 No.2 NO.3
x 33 to 40 mm x 40 to 46 mm x 46 mm or NO.2 x 46 to 50 mm or No.3 x 50 to 55 mm or NO.4 or No.5 x 50 to 68 mm
mm
to 6 mo 6 mo to 3 yr
4 mm
3 to 12 yr 12 yr +
5 mm 6mm
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
Esophagoscopy (Fig. 4-5)
Flexible Esophagoscopy
Highpoints
In addition to the rigid esophagoscope, flexible fiberoptic instruments are utilized. These are usually flexible gastroscopes and are the preferred instrument for routine examination by gastroenterologists. The advantage of these is that there is magnification and that the esophageal lumen can be dilated with insufflation. Endoscopic photographs are easily performed as well as endoscopic excision of small areas of cancer in situ. Using the flexible scope, the Japanese have reported early detection of esophageal cancer in patients with known head and neck cancer utilizing half-strength glycerine-free Lugol's solution instilled into the esophageal lumen. The Japanese have also reported endoscopic resection of intraepithelial and intramucosal early and superficial esophageal cancers, which do not involve the muscularis mucosa. The disadvantages include problems with performing dilatation, removal of foreign bodies, and Gelfoam smears of suspicious mucosal lesions. Caution: Extreme care must be taken with both the rigid and flexible esophagoscope not to perforate a pharyngoesophageal diverticulum (Zenker) because the scope may have a tendency to go into the diverticulum rather than follow the lumen of the esophagus. Although not encountered by the authors, there is the possibility that the stiff plastic cardiac monitor tube inserted by the anesthesiologist could likewise perforate a diverticulum.
1. Never advance the esophagoscope forcibly. 2. Advancement is made only when an actual lumen is seen. 3. The Jesberg type of esophagoscope is preferred. 4. The danger area is at cricopharyngeus sphincter, at the cardioesophageal region, or at any area of constriction. 5. In removal of foreign bodies, the esophagoscope is never passed to an assistant. Such manipulation may lose the foreign body, which if sharp may cause esophageal perforation. 6. If feasible, always perform mirror laryngoscopy first under topical anesthesia. Pooling of saliva in the pyriform sinus (Jackson sign) is an indication of esophageal obstruction. 7. If unable to pass the esophagoscope, pass a red rubber catheter into the lumen of the esophagus and use this as a guide. If this fails, do not persist and postpone until another day. Perforation is an extremely serious complication. Primum non nocere is the dictum. Anesthesia
Virtually all esophagoscopies are performed under general endotracheal anesthesia. This is usually preceded by topical anesthesia (see p. 182) to the mucous membrane of the oropharynx, hypopharynx, and larynx. Careful scrutiny of these structures is always performed. If there is filling of the pyriform sinuses, this is an indication of a distal obstruction in the esophagus. Usually, esophagoscopy is preceded by full-length pharyngoesophagograms. An exception to these radiographs is the presence of a radiopaque foreign body. A suspected nonradiopaque foreign body may be visualized with the ingestion of some cotton soaked with the radiopaque material. Otherwise, the radiopaque material may completely obscure the visualization of the foreign body. Cervical Esophagoscopy After Total Laryngectomy or Cervical Esophageal Surgery Examination of the pharyngoesophageal area and the cervical esophagus can be performed with the use of a flexible nasopharyngoscope that has a suction port and a second port for instillation of medication by attaching a short section of tubing with a bulb for inflation to the second port (similar to the bulb used on a sphygmomanometer) to inflate and distend the esophagus (see Fig. 4-SB and C).
A A Jesberg esophagoscope is preferred because its tip is so shaped that it acts as a blunt dilator. There are no sharp angles at the tip, which might become engaged with folds of mucous membrane. The esophagoscope, lubricated with water-soluble jelly,is introduced exactly the same as the laryngoscope or bronchoscope, following steps E, F,G, and H in Figure 4-2, except that the instrument is held in the right hand. The other variant is that introduction is almost always through the right side of the mouth, especially if a full-length esophagoscopy is anticipated. When the posterior commissure of the larynx and the arytenoid cartilages are exposed, the tip of the esophagoscope is placed exactly in the midline and the entire instrument is brought into the same midline plane. This is achieved by slightly rotating the head to the side opposite the side of introduction through the mouth. The tip of the esophagoscope is then gently advanced along the space posterior to the bodies of the arytenoid cartilages and the cricoid cartilage. This technique differs from the pyriform sinus approach to the cricopharyngeus sphincter in that the esophagoscope tip is in the midline, stays in the midline, and never enters either pyriform sinus. However, the pyriform sinuses are
DIAGNOSTIC ENDOSCOPY
FIGURE 4-5
carefully examined before the introduction of the scope into the lumen of the esophagus. By staying in the midline there is less danger of perforating either the hypopharynx or the esophagus. The pyriform sinus approach is through the pyriform sinus. With this approach the instrument is introduced into the sinus and when near the apex of the sinus it is carefully displaced medially to the midline above the cricopharyngeus muscle. The next structure encountered is the cricopharyngeus sphincter, which is the most dangerous area in esophagoscopy. With waiting and applying gentle pressure and sometimes with gentle elevation of the tip of the esophagoscope, the lumen is almost always perceptible. The esophagoscope
is never advanced unless the lumen through this sphincter is seen. In difficult exposure problems, switching to a smaller-lumen esophagoscope will help. Another technique that provides aid is to pass a red rubber catheter before instrumentation and follow the tube through the cricopharyngeus sphincter. The red rubber catheter is inserted through the nose and enters the esophagus through the pyriform sinus. This method has been found more suitable than using a filiform bougie passed through the esophagoscope to identify the lumen, and it is much safer. A bougie may perforate the esophagus when there is significant obstruction due to neoplasm.
Continued
DIAGNOSTIC ENDOSCOPY
Rigid Esophagoscopy
(Continued)
(Fig. 4-5) As the esophagoscope is advanced through the sphincter, the operator must not be so engrossed in the instrumentation that he or she neglects to examine this region carefully for any lesions, if the signs and symptoms of the patient so indicate examination. This area-especially the postcricoid region-can also be evaluated during slow removal of the esophagoscope at the close of the procedure. Biopsy
Biopsy of neoplastic or suspicious neoplastic lesions of the esophagus must be very carefully performed because of the danger of perforation. If the lesion is small and relatively nonprotruding, a cytologic smear is obtained using Gelfoam, as described under Bronchoscopy (see Fig. 4-3E). Avoid any deep biopsy of any lesion. Frozen sections are often utilized to avoid repeat biopsies. If the biopsy of the lesion is reported as benign on several judicious attempts, consideration should be given to open transcervical or transthoracic biopsy rather than risk perforation. The early signs and symptoms of perforation are heart rate and temperature elevation and either cervical, back, or epigastric pain. Hence, after all esophagoscopies, the patient is kept NPO for several hours and is carefully observed. Complications
• Esophageal perforation • Mediastinitis • Hemorrhage
Management
of Perforated
Esophagus
If the perforation is in the cervical area, the management is intravenous administration of a broad-spectrum antibiotic with maximum dosage. If symptoms persist or worsen, then external drainage is indicated. Extreme care must be taken not to injure any major vessel, for example, the internal jugular vein or the common carotid artery, nor the recurrent laryngeal nerve. Closure of the perforation is not recommended nor is a proximal diversion recommended. One patient was reconstructed with an oblique end-to-side anastomosis after another surgeon transected the esophagus at the thoracic inlet with a proximal diversion of the esophagus and closure of the distal segment of the esophagus. This was a very difficult reconstruction performed through the cervical area. Exposure was enhanced by resection of the medial third of the clavicle to expose the posterior superior mediastinum (see pp. 1041 to 1045). There was a temporary left vocal cord paralysis, and reconstruction was successful without leak. If the perforation is in the thoracic esophagus, open thoracotomy with closure is usually immediately indicated. However, small perforations may be observed from 8 to 12 hours while on antibiotics. Note: These perforations may be the result of the esophagoscope itself or the result of a deep biopsy of a neoplastic lesion. Remember also there are diverticula in the thoracic esophagus as well as in the pharyngoesophageal area. Depicted is the fiberoptic flexible nasolaryngoscope with an inflatable bulb attached to the medicinal channel that can now be used as a cervical esophagoscope. Air is gently insufflated into the cervical esophagus for dilatation, which facilitates inspection.
8, C
Continued
DIAGNOSTIC ENDOSCOPY
B
c FIGURE4-5 Continued
DIAGNOSTIC
ENDOSCOPY
Rigid Esophagoscopy
(Continued)
(Fig. 4-5) D, E After passage of the esophagoscope through the cricopharyngeus sphincter, the lumen of the cervical esophagus is exposed. Advancement is now quite easy, but again the strict axiom applies that this be done only when a clear lumen is seen. When the thoracic esophagus is reached, the lumen will be seen to open and close with respirations. As the instrument is advanced past the landmarks of the arch of the aorta and the point of crossing of the left bronchus, raising and lowering the head, neck, and shoulders will be necessary to keep the esophageal lumen exactly in the center of the esophagoscope. As the cardioesophageal junction is approached, the lumen will tend to become obscure. This is the second danger site and indicates the level of the diaphragm, and extreme care must again be exercised to proceed only when the lumen is fully exposed. The two leaves of the right crus of the diaphragm form the hiatus, which may be quite evident as a distinct site of sphincter-like action during the phases of respiration. The esophagus usually bends slightly to the left in this region, and this will necessitate pointing the distal end of the esophagus toward the left.
If the lumen does not become evident, gentle forward pressure usually demonstrates it. The technique of using the red rubber catheter is occasionally necessary.
Beyond the esophageal hiatus of the diaphragm, the esophagus continues for about 2 cm as the abdominal portion before it joins the stomach at the cardioesophageal junction. The stomach is easily entered and is recognized (E) by the change of the whitish esophageal mucous membrane to the reddish larger folds of gastric mucosa. There may be a regurgitation of gastric juices into the lumen. The esophagoscopic distances from the upper incisors are depicted along with the three constricted areas in which foreign bodies are most likely to become lodged: 1. The cricoid cartilage, which marks the cricopharyngeus muscle and the beginning of the esophagus 2. The bifurcation of the trachea, which is at the level of the descending portion of the arch of the aorta or the crossing of the left bronchus 3. The level of the diaphragm, which is slightly above the cardioesophageal junction Just above the level of the diaphragm there may be a slight dilatation, which is more noticeable on a radiograph; that is the phrenic ampulla. Another word of caution is needed about the danger of esophageal perforation through the sac of an esophageal diverticulum. A full-length esophagogram 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 make subsequent esophagoscopy somewhat difficult unless it is irrigated and removed by suction. Always use blunt closed-tip suction in esophagoscopy.
DIAGNOSTIC ENDOSCOPY
Distance from upper incisors ADULTS Female-Male
12 to 16 em.
Cricoid cartilage
22 to 29 em.
D
Bifurcation of trachea
32
to
50
em.
Cardioesophageal
junction
E
FIGURE4-5 Continued
200
DIAGNOSTIC ENDOSCOPY
Microscopic Endolaryngoscopy (Fig. 4-6) (After Kleinsasser, 1961; Jako and Kleinsasser, 1966) The history of direct laryngoscopy dates back at least to Kirstein (1894), with the first optical laryngoscopy by Briinnings and the first binocular laryngoscopy by Yankauer (1910). There are basically two methods of obtaining magnified visualization of the larynx. One uses the microscope, whereas the other uses rigid or flexible telescopes. At this point, only the microscope and rigid telescopes are adaptable to endolaryngeal surgery. Although the flexible scopes are useful in bronchoscopy for biopsy purposes, this methodology has not been in general use for the larynx. Kleinsasser (Karl Storz) has designed rigid telescopes for use via his laryngoscope mainly for visualization and photography. Lore and Karl Storz have designed rigid telescopic laryngeal instruments not only for visualization but also for biopsy purposes and removal of benign lesions as well as of carcinoma in situ of the larynx. These procedures are performed using a standard type laryngoscope (e.g., the Holinger hourglass laryngoscope) and stripping forceps incorporated with the rigid telescope (0, 30, and 70 degrees). Indications
• Diagnosis • Surgery • Teaching Anesthesia
Topical plus general anesthesia, using a small (26 to 30 gauge) endotracheal tube with cuff, is used. One must be careful to avoid overdose with muscle relaxants when stripping of vocal cords is performed. The muscle relaxant must be entirely worn off at the time of the stripping otherwise bowing of the vocal cord may occur. This complication is caused by the relaxation and hence convexity of the vocal cord. Topical anesthesia (see p. 182) is applied by the operating surgeon, who then carefully inspects the larynx by indirect laryngoscopy. This gives up-to-theminute information regarding any pathologic change, including motility of the vocal cords. This is most important, and this portion of the examination can be more easily performed with a flexible nasopharyngoscope. The cuff is inflated to prevent aspiration of blood and air leak, which might cause fogging of the optical system and mirror. Some surgeons use intravenous analgesia combined with a Lynch suspension apparatus with a naso-oral tube
to supply oxygen. No endotracheal tube is utilized. There is a significant danger in utilizing this method without control of the oxygen exchange because of cardiac arrhythmia. The author prefers an endotracheal tube, using topical plus general anesthesia. In certain conditions in which an endotracheal tube is impractical (e.g., evaluation of subglottic stenosis), neuroleptanalgesia is utilized along with topical anesthesia. Neuroleptanalgesia is the combination of a narcotic analgesic with a tranquilizer. A combination of meperidine (Demerol) and promethazine (Phenergan) could be considered in this category. More commonly, it is the combination of fentanyl (narcotic analgesic) and droperidol (tranquilizer) under the trade name of Innovar. Innovar has a fixed amount of each of these drugs; some surgeons prefer a different amount of each of these drugs. Cardiac monitoring is advised, with the monitoring continued during the postoperative period. Innovar is not believed to be warranted as a preoperative medication, because muscle rigidity and hypotension are complications that could lead to death. Succinylcholine is used to counteract the muscle rigidity. Although the usual location of the endotracheal tube is at the posterior commissure for operative procedures on the vocal cords, the tube is placed anteriorly for evaluation and biopsy posteriorly. This can be achieved by using a portion of a plastic tooth guard. An anesthetic device has been designed based on the Venturi effect. The author has no personal experience with this apparatus. Instruments
1. Jako, Kleinsasser, Riecker, Lynch, or Dedo laryngoscope. All too often these wide proximal endoscopes cannot be introduced safely. A Holinger hourglass or Jackson anterior commissure speculum can be utilized with the lateral oral approach. Monocular vision is then necessary. 2. Operation microscope with 400-mm (if short instrument used) or SOO-mm lens, x16 to x2S magnification 3. Microsurgery instruments plus standard laryngeal instruments 4. Lewy laryngoscope holder S. A plastic guard for upper teeth Diagnosis
Evaluation of small malignant lesions is possible with staining by toluidine blue 1 % (Strong et al., 1968; Shedd and Gaeta, 1971). Toluidine blue stain is picked up by any ulcerative lesion and hence not diagnostic of dysplasia, carcinoma in situ, or carcinoma, only suggestive. It may be helpful in directing the biopsy to the
DIAGNOSTIC
most suspicious area. With vocal cord lesions, for example, in which virtually the entire cord is involved with a whitish area, it is usually best to strip the entire vocal cord and have the pathologist do serial sections. First, gently cleanse mucous membranes with acetic acid 1 %, apply the toluidine blue 1 % or 2 %, and then gently wipe with acetic acid 1 % and water. Respiratory epithelium and any benign ulcer yields a false-positive result. The ventricles are lined with respiratory epithelium. Multiple exacting biopsies with small forceps are possible. Using the staining technique with the microscope, biopsies are possible of areas that otherwise might be missed. Hence, the unrecognized lesion on mirror laryngoscopy and ordinary direct laryngoscopy can be seen, and a biopsy sample can be taken, thus often avoiding repeat examinations. Carcinoma in situ is a specific example of a lesion that may go unrecognized by the ordinary methods. A large diagram of the larynx can be used to locate the sources of the biopsies. Flexibility of the structures as well as subglottic space and ventricles is evaluated. Transillumination of the vocal cords and ventricular bands is possible but of questionable value. A telescope, Hopkins rod (Karl Storz), foreoblique or retrograde, can be used through the laryngoscope to yield additional information of the subglottic space. When borderline lesions are present the technique is especially helpful to evaluate the feasibility of partial laryngectomy. In addition, hypo pharyngeal lesions can be evaluated. A photograph is taken through the standard beam splitter and sidearm attachments. Videotapes are much
ENDOSCOPY
easier to make than still photographs. Television, for teaching purposes, is also possible and yields an excellent picture of the larynx and the surgical procedure. Surgery 1. Removal of webs 2. Stripping of vocal cords (using adult- or child-sized Lore, Sf. forceps) (see Figs. 4-7 and 20-5) 3. Selective biopsy 4. Intralaryngeal incision and/or excision of lesions 5. Cryosurgery 6. Transoral arytenoidectomy (Thornell) 7. Injection of vocal cords with Teflon or Gelfoam (temporary) for adductor cord paralysis or bowing. (General anesthesia is not used; rather Innovar is given intravenously to evaluate amount of material injected.) 8. Carbon dioxide laser Complications
• Injury to teeth. A percentage of patients cannot be examined by the laryngoscopes and holders now available for micro laryngoscopy. A substitute for the use of the microscope is the telescopic endolaryngeal instruments designed by Lore and Karl Storz. • Cardiac arrhythmia • Although both vocal cords can be operated on, there is danger that web formation can occur if the mucous membrane on both vocal cords is denuded at the anterior commissure.
DIAGNOSTIC
ENDOSCOPY
Microscopic Endolaryngoscopy (Continued) (Fig. 4-6) (After Kleinsasser, 1961; jako and Kleinsasser, 1966) A The basic setup is depicted. A Mayo stand is used to support the elbows of the operating surgeon, thus steadying his or her hands. The laryngoscope is in the midline. This is the main drawback of the technique,
because there can be undue pressure on the upper incisors. At times a contralateral approach can be used with a smaller-diameter laryngoscope. B The location of the laryngoscope holder with the cuffed endotracheal tube placed at the posterior commissure of the larynx is depicted.
DIAGNOSTIC ENDOSCOPY
FIGURE 4-6
DIAGNOSTIC
ENDOSCOPY
Telescopic Endolaryngeal Surgery
Tracheoscopy
(Fig. 4-7) Several modifications of the original vocal cord stripping forceps designed by Lore, Sr. (after the Imperatori Subglottic Forceps by Pilling) have been developed by Lore, Jr. and Karl Storz. These instruments incorporate a 0-, 30-, and 70-degree telescope with either a short or a long right-angle forceps. Other types of microsurgical forceps, for example those used with the microscope, could be manufactured with the tube to carry the telescope. This methodology is a substitute for the operation microscope. These instruments are inserted through a Holinger hourglass anterior commissure speculum with the use of a Lewy holder under general endotracheal anesthesia. These instruments do not require the large laryngoscopes that are usually necessary when the microscope is employed, so there is less danger of injury to the teeth. The telescopes are first utilized without the forceps for a careful inspection of all of the intrinsic structures of the larynx, initially using the 0- and 30- degree telescope. The 70-degree telescope is utilized primarily for visualization of the subglottic area as well as the walls of the ventricles. Fogging is eliminated by inserting the scope in warm water. After careful scrutiny, the telescope is then inserted into a tube within the forceps. Biopsy or definitive stripping of a vocal cord is then performed under magnification through the telescope. The exact extent and depth of the excision are clearly visualized.
These instruments afford excellent magnified visualization of the cervical trachea when inserted through a Holinger anterior commissure speculum. Although the trachea can be examined using a rigid or flexible bronchoscope, magnified visualization and biopsy of tracheal lesions is better achieved with the instruments depicted here. Tracheoscopy can be performed through an existing tracheostomy site using the 70-degree Lore-Storz Hopkins rod scope, which is used for endoscopic visualization of the nasopharynx (see Fig. 4-1B; the scope is removed from the biopsy forceps). This instrument can be rotated 180 degrees to examine the trachea both proximal and distal to the tracheostomy. The vocal cords can also be seen proximally. The instruments are also very adaptable during mediastinoscopy (see Chapter 19) for visualization and biopsy.
A
The 30-degree telescope.
B The 30-degree telescope inserted into the tube of the forceps. C Close-up view of long right-angle forceps for stripping a vocal cord and for subglottic biopsy. This instrument is also excellent for cervical tracheal biopsy as well as mediastinoscopy and biopsy. (Allinstruments shown are manufactured by Karl Storz.)
A
B
Lore-Storz LaryngealTelescopic Forceps FIGURE4-7
DIAGNOSTIC ENDOSCOPY
Nasopharyngoscopy (Figs. 4-8 and
Small-lumen 70-degree scope with or without incorporated biopsy forceps (with forceps-see Figs. 4-7B and 4-9C) (Lore) ii. Large-lumen 70- to 90-degree scopes I.
4-9) Nasopharyngoscopy can be divided into two forms, based on the type of instruments utilized: (1) indirect mirror, which offers a good overall view but is many times quite difficult to perform, and (2) direct visualization, which is performed in two basic ways (see Fig. 4-BA to E). The optical technique is done with a non flexible scope, such as a Hopkins polished glass rod via the nasal cavity or a Berci-Ward (Karl Storz) via the oral cavity or a flexible nasopharyngoscope. The rigid Yankauer nasopharyngoscope affords a limited view of the posterior wall of the nasopharynx. It has no application to ambulatory diagnostic nasopharyngoscopy. Its main use is when the patient is under general anesthesia. At that time it does afford a reasonably good view of the posterior wall of the nasopharynx. Nasopharyngoscopy can also be divided according to the route of examination: nasal route or oral route. 1. Nasal route a. Flexible scope b. Rigid scopes: 0, 30, and 70 degrees 2. Oral route a. Mirror b. 70- to 90-degree scopes
Indications
• • • •
Every head and neck examination Nasal obstruction After epistaxis For enlarged spinal accessory lymph nodes (posterior cervical triangle), such as undifferentiated squamous cell carcinoma (previously known as Schmincke tumor or lymphoepithelioma) or lymphoma of the nasopharynx • Paralysis of any cranial nerves • Any mass in neck or extracranial head • Ear pain or persistent discomfort Highpoints
1. Mirror technique, if feasible, affords a good overall view. 2. Optical nasopharyngoscopes, rigid and flexible, are used. 3. Topical anesthesia is necessary.
DIAGNOSTIC ENDOSCOPY
Nasopharyngoscopy
(Continued)
(Figs. 4-8 and 4-9) A, B The tongue is depressed, and the patient is asked to breathe through the nose. This usually throws the soft palate forward. A suitable-sized warmed mirror is then inserted, using a head mirror or headlight for illumination. The angle of the mirror may require adjustment, depending on the configuration of the vault of the nasopharynx. Occasionally, grasping the tongue as is done in mirror laryngoscopy (see Fig. 20-2) is of aid. C The area so visualized is depicted. To obtain complete visualization, the mirror is simply rotated a few degrees. The posterior wall of the vault is first examined for any tumefaction, benign or malignant. The ostia of the sphenoidal sinus may be seen. The roof of the vault is likewise scrutinized and then the posterior end of the nasal septum. The posterior tips of all six turbinates should be visualized lying in the posterior nares. Laterally, the eustachian tube orifices in Waldeyer's ring are evaluated. The posterosuperior aspect of the soft palate is checked. D Another technique of nasopharyngoscopy is the use of a rigid optical endoscope-O, 30, and 70 degrees (e.g., scopes used for rhinoscopy via the nasal route). Another instrument, preferred by many physicians, is the flexible nasopharyngoscope (see Fig. 4-9E). After topical anesthesia to the nasal cavity, the instrument is inserted through the anterior naris. Rotation of the scope at various depths is necessary to cover the nasopharynx. Because only smaller visual fields are available at each degree point, a composite picture is
more difficult. This technique is best reserved for occasions when the mirror method fails or when a specific area noted on mirror examination requires more scrutiny. A biopsy forceps is combined with the rigid endoscope (see Fig. 4-9A and B) and affords good visualization of the suspected area with the jaws of the biopsy forceps (Karl Storz) in full view. An oral nasopharyngoscope, preferred by some physicians, affords a larger field of vision similar to that seen with a mirror. This instrument consists for the most part of a rigid endoscope. The earlier models were designed by and known as the Beck, Proud-Beck, and Wolf. The more modern ones utilize the Hopkins rod principle and include the Berci-Ward instrument manufactured by Karl Storz (see Fig. 4-90). This instrument is also used to visualize the hypopharynx and larynx. Digital examination is also performed to evaluate the consistency of any abnormality visualized. The index finger is inserted through the mouth and behind the soft palate. The operator may find that standing to the side of the patient facilitates this examination. Retraction of Soft Palate When the soft palate obstructs visualization of the vault either during examination or biopsy or in minor operations, it may be retracted in several ways. E A specific soft palate retractor is available that has its fixed point on the upper lip and alveolar ridge. The drawbacks of the instrument are its size and the fact that it tends to slip and is awkward. Continued
DIAGNOSTIC ENDOSCOPY
FIGURE 4-8
DIAGNOSTIC ENDOSCOPY
Nasopharyngoscopy (Continued) (See Fig. 4-8F to I) Complications of Nasopharyngeal
Biopsy
Hemorrhage
1. Never perform biopsy on an ambulatory basis of any lesion suspected to be an angiofibroma. If biopsy is necessary, perform it in the operating room with endotracheal anesthesia and several units of blood available. Be prepared to perform definitive surgery following frozen section. 2. Never perform a biopsy of a pulsating mass (e.g., carotid-cavernous fistula) (Feuerman et al., 1984). F A small curved retractor of the Cushing venous type may be used. Usually, the tongue must also be depressed, in which case an assistant is necessary. G A small catheter may be inserted through one naris and out through the mouth. Traction with a clamp retracts the soft palate. Biopsy of Nasopharynx
H Using the mirror method for visualization, a very slender cup forceps is inserted through one naris. The tip of the forceps and the tumor are visualized in the mirror and the biopsy is performed. I, P A transoral biopsy requires a curved forceps (Karl Storz, Jl; Lawton). Visualization is in either a mirror or a nasopharyngoscope or through the nasal cavity. Visualization through the nasal cavity is seldom possible and requires complete shrinkage of the nasal mucosa. Only lesions in the visual range of the posterior nares can be seen.
Random biopsies are also resorted to in the search for an unknown primary tumor in the head and neck. Caution: Do not perform a biopsy if any mass is suspected to be an angiofibroma or pulsating mass. If biopsy is necessary, this should be performed in the operating room with blood replacement available. One helpful way to detect an unsuspected primary tumor of the nasopharynx is to apply cotton tamponades in each nostril and extend them into the nasopharynx. They will serve as a topical anesthetic; with their removal, they may occasionally be spotted with blood in the area in which the primary tumor is located. In addition, all crusted mucus must be removed, because this may well overlie the primary neoplasm. Anatomically, the nasopharynx can be divided into the following regions: 1. 2. 3. 4. S. 6.
Vault-most superior portion Posterior wall Lateral walls and eustachian tube orifices Nasopharyngeal side of the soft palate Posterior edge of the nasal septum Posterior choanae
The examiner should localize as accurately as possible the region of the pathologic process. This is most important from a therapeutic as well as a prognostic point of view. For example, regions 3, 4, 5, and 6 may be amenable to surgical resection when involved by a malignant lesion. Resection of lesions in regions 1 and 2 are usually relegated to chemotherapy and radiation therapy for malignant lesions and surgery for benign lesions. This designation, however, depends on local invasion. Hard and fast rules are variable depending on cell type and other factors; that is, chemotherapy and radiation therapy may be the choice for the treatment of malignant lesions in all or any of these areas.
DIAGNOSTIC ENDOSCOPY
F
G
FIGURE 4-8 Continued
DIAGNOSTIC
ENDOSCOPY
Rigid and Flexible Direct Optical Nasopharyngoscopy, Laryngoscopy, Cervical Esophagoscopy, and Rhinoscopy (See Fig. 4-9)
hypopharynx photography
are visualized. It is also of these structures.
used
for
Flexible Nasopharyngoscopes Rigid Nasopharyngoscopes The rigid nasopharyngoscopes utilizing the Hopkins rod principle are depicted on the accompanying photographs. These are the ones preferred by the author and manufactured by the Karl Storz Company of Germany and distributed by Karl Storz Endoscopy-America, Inc. There are a number of types depending on the route of introduction. Nasal Route A, B Depicted are two models each with a rigid Hopkins rod optical telescope with biopsy forceps. Each can be used with or without biopsy forceps. The nasopharynx, eustachian tube orifices (patient at rest and swallowing), and nasal cavity can be examined. It can visualize not only the nasopharynx but also the nasal cavity. In addition, any operative defect or any antrum with a window can also be scrutinized. One optical arrangement is categorized as 0 degrees (A) for vision directly in front of the instrument; the other is listed as 30 degrees (B) for angulated visualization. Biopsy forceps are available through which the telescope is inserted, affording exact visualization of the area to be sampled. Oral Route C Depicted is the transoral 70-degree telescope and biopsy forceps (Lore-Storz). The advantage of this instrument is it has a wider field of vision than that obtainable with the transnasal instruments. The telescope can be utilized independently of the forceps. With the combination of both forceps and telescope, the field of vision includes the biopsy forceps, affording exact visualization of the area to be sampled. This instrument can also be utilized to visualize areas of biopsy specimens of lesions of the hypopharynx by simply rotating the instrument 180 degrees. D The Berci-Ward telescope can also be utilized via the oral route to visualize the nasopharynx as well as the larynx and hypopharynx. The advantage of this instrument is the wider field of vision and its excellence for photography of the nasopharynx. Karl Storz manufactures the light source and the camera. By rotating this instrument 180 degrees the larynx and
E Depicted is the flexible optical nasopharyngoscope. Although it is almost always introduced through the nasal cavity, if there is severe bilateral nasal obstruction, it can be introduced orally. The nasopharynx, eustachian tube orifices (patient at rest and swallowing), and nasal cavity can be examined and any operative intranasal or sinus defects identified. It is likewise used to visualize the hypopharynx and larynx. Its only drawback is the smaller image as compared with the rigid Berci-Ward instrument, which yields a much larger image and more detail. F Depicted is the flexible instrument within the nasopharynx. This instrument is manufactured in two sizes, one for the adult and the other for the infant and child. G This is a flexible observer's attachment for the nasopharyngoscope. Karl Storz manufactures rigid and jointed observation attachments that attach to the eyepiece of its telescopes. For the head and neck surgeon both rigid and flexible scopes are a sine qua non for examination, biopsy purposes, photography, and television recording. Often when one instrument does not suffice, the other instrument solves the problem.
Rigid and Flexible Direct Optical Rhinoscopy These rigid instruments (A and B) utilize the Hopkins rod principle, as incorporated in the scopes manufactured by Karl Storz. They are 0 and 30 degree and of narrow diameter and are excellent optical instruments for scrutinizing selected areas in the nasal cavity and the sinuses. For examination, the telescopes are used without the forceps. These instruments are not only utilized for primary diagnostic purposes but also for follow-up examination of any sinus surgery whether for infectious disease or neoplastic disease. When combined with the forceps, they are utilized for endoscopic biopsy and sinus surgery (see p. 220). The flexible nasopharyngoscope and laryngoscope (E) are also suitable for rhinoscopy. However, for detailed examination, the previously described rigid scopes are more suitable.
DIAGNOSTIC ENDOSCOPY
A
o
B
c D
FIGURE4-9
oIf()
DIAGNOSTIC ENDOSCOPY
Cervical Esophagoscopy (See Fig. 4-5B and C) A bulb insufflator can be attached to a flexible optical scope that has a channel for instillation of medication and suctioning in the nasopharynx, hypopharynx, or larynx. A bulb insufflator can be attached to the medicinal channel for instillation of air. This will distend the esophagus for insertion of the optical scope. The cervical esophagus can thus be visualized and inspected as well as suctioned. BIBLIOGRAPHY Adriani J: Anesthesia for endoscopy. Ann Otol 78:1129-1143, 1969. Alavi SM, Keats TE, O'Brien WM: The angle of tracheal bifurcation: Its normal mensuration. AJR Am J RoentgenoI108:546-549, 1970. Barr NL Jr, Itscoitz 5, Chan C, et al: Oxygen injection in suspension laryngoscope. Arch Otolaryngol 93:606, 1971. Bean WJ, Graham WL, Jordan RB, Eavenson LW: Diagnosis of lung cancer by the transbronchial brush biopsy technique. JAMA 206:1070-1072,1968. Benson OW: A survey of general anesthesia for endoscopy. Ann Otol 78:459, 1969. Brimacombe JR, Brimacombe JC, Berry A, et al: A comparison of the laryngeal mask airway and cuffed oropharyngeal airway in anesthetized adult patients. Anesth Analg 87:147-152, 1998. Brummit WM, Fearon B: Anesthesia and pediatric endoscopy. J OtolaryngollO:1, 49-51,1981. Carlens E: Mediastinoscopy: A method for inspection and tissue biopsy in the superior mediastinum. Dis Chest 36:343-352, 1959. Cohen SR, Herbert WI, Lewis GB, Geller KA: Foreign bodies in airway five year retrospective study with special reference to management. Ann Otol Rhinol Laryngol 89:437-442, 1980. Doctor AH: Mediastinoscopy: A critical evaluation of 220 cases. Ann Surg 174:965-968, 1971. Drinnan AJ: Dangers of using radiolucent dental materials. J Am Dent Assoc 74:446-450, 1967. Dunbar JS: Upper respiratory tract obstruction in infants and children. AJR Am J Roentgenol 109:227-246, 1970. Duvall AJ, Johnsen AF, Buckley J: Bronchoscopy under general anesthesia using the Sanders ventilating attachment. Ann Otol 78: 490, 1969. Fearon B: Anesthesia in pediatric peroral endoscopy. Ann Otol 78: 469, 1969. Fearon B, Short breed R: Tracheobronchial compression by congenital cardiovascular
anomalies
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Ann Olol 72:949-969.
1963. Fearon S, Whalen JS: Tracheal dimensions
in the living infant. Ann
Otol 76:964, 1967. Ferguson CF: Interesting
brancho-pulmonary
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Laryngoscope 80:1347-1363,1970. Feuerman
TF, Hieshima
CS, Bentson JR, Batzdorf
U: Carotid-cavernous
fistula following nasopharyngeal biopsy. Arch Otolaryngol 110: 412-414, 1984. Fry WA, Manalo-Estrella P: Bronchial brushing. Surg Gynecol Obstet 130:67-71, 1970. Goldberg EM: Mediastinoscopy for assessing mediastinal spread. In Clinical Staging of Carcinoma of the Lung, Vol V, Armamentarium.
Chicago, V. Mueller, 1970. Gross CW, Gross JC: Rare complications after prolonged translaryngotracheal intubation. Ann Otol 80:582, 1971. Hall JE: The physiology of respiration in infancy and young children. Proc R Soc Med 48:761-764, 1955.
Hendren WH, Henderson BM: Immediate esophagectomy for instrumental perforation of the thoracic esophagus. Ann Surg 168:997-1003, 1968. Hoeksema PE, Huizinga E: On foreign bodies and perforations of the esophagus. Ann OtoI80:36-41, 1971. Holinger PH: Complications of esophageal perforations. Ann Otol 50:681, 1941. Holinger PH: Management of esophageal lesions caused by chemical burns. Ann Otol 77:819-829, 1968. Holinger PH: Photography in otorhinolaryngology and bronchoesophagology. In Coates, Schenk, and Miller (eds): Otolaryngology. Hagerstown, MD, WF Prior, 1957. Holinger PH, Holinger LD: Endoscopy of the head and neck. In Goldsmith HS (ed): Practice of Surgery. New York, Harper & Row, 1976, chap 7. Holinger PH, Johnston KC: Postsurgical endoscopic problems of congenital esophageal atresia. Ann Otol 72:1035, 1963. Holinger LO, Lore JM Jr: Direct endoscopy. In Goldsmith H (ed): Practice of Surgery. New York, Harper & Row, 1985. Holmes TW Jr: Chalasia, peptic esophagitis and hiatal hernia: A commQn syndrome
in patients
with central nervous
system disease.
Chest 60:441-445, 1971. Hujala KT, Sipila JI, Grenman R: Mediastinoscopy: Its role and value today in the differential diagnosis of mediastinal pathology. Acta Oncol 40:79-82, 2001. Jackson C, Jackson CL: Bronchoesophagology. Philadelphia, WB Saunders, 1950. Jako GJ, Kleinsasser 0: Endolaryngeal microdiagnosis and microsurgery. Scientific Exhibit, American Medical Association, June 1966. Jepsen 0, S0rensen HR (eds): Proceedings of an International Symposium: Mediastinoscopy. Odense, Denmark, Odense University Press, 1970. Jordan PH Jr, Longhi EH: Diagnosis and treatment of an esophageal stricture (ring) in a patient with Barrett's epithelium. Ann Surg 169:355-363, 1969. Jordan WS, Graves CL, Elwyn RA: New therapy for postintubation laryngeal edema and tracheitis in children. JAMA 212:585-588, 1970. Kane AM, Lore JM Jr: Endoscopy of the head and neck. In Goldsmith HS (ed): Practice of Surgery. New York, Harper & Row, 1976. Kleinsasser 0: A larynx-microscope for early diagnosis and differential diagnosis of carcinoma of the larynx and oral cavity. Z Laryngol RhinoI40:277-279, 1961. Kleinsasser 0: Microlaryngoscopy and Endolaryngeal Microsurgery. Philadelphia, WB Saunders, 1968. Kobayashi T, Shima K: Removal of bronchial foreign bodies in children. Arch OtolaryngoI108:265-266, 1982. Lerche W: The Esophagus and Pharynx in Action. Springfield, fL.
Charles C Thomas, 1950. Lore JM Jr: Fiberoptic headlight: Adaptation for observation and teaching. Arch Otolaryngol 102:511, 1976. Lore JM Jr: Optical nasopharyngeal biopsy forceps. Arch Otolaryngol 104:167, 1978. Lore JM Jr: Telescopic endolaryngeal surgery. Ann Otol Rhinol Laryngol 96:525-526, 1987. Lubarsky FE, Drummond BJ, Penta AQ: Recent advances in the removal of magnetic foreign bodies from the esophagus. stomach
and duodenum with controllable permanent magnets. AJR Am J Roentgenol 92: 1021-1025, 1964. Mark JBD, Goldenberg IS: Second congenital esophageal web: A sequel. J Thorac Cardiovasc Surg 48:506-510, 1964. McRae K: Anesthesia for airway surgery. Anesthesiol Clin North Am 19:497-541,2001. Mendelsohn HJ, Maloney WH: The treatment of benign strictures of the esophagus with cortisone injection. Ann Otol 79:900, 1970.
DIAGNOSTIC ENDOSCOPY
Morton JR, Guinn GA: Mediastinoscopy using local anesthesia. Am J Surg 122:696-698, 1971. Moskowitz M, Freihofer A: Seldinger brush biopsy: A synthesis of techniques. Chest 57:426-427, 1970. Newell RC, Watson RL, Po BT, et al: Intravenous anesthetic techniques for peroral endoscopy. Trans Am Acad Ophthalmol Otolaryngol 73:71-77, 1969. Norris CM, Tucker GF Jr, Woloshin HJ: Bronchoesophagologic application of recent advances in lluoroscopy. Ann Otol 80:528-534, 1971. Olsen AM: The esophagogastric sphincter. Chest 60:421-422, 1971. Ono J, Saito S: Endoscopic microsurgery of the larynx. Ann Otol 80:479, 1971. Pearson FG: An evaluation of mediastinoscopy in the management of presumably operable bronchial carcinoma. J Thorac Cardiovasc Surg 55:617-625, 1968. Pearson FG: Mediastinoscopy: A method of biopsy in the superior mediastinum. Can J Surg 6:423-429,1963. Pereira W Jr, Kovnat D, Snider G: A prospective cooperative study of complications following flexible fiberoptic bronchoscopy. Chest 73:813-816, 1978. Puryear GH, Osborn JJ, Beaumont 10, Gerbode F: The influence of adjuvant ventilators in the respiratory effort of acutely ill patients: Continuous measurement by digital computer. Ann Surg 170: 900-909, 1969. Putney FJ: Bronchoesophagology. Arch Otolaryngol 92:293-298, 1970. Ramsey MA, Salyer JE: The management of a child with a major airway abnormality. Plast Reconstr Surg 67:668-670, 1981. Rinker CT, Garrotto LJ, Lee KR, Templeton AW: Bronchography:
Diagnostic signs and accuracy in pulmonary carcinoma. AJR Am J RoentgenoI104:802-807, 1968. Rybak LP, Maisel RH: Endoscopic findings in sieep apnea syndrome. J Otolaryngol 8:6, 487-493, 1979. Sanders RD: Two ventilating attachments for bronchoscopes. Delaware MedJ 39:170,1967. Saunders WH: Cervical osteophytes and dysphagia. Ann Otol 79: 1091, 1970. Shedd DP, Gaeta JF: In vivo staining of larynx and pharynx cancer. Arch Surg 102:442-446, 1971.
Shedd DP, Kirchner JA, Scatliff JH: A radiologic study in surgical patients of oral and pharyngeal components of deglutition. Arch Surg 82:373, 1961. Slater G, Sicular A: Esophageal perforations after forceful dilatation in achalasia. Ann Surg 195:186-188, 1982. Snow JC: Anesthesia in Otolaryngology and Ophthalmology. Springfield, IL, Charles C Thomas, 1972, p 32. Stetson JB: Retropharyngeal abscess and endotracheal intubation. Communications to the Editor. Chest 74:4, 1978. Strong MS, Vaughan CW, Incze JS: Toluidine blue in the management of carcinoma of the oral cavity. Arch Otol 87:527,1968. Tucker JA: Application of mediastinoscopy to carcinoma of the larynx: A preliminary report. Laryngoscope 79:118-124, 1969. Valaitis J: Bronchial brushing cytology in localization and sputum cytology in detection of bronchogenic carcinoma in-situ of high risk smoker population. Med Ecol Clin Res I (Summer), 1968. Ward PH, Jafek B, Harris P: Interesting and unusual lesions encountered during mediastinoscopy. Ann Otol 80:487-491, 1971. Waterman DH, Domm SE, Rogers WK, Borrell JL: The effective use of bronchoscopy in chronic bronchitis: A review of 15,719 cases. Ann Otol 78:449, 1969. Webb WA, McDaniel L: Endoscopic evaluation of dysphagia in 293 patients with benign disease. Surg Gynecol Obstet 158:152-156, 1984. Weed DT, Courey MS, Ossoff RH: Microlaryngoscopy in the difficult surgical exposure: A new micro laryngoscope. Otolaryngol Head Neck Surg 110:247-252, 1994. Willson JKV, Eskridge M: Bronchial brush biopsy with a controllable brush. AJR Am J RoentgenoI109:471-477, 1970. Wilson HE: Control of massive hemorrhage during bronchoscopy. Dis Chest 56:412-417,1969. Wychulis AR, Fontana RS, Payne WS: tnstrumental perforations of the esophagus. Chest 55:184-189, 1969. Zavala DC: Complications following fiberoptic bronchoscopy. Chest 73:783-785, 1978. Zeitels SM, Burus JA, Dailey SH: Suspension laryngoscopy revisited. Ann Otol Rhinol Laryngol 113:16-22,2004.
5
THE SINUSES AND MAXILLA
Intranasal Antrostomy (Fig. 5-1)
Anesthesia
Rhinoscopy
• Local, topical lidocaine
In addition to the usual intranasal examination with speculum, topical anesthetics, and decongestants utilizing a head mirror or head light, telescopic examination yields considerably more information. The instruments suggested are the Karl Storz Hopkins rods: the O-degree, 30-degree, and, at times, the 70-degree telescopes. The flexible scopes are also helpful, but the rigid scopes can be directed in a more precise manner. Following the technique described by Kennedy et al. (1985), the 30-degree telescope is inserted in three "passes": (1) along the floor of the nasal cavity; (2) between the inferior and middle turbinates; and (3) into the middle meatus. The third pass may be difficult and is best achieved by inserting the telescope medial to the middle turbinate to its posterior extent and then rolling the scope into the middle meatus. Expertise in this examination is the most important step before the performance of any endoscopic sinus surgery (see p. 220). After rhinoscopy, transillumination of the antra and ethmoidal and frontal sinuses still affords a screening evaluation, especially in the asymptomatic patient. Routine sinus radiographs can also be used as a screening method, but for precise detail computed tomography (CT) is recommended. CT serves as an excellent guide during any type of sinus surgery, whether it be the intranasal approach with or without endoscopes or the external approach (see Chapter 4). Magnetic resonance imaging (MRI) will afford more soft tissue detail whereas CT provides more bone detail. Highpoints 1. The site of opening must be behind the anterior wall of the antrum. 2. The direction of the instrument must be either horizontal or pointed slightly downward to avoid injury to the floor of the orbit. 3. When irrigating, no air should be injected, to avoid air embolism. See Figures )-5 and )-6.
214
2 % tetracaine,
Postoperative Management Follow-up
10 % cocaine,
or 4 %
and Additional
When an antral window is performed, inspection of the antrum through the antral window is facilitated by the use of a telescope. The telescope can be anyone of various manufacturers and can be at various angles so that the entire antrum is thus visualized (Karl Storz's O-degree, 30-degree, and 70-degree telescopes; see Fig. 4-9). Biopsy specimens can then be obtained via the endoscope. Complications • Injury to the orbit • Air embolism • Insertion of trocar anteriorly to anterior wall of antrum and then into soft tissue of cheek could result in subcutaneous emphysema.
A, A1 A small hollow antral trocar (Douglas) is placed beneath the inferior turbinate. Occasionally, the turbinate will hang and obstruct the approach. In such casesit is fractured medially and elevated with a blunt instrument. Its mucosa should not be injured. With steady pressure,the trocar punctures the medial wall of the antrum (the lateralwall of the inferior meatus). The antrum is then gently irrigated with sterile normal saline.The return flow is through the natural ostium. If the bony wall is very thin, a spinal needle may be substituted for the trocar. 8, 81 When the medial wall of the antrum is thick, a Faulkner trocar chisel is used to perform the antrostomy.
82, 83 If an antral window is desirable for continuous drainage of the antrum, the instrument is
THE SINUSES AND MAXILLA
c
c' FIGURE 5-1
rotated 180 degrees after the antral wall is punctured. The undercut edge of the instrument then engages the rim of the opening. As the instrument is withdrawn, the opening is thus enlarged.
To enlarge the antrostomy are available.
farther, several techniques
C, C1 A curved rasp (Wiener) is inserted, and with to and fro motion the opening is enlarged. Care must be taken that the tip of the rasp is pointed downward. 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 at the base.
Continued
116
THE SINUm ANDMAXIll~
Intranasal Antrostomy
(Continued)
(Fig. 5-') D A bone-cutting punch is also utilized to enlarge the opening, as is a double-action cutting forceps if the bone is thick. Again, the important direction is downward, so that the nasoantral ridge is removed at the antrostomy site. The floor of the nasal cavity is usually slightly lower than the antral floor, allowing free flow of secretions from the antrum into the nose if the nasoantral ridge is adequately removed. At times, however, the floor of the antrum may be lower than the floor of the nose. D1 ing.
E The antrum may be explored using Coakley curets. Cysts and diseased mucous membrane can be removed if so indicated. Any sizable polyp, however, should be removed through a Caldwell-Luc approach or a medial meatus anthrostomy created endoscopically.
A small drill hole is made in the same area in the canine fossa as the Caldwell-Luc procedure. Various endoscopes of 0 degrees, 30 degrees, and 70 degrees can then be inserted into the antrum. Biopsies are also feasible. The same precautions and complications apply as with the Caldwell-Luc operation.
A Kerrison forceps is used to enlarge the open-
FIGURE 5-1 Continued
THE SINUSES AND MAXILLA
Caldwell-luc Antrotomy (Fig. 5-2) Indications
• • • •
Benign tumors Chronic empyema resistant to conservative treatment Complicated fractures of maxilla Exploration
This procedure should be avoided when a malignant lesion is suspected. Needle aspiration through the inferior meatus or the use of an intranasal antrostomy with curettage using Coakley curets is preferred (see Fig. 5-1). If these methods fail, do not hesitate to explore the antrum through this Caldwell-Luc antrotomy. Refer to Figure 6-10 for the trans maxillary approach to the nasopharynx and base of the skull.
Refer to Figures 1-1, 1-5, and 1-6. Complications
• • • • • • • •
Injury to infraorbital nerve Injury to roots of teeth Injury to the floor of the orbit Hypoesthesia or paresthesia of the cheek Injury to the globes Subcutaneous emphysema Injury to the superior alveolar nerve and tooth sockets Prolonged edema
A In the gingivobuccal sulcus (canine fossa), well above the tooth sockets, an incision is made through mucosa and periosteum several centimeters from the midline. Sufficient mucosa is preserved inferiorly for ease of closure.
B The periosteum is elevated. The insertion of the facial muscles may require sharp dissection to free them from the anterior wall of the antrum.
FIGURE 5-2
Continued
THE SINUSES AND MAXILLA
Caldwell-luc Antrotomy (Continued) (Fig. 5-2) C The exposure is carried upward to a point just below the infraorbital rim, where the infraorbital nerve is identified and carefully preserved. With the use of an osteotome or power-driven bur, the anterior wall of the antrum is opened. This opening must be well above the tooth sockets and above the floor of the antrum. All the fractured fragments of bone are removed. D With a Kerrison back-biting forceps, the opening is enlarged to the desired size to permit exploration. E Removal of benign tumors and cysts is then easily accomplished by grasping forceps and scissors.Normal mucosa should not be injured; however, all diseased mucosa should be removed. F Usually,an intranasal antrostomy beneath the inferior turbinate is done to facilitate drainage (see Fig. 5-1).
G This intranasal antrostomy may be enlarged through the original operative opening using forward bonecutting forceps, depending on the purpose of the operation. H
Close-up of antrostomy in G is shown.
I Cross-sectional anatomy shows the dependent intranasal opening. The arrow depicts the natural ostium. Some surgeons have stressed the importance of verifying the patency of this natural ostium and its free communication with the middle meatus. The natural ciliary motion is toward this ostium. Diseased tissue should thus be removed to reestablish this communication, otherwise antral disease is likely to recur. Lining an enlarged ostium may require opening and reflection of antral mucosa medially. Ethmoidal disease may also require removal. This area on the nasal side is termed the osteomeatal complex (see Figs. 1-2 to 1-4).
J
The mucosal flap over the anterior wall opening is approximated with interrupted or continuous 4-0 nylon or absorbable suture.
FIGURE 5-2 Continued
THE SINUSES AND MAXilLA
Intranasal antrostomy
FIGURE 5-2 Continued
219
220
THE SINUSES AND MAXilLA Uncapping of Anterior
Intranasal Ethmoidal Surgery for Benign Disease (Fig. 5-3)
Ethmoidal Cells
A The point of entrance is just lateral to the attachment of the middle turbinate. The middle turbinate may require displacement medially. This is done with a blunt instrument to minimize damage. The turbinate is not removed. If the turbinate is cystic, it may be gently crushed.
Indications • Chronic ethmoidal sinusitis • Ethmoidal polyposis Highpoints 1. Avoid injury to thin lamina papyracea laterally. 2. Avoid injury to cribriform plate superiorly. 3. Never use a curet in an upward fashion, because injury to the cribriform plate could occur; always use a downward and slightly medial motion. 4. Be certain that disease is entirely intranasal, because meningiomas may mask as polypoid disease. 5. Frequently monitor the eyes during and after the operation for evidence of intraorbital hemorrhage. 6. Avoid too tight intranasal packing in the region of the cribriform plate and the lamina papyracea. Various illustrations (Figs. 1-2 to 1-10 and 6-1) show the lateral view of the nasal cavity. Postoperative Care • Monitor vision hemorrhage.
and
search
for any
proptosis
or
Complications • Hemorrhage either intranasally or into the orbit, usually from ethmoidal arteries arising from the ophthalmic artery • Injury to the orbit and optic nerve, with resulting blindness. Do not drape eyes during surgery. • Meningitis • Cerebrospinal fluid rhinorrhea • Injury to the cribriform plate and frontal lobe leading to death If periorbital edema occurs, extreme care and evaluation of the globe are necessary. Immediate decompression of the orbit may be required to prevent permanent damage to the optic nerve. The surgical approach is as depicted in Figure 5-6A. The incision is carried through the orbital septum toward the lamina papyracea. For details of immediate treatment of blindness refer to Chapter 2, page 66.
B Using an asymmetrical, oval, thin-beaked curet, the anterior ethmoidal cells are opened with a downward and inward motion. This involves removal of the uncinate process and leads to the hiatus semilunaris and the infundibulum. The curve of the curet is turned medially to avoid injury to the lacrimal plate. C Further curettage is downward and backward. A ,- to 2-cm introduction often suffices for simple drainage. However, if there is evidence of extensive involvement, further exenteration becomes necessary.
Ethmoidectomy D, E With a Faulkner curved-ring curet, the ablation of the more posterior cells is performed, always with a downward and slightly medial motion. This will avoid injury to the cribriform plate. The lamina papyracea is the lateral guide, whereas the middle turbinate is the medial guide. Extreme care must be taken not to injure the lamina papyracea; otherwise bleeding can extend into the orbit, causing blindness. The eye is visualized during surgery. F As the operation progresses posteriorly, a smaller curved-ring curet is employed if the space narrows. G The exenteration continues the sphenoidal sinus .
to the anterior wall of
H Ethmoidal-type blunt forceps are used to remove any remaining diseased cells. The superior turbinates may be removed with scissors if additional space superiorly is required. However, the less injury and removal of nasal-lining mucosa that are done, the better. In any case, atrophic rhinitis must be avoided. Some surgeons prefer an external for extensive disease. The approach Figure 5-4.
ethmoidectomy is depicted in
THE SINUSES AND MAXilLA
FIGURE 5-3
THE SINUSES AND MAXILLA
Intranasal Ethmoidal Surgery for Benign Disease (Continued) (Fig. 5-3) Endoscopic Diagnosis and Surgery for Sinusitis Another approach to inflammatory ethmoidal sinus disease as well as antral and frontal sinus involvement has been detailed by a number of authors. Messerklinger, in Austria, and Kennedy, in the United States, as well as others have described telescopic endoscopic diagnosis. These techniques are described in detail later in this chapter. Instruments are shown in Figure 4-9A and B, for anatomy see page 267, and the technique as outlined by Messerklinger (1985) is as follows (with permission from Elsevier Science Publishers): Numerous endoscopic investigations and examinations have indicated the following relating to the pathophysiology of chronic and recurring sinusitis: Most infections of the paranasal sinuses are rhinogenic, spreading from the nose into the sinuses. If a sinusitis does not heal or is constantly recurring, a focus of infection usually has remained in a stenotic area, which keeps the infection ongoing, or wherefrom the dependent larger sinuses are reinfected time and again. This is true as well for primarily dentogenic, traumatic, or blood-borne sinusitis that is recurring after the primary source of infection has been cured. The narrow or stenotic areas involved are the ethmoidal infundibulum at the entrance to the maxillary sinus and the frontal recess at the entrance to the frontal sinus. They build up a system of fissures and folds in the middle nasal meatus, all of them being parts of the anterior ethmoidal sinus. Thus, the physiologic status and pathologic status of the maxillary sinus and frontal sinus are dependent on any disease process of the anterior ethmoidal sinus and the osteomeatal complex. Narrow space-like fissures and ostia under normal conditions are very resistant to infections; as, for instance, in a fissure the ciliary beat can transport a pathologic mucus from two sides, in an ostium even circularly. If, however, corresponding mucosal areas are firmly pressed together, only the superficial secretion around the contacting area can be transported away. The mucus in between contacting or inflamed mucosal areas is retained and provides ideal conditions
for bacterial growth. Depending on the duration and intensity of an infection in such a place, mucosal hyperplasia occurs and thus results in a focus of permanent infection. From areas like these, which can be free of symptoms for quite a long time, infections can spread time and again to the immediate vicinity and especially into the dependent larger sinuses. Nasal endoscopy combined with CT enables us to localize exactly the diseased areas. Transnasal, endoscopic surgery is then carried out. The patient is sedated and the medial wall of the ethmoidal infundibulum is resected under local and surface anesthesia. This procedure opens the middle nasal meatus, and the view is free into the ethmoidal bulla, the frontal recess, and the sinus of the middle turbinate. Depending on the localization and the extent of the disease, the ethmoidal bulla is resected and the frontal recess, the conchal sinus, and/or the ethmoidal infundibulum are cleared of diseased mucosa. If the maxillary ostium is stenotic, it is enlarged into the anterior nasal fontanel. This area is the osteomeatal complex-a critical region. If the posterior ethmoidal or the sphenoidal sinus is diseased, it is cleared endoscopically after resection of the ground lamella of the middle turbinate. In the first 2 days after operation, wound secretion is removed with an aspirator. For 8 to 10 days, an oral antibiotic effective in the nasal mucosa is prescribed. After this procedure even chronically recurring infections of the dependent larger sinuses usually heal within 5 to 6 weeks, even if their mucosal pathology seemed almost irreversible. (See Figures 1-1 to 1-15 for radiographic anatomy and imaging studies.) Complications • Perforation of cribriform plate and lamina papyracea • Blindness (see Chapter 2): order stat ophthalmologic consult; perform lateral canthotomy and external ethmoidectomy. • Injury to the lacrimal duct or sac • Bleeding from the anterior or posterior ethmoidal arteries • Injury to internal carotid artery just lateral to posterior ethmoidal and sphenoidal sinuses Admonition "Stop if you cannot see" (Kennedy).
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External Ethmoidectomy (Fig. 5-4) (Chiari, 1912) (After Kirchner et aI., 1967; Montgomery, 1971) Indications
• Extensive ethmoiditis refractory to conservative management as well as intranasal ethmoidectomy (see Fig. 5-3). This indication is believed to be rare because intranasal ethmoidectomy usually accomplishes the desired results. • Epistaxis high in the nasal cavity refractory to ethmoidal artery and internal maxillary artery ligations • Mucocele and benign tumors of the ethmoidal sinus; malignant tumors of the ethmoidal sinus almost always require a combined craniofacial resection of the cribriform plate. • Approach to the frontal sinus (Lynch, 1921; see Fig. 5-70 and E) • Approach to sphenoidal sinus and pituitary • Repair of cerebrospinal fluid leak through the cribriform plate • Approach to the anterior cavernous portion of the internal carotid artery-possible application in carotid cavernous fistula • Approach to the optic foramen for decompression and biopsy
3. Elevate the periosteum carefully from the lacrimal bone, lacrimal sac, and lamina papyracea. Do not injure the lacrimal sac, its proximal canaliculi, or its distal outflow, the nasolacrimal duct (see Fig. H-12B). 4. Extreme care should be taken not to injure the globe and orbital contents (tarsorrhaphy and gentle pressure when retracting the periosteum and orbital contents). 5. Remove major portion of the lacrimal bone, portion of the lamina papyracea, frontal process of the maxillary bone, and, at times, varying portions of the nasal bone, depending on the exposure necessary. 6. Remove at least the anterior portion of the middle turbinate. If the purpose of the operation is to reach the sella, the medial wall of the ethmoidal labyrinth and thus the middle turbinate are not removed. 7. Take care to achieve good hemostasis to prevent increased intraocular pressure as well as any pressure on the optic nerve. Danger: blindness! 8. If there is any question regarding the patency of the nasofrontal duct, insert a fine polyethylene tube. Anesthesia
The trans septal approach to the sphenoidal sinus and pituitary (see Fig. 23-11) is preferred rather than an external ethmoidectomy approach.
Although the operation can be performed under local and topical anesthesia, this author (JML) prefers general anesthesia for patient comfort as well as control of the airway. However, topical anesthesia consisting of 10% cocaine and oxymetazoline (Afrin) is used in the nasal cavity to control mucosal bleeding. A tarsorrhaphy is performed using 3-0 silk sutures, and the eyes are protected with soft moist eye pads.
Anatomy (See Figs. 1-2 to 1-7.)
Surgical Technique
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 far medially as is shown for the external frontoethmoidectomy. Bovie cutting current is used to transect the soft tissue down to the periosteum. Stay sutures are utilized to retract the skin edges, with care taken not to contact the globe. The angular vessels are clamped and ligated.
Highpoints
1. Important landmark: the foramina of the anterior and posterior ethmoidal vessels as they perforate the medial orbital wall mark the level of the cribriform plate. This is the suture line between the frontal bone above and the ethmoidal labyrinth below. Hence, do not go above this line to avoid injury to the cribriform plate. The foramen of the posterior ethmoidal artery indicates the plane of the most posterior ethmoidal cells. 2. If necessary to transect the medial canthal ligament for additional exposure, be certain to preserve a medial stump of the ligament for approximation of the ligament at the close of the operation.
Complications
• Hemorrhage-must have careful hemostasis • Blindness (see Ophthalmic Complications Chapter 2) • Diplopia • Meningitis
III
THE SINUSES AND MAXILLA
External Ethmoidectomy (Continued) (Fig. 5-4) (Chiari, 1912) (After Kirchner et aI., 1967; Montgomery, 1971) A The periosteum is elevated over the frontal process of the maxillary bone and lacrimal bone. The trochlea (see Fig. 6-4B), the fibrocartilaginous pulley through which the tendon of the upper oblique muscle passes, may be elevated with the periosteum (Kirchner et aI., 1967), depending on the exposure that is necessary. The lacrimal sac is carefully mobilized from its fossa, with care taken not to injure its proximal canaliculi and distal nasolacrimal duct. As the periosteum is further elevated from the lamina papyracea, the anterior and posterior ethmoidal vessels are exposed as they pass through their foramina along the frontoethmoidal suture line. These vessels are clamped with House clips and transected. Bipolar coagulation could be used on the anterior ethmoidal vessels but should be used only if absolutely necessary on the posterior ethmoidal vessels because of the proximity to the optic nerve. Transmitted heat could injure the optic nerve; therefore, use a very low cu rrent. The ethmoidal sinus is now entered just posterior to the posterior lacrimal crest. This portion of the lacrimal bone is thin and may be removed initially with a curet or infractured with a chisel. The opening is further expanded with Kerrison forceps and forward-biting rongeurs. A major portion of the lacrimal bone is removed with the lacrimal crest along with a portion of the frontal process of the maxillary bone, portion of the lamina papyracea, and, depending on the amount of exposure, a portion of the nasal bone. Again, remember that the frontoethmoidal suture line marks the cribriform plate level. B The extent of possible osseous resection is depicted. The stippled area includes the lacrimal bone and the lamina papyracea, and the diagonally lined area indicates the frontal process of the maxillary bone and a portion of the nasal bone. The nasal bone area is only removed if additional exposure is necessary anteriorly. With the exposure now afforded, the anterior ethmoidal cells are removed using small duckbill forceps and Takahashi forceps. Care is taken once again not to introduce the Takahashi forceps too close to the cribriform plate because of the danger of perforation. This now exposes the anterior portion of the middle turbinate. During this stage of the operation, the uncinate process and bulla of the ethmoid are removed (see Fig. 6-1). If purulent material is encountered, aerobic and anaerobic cultures are obtained.
Depending on the purpose of the operation, the entire middle turbinate is removed with scissors, one blade in the ethmoidal sinus below and the other blade just above the turbinate. The attachment of the middle turbinate along with ethmoidal cells is removed with an ethmoidal curet and/or duckbill or Takahashi forceps. When the curet is utilized, the motion must always be in a downward direction to avoid injury to the cribriform plate (see Fig. 5-3). The cribriform plate indicates the superior extent of the resection, the lamina papyracea the lateral extent, and the anterior wall of the sphenoidal sinus the posterior extent. It is obvious at this point that, if necessary, the sphenoidal sinus and the approach to the sella can then be achieved. Small vessels-some branches of the ethmoidal arteries and possibly meningeal vessels-perforate the cribriform plate. It is these vessels that may be the source of hemorrhage in severe protracted epistaxis and may require clamping with House clips and/or cautery. The olfactory nerves are distributed to the mucous membrane of the superior turbinate and the corresponding portion of the nasal septum. This latter structure is easily visualized in a more medial location in the operative wound. If at all possible, these branches of the olfactory nerves are best preserved. If there is any question regarding the patency of the nasofrontal duct (see Fig. 6-1), a fine polyethylene catheter is inserted into the nasofrontal duct and brought out through the naris. It is held in place with a 4-0 silk suture secured to the floor of the naris. This tubing is removed from 1 to 3 weeks postoperatively. The operative site is gently packed with O.S-inch strip gauze heavily impregnated with chlortetracycline (iodoform) ointment. This packing must not impinge on the globe, because a portion of the lamina papyracea has been removed. The end of the gauze strip is brought out through the anterior naris and secured externally, so that if it becomes dislodged posteriorly, it can be removed forthwith. Generally, it is removed in 3 to 4 days. If the medial canthal ligament was transected, it is approximated with two sutures of 4-0 nylon. The periosteum is returned to its normal position and reapproximated wherever possible, and the skin is closed in layers. Antibiotics are utilized preoperatively and postoperatively. Careful evaluation of the patient's sight postoperatively is a sine qua non. If there is any question regarding hemorrhage with increased ocular pressure, the wound is rapidly opened and decompressed. This raises the question whether the external wound should be drained. The author (JML) by and large prefers the use of a small section of rubber band drain that then can be removed within 24 hours.
THE SINUSES AND MAXilLA
T EDGE
OF MEDIAL CANTHAL
I
A
FRONTOMAXILLOLACRIMAL "SUTURE
,
FRONTAL PROCESS MAXILLARY BONE
FRONTOETHMOID SUTURE (PLANE OF CRIBRI PLATE)
LACRIMAL FOSSA ANGULAR A.
B FIGURE 5-4
THE SINUSES AND MAXilLA
Sphenoidal Sinusotomy
(Fig.
5-5)
Puncture of Anterior Wall of Sphenoidal Sinus
Highpoints Highpoints
1. Check radiographs for possible ossification of sphenoidal sinus. CT scans are important. 2. Asymmetry of sphenoidal sinuses is the rule rather than the exception. 3. Dividing partition is almost never in the midline. 4. Optical telescopes are very helpful. Refer to Figures 1-2, 1-3, 1-4, and 1-7. S. Distance from anterior nasal spine to sphenoidal ostium in adult is from 6.5 to 8 cm. 6. Using floor of nose as a baseline, the angle to reach the sphenoidal ostium is between 20 and 30 degrees. 7. The ostium is usually located just behind and slightly above the posterior end of the superior turbinate. 8. Use CT to be certain all walls of sinuses are intact. 9. Use MRI for additional soft tissue detail. Indication
• For emergency irrigation of acute empyema of the sphenoidal sinus Complication
• Edema surrounding natural ostium may hinder egress of irrigation solutions.
1. Keep to midline-laterally are the internal carotid artery and cavernous sinus. 2. Keep low and posterior-high and anterior are the floor of the anterior cranial fossa and cribriform plate of the ethmoid. The level of the inner canthus of the eye corresponds to the level of the cribriform plate. 3. Hook on instrument must face downward. 4. Check radiograph and other images for details of sphenoidal sinus and relationship to surrounding structures (e.g., internal carotid artery, cavernous sinus, sella turcica). See Figures 1-2, 1-3, 1-4, and 1-7. Indication
• Puncture of the anterior wall of the sphenoidal sinus is performed if cannulation of the natural ostium is not feasible.
Enlargement of Natural Sphenoidal Ostium or Anterior Wall Puncture Site Highpoints
With topical anesthesia and use of a vasoconstrictor, a malleable cannula is inserted into the nasal cavity closely hugging the septum. It is directed toward the posterior ends of the middle and superior turbinates at an angle of 20 to 30 degrees from the floor of the nose. The anterior wall of the sphenoidal sinus is thus reached, and by gentle manipulation the ostium is located and entered. Optical telescopes-flexible or rigid-aid in localization of the ostium. If necessary, radiographs may be used to confirm the location of the cannula. Gentle irrigation is then performed. Deviation of the nasal septum and other anomalies may make access to the ostium impossible. The sphenoidal cannula pictured is the Van Alyea instrument, which is 10 em in length and is equipped with markers on the proximal end at 9 em. These markers are placed at an angle of 23.5 degrees from the shaft, thus simulating the angle of insertion using the floor of the nose as the baseline. The distal end of the cannula has a smooth 4-mm curve laterally. A, B
Continued
1. Avoid injury to or removal of posterior end of middle turbinate. 2. Keep angle of biting forceps facing downward. Indications
• Usually used for emergency sphenoidal sinus drainage when irrigation through natural ostium or anterior wall puncture appears inadequate. • It is also used for exploration and biopsy of sphenoidal sinus. Complication
• Injury to sella turcica, internal carotid artery, and cavernous sinus
THE SINUSES AND MAXILLA
Natural ostium of sphenoid sinus
B FIGURE 5-5
227
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Sphenoidal Sinusotomy (Continued) (Fig. 5-5) D A sharp pointed instrument with hook facing downward (Sluder or Hajek sphenoidal hook, preferably with a Tremble guard) is inserted into the nasal cavity, keeping close to the nasal septum. It is directed toward the plane of the posterior end of the middle turbinate. The anterior wall of the sphenoidal sinus is thus reached, and the instrument is inserted through a thin section of the wall (X). The point of entry is as close to the midline as possible and as low and posterior as possible. The lower and more posterior one goes, however, the thicker the anterior wall of the sinus becomes. Puncture then becomes somewhat more difficult. C,
E Using either the natural ostium or anterior wall puncture site as the point of entry, a Hajek or Kerrison biting forceps is employed to enlarge the opening. The enlargement is directed downward. It must be remembered that the dividing septum of the sphenoid bone may not be in the midline, and hence the sinus entered may not be the one corresponding to the side of the nasal approach. In such cases, careful breakdown of the dividing partition is necessary. Confirmation is obtained by radiographic examination when necessary.
Other Approaches Sinus
to the Sphenoidal
When the rare condition occurs that requires more adequate exposure of the sphenoidal sinus, for example, removal of a "fungus ball," a more direct approach is the transpalatal (see pp. 288 to 293, Fig. 6-9). The exposure depicted is much larger than necessary, only 1.0 to 1.5 cm of hard palate is all that is required to be resected. The patient with the "fungus ball" had extension into the sella turcica and erosion of the clivus and lateral walls of the sphenoidal sinus, with pressure on the optic nerves, cavernous sinuses, and internal carotid arteries. This approach was in the midline and anterior, thus avoiding the clivus, sella turcica, internal carotid arteries, and the cavernous sinuses. The "capsule," which enveloped the "fungus ball," was very thick and this approach facilitates a very careful controlled incision and excision of the portion of this capsule to evacuate the contents of the sphenoidal sinus. Currently, this procedure can be done trans nasally using endoscopic techniques. Another approach to the sphenoidal sinus is transseptal (see Fig. 23-11A to I).
THE SINUSES AND MAXilLA
Point of entry Mid. turbinate'
D
c
FIGURE5-5 Continued
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Frontal Sinusotomy (Trephination) (Fig. 5-6) Indications
• Purulent acute frontal sinusitis refractory to conservative management (e.g., nasal decongestants and 10% cocaine applied on cotton tampon plus antibiotics in large doses) • Persistent pain and tenderness with or without local edema • Exploration for chronic frontal sinusitis • Biopsy See Figures 1-2 through 1-7 for radiographic anatomy. See Figure 6-1 for lateral view of the nose and frontal sinus ostia. If there is a bulge over the frontal sinus (usually just below the supraorbital rim) immediate decompression is achieved with needle aspiration. Highpoints
1. Keep incision well above the medial canthal ligament. 2. Continue conservative management. 3. Careful radiographic evaluation preoperatively and postoperatively, especially for any evidence of dehiscence of the inner wall, thus exposing dura. Remember plain Caldwell radiographic films of the frontal sinus can be deceptive. This radiographic view is obtained by placing the nose and the forehead on the table top so that the orbital meatal line (joining the outer canthus of the eye to the superior margin of the external auditory canal) is perpendicular to the film. The angulation of the x-ray beam is 15 degrees craniocaudad. CT scans and/or tomograms are necessary for complete evaluation of the status of the inner and inferior wall of the frontal sinus. 4. Avoid injury to the globe. S. A trephine is used in or near the floor, not the anterior wall, thus avoiding cancellous bone containing marrow, which could be an excellent avenue for osteomyelitis. 6. Do not irrigate if roof of orbit has a dehiscence; this may cause blindness! (Thompson et aI., 1980.) (See the discussion of blindness in Chapter 2.)
A A slightly curved incision is made just below the eyebrow. It is carried through the periosteum, exposing the bone. B A small periosteal elevator exposes the underlying bone just below the prominence of the frontal sinus. The exact point of entrance is checked on the radiographs. A small bur or curet is used to enter the sinus. Cultures of any purulent material should be taken, followed by gentle irrigation with normal saline. Patency of the nasofrontal duct can be checked with methylene blue inserted through the tubes (see C). The duct usually should not be probed, because this may result in stenosis. An optical telescope can be inserted through the trephine to inspect the inner lining of the sinus. One must be certain that the inner bony wall is intact, otherwise a more radical operation is indicated. C Two small plastic tubes are inserted and held in place with sutures. One tube can be used for daily irrigations with a suitable antibiotic solution (e.g., neomycin, 1%) for 24 to 48 hours. The other tube acts as the release for the irrigation fluid. After the frontal sinusotomy, the cause of the sinusitis must be ascertained, and treatment must be initiated as soon as possible to prevent chronic frontal sinusitis. The object is to reinstate intranasal drainage. Probing and any attempt to recanalize or simply enlarge the nasofrontal duct will only worsen the condition, because such procedures will lead to complete stenosis of the nasofrontal duct. The steps to take are the following: 1. Meticulous and complete submucous resection of the nasal septum 2. Removal of any nasal polyps 3. Resection of anterior portion of the middle turbinate, if necessary 4. Anterior ethmoidectomy, as indicated For details on fractures of the frontal sinus and ethmoidal sinus, refer to the discussion on page 638.
THE SINUSES AND MAXilLA
c
FIGURE 5-6
231
THE SINUSES AND MAXilLA
External Frontoethmoidectomy (Fig. 5-7) (After Lynch, 1921) Indications • Mucocele • Externa] fistula • Minor orbital complications Recurrent frontoethmoidal sinusitis refractory to conservative management, including intranasal ethmoidectomy, submucous resection of the nasal septum, and frontal sinusotomy, is an indication for this procedure. In this day and age, this operation is seldom indicated for chronic sinusitis. If, in fact, chronic frontal sinusitis exists, then serious consideration is given to endoscopic frontal sinus surgery and, if it is not possible, to a bilateral or unilateral osteoplastic frontal sinus operation. If there is any doubt, it would be best to use the osteoplastic approach (see Fig. s-8A to E): ]n the absence of ethmoidal disease a frontoethmoidectomy is not usually indicated but rather an osteoplastic frontal operation. It is not suitable for malignant lesions. Another consideration for use of this procedure is severe polyposis and inverted papillomatosis. This approach is also used by some surgeons (Bateman, 1961) for hypophysectomy (see Chapter 23). Refer to Figures 1-2 through 1-7 for radiographic anatomy.
Highpoints 1. Use meticulous hemostasis. 2. Avoid injury to the eye and associated structures: a. Medial palpebral ligament b. Lacrimal sac and duct 3. Do not perforate the cribriform plate. 4. Preserve as much normal mucous membrane as compatible with a good drainage operation. 5. Problems with adequate and safe removal of frontal sinus disease include: a. Incomplete removal b. Entrance into anterior cranial fossa through a bony dehiscence in long-standing disease 6. Distance and depth between the anterior portion of the resection and the posterior or deep portion of the resection varies considerably. 7. Remove entire floor of frontal sinus and establish a wide new frontonasa] communication. This is one of the main objectives of the operation. 8. Any high (superior) deviation of the nasal septum should be corrected; however, extreme caution must be taken during this step not to injure the cribriform plate.
Complications • Orbital injuries • Hemorrhage
• Stenosis of frontonasal communication • Recurrent sinusitis, polyposis, or mucocele • Perforation of cribriform plate or inner wall of frontal sinus to dura A The incision is 2.5 to 3.5 em long and extends about 1 em below the level of the medial palpebral (canthal) ligament. It lies midway between the attachment of this ligament (see Figs. 11-1 and 11-12A to B1) and the dorsum of the nose. A temporary tarsorrhaphy is performed to protect the globe. The incision exposes the orbicularis oculi (orbicularis palpebri) as well as the superior pa]pebral vessels (branches of angular vessels), which are ligated. The medial palpebra] ligament is exposed and preserved. The periosteum is incised, elevated, and retracted laterally, carefully freeing the superior portion of the lacrimal sac. The periosteal dissection is continued posteriorly exposing the entire lamina papyracea and the floor of the frontal sinus. Avoid tearing the periosteum and the periorbital fascia, especially along the frontoethmoidal suture, where the former is quite adherent. Otherwise, periorbital fat will herniate through, obstructing vision. Two smooth retractors or a Luongo self-retaining retractor is inserted. The anterior and posterior ethmoidal arteries are occluded, as shown in Figure 6-4. B At a point just posterior to the lacrimal fossa, the medial orbital wall is entered with a sharp perforator. With bone Kerrison forceps and curet, the bone posteriorly (dotted line) is now removed, including the posterior edge of the nasal process of the maxilla (preserve the nasal mucous membrane) and thence the lacrimal bone and the anterior portion of the lamina papyracea. The preserved mucoperiosteum will be used as a superior-based flap to line the new nasofrontal communication. The anterior ethmoidal cells are then removed. The upper medial orbital bone is then removed, thus entering the frontal sinus and removing the entire floor of this sinus. As much as possible of the lining mucous membrane is removed from the frontal sinus. Locu]ations and septa can make this step difficult and frustrating. Care must be exercised that if dehiscence in the posterior or roof of the frontal sinus exists, perforation of dura lining the anterior cranial fossa does not occur. If incomplete removal occurs, this could lead to recurrent frontal sinus problems, especially with marked polyposis-a failure for this procedure. An osteoplastic
THE SINUSES AND MAXILLA
FLOOR FRONTAL SINUS
LACRIMAL SAC MEDIAL CANTHAL
A
B
c
FIGURE 5-7
frontal sinus operation may then be necessary at a later stage (see Fig. S-8A to E). As much of the middle turbinate is removed (by punch, not tearing) as is necessary to provide a suitable communication into the nasal cavity. This is accomplished both through the operation wound and through the naris. C The posterior cells are removed with punch forceps both through the wound and through the naris, taking care not to perforate the cribriform plate. This is most important. The complete operation consists of removal of the floor of the frontal sinus, portion of lacrimal bone, lamina papyracea, ethmoidal cells, and portion of middle turbinate. If the sphenoidal sinus is to be entered, this is accomplished by either making an opening with a sharp curet or enlarging the natural opening. Kerrison or Hajek forceps are used to enlarge the opening. Inferiorly and
anteriorly the sphenopalatine vessels may be encountered, which then will require occlusion with silver clips or electrocoagulation. If the purpose of the operation is to perform a hypophysectomy, the frontal sinus portion of the operation is deleted. From here on the reader is referred to the section dealing with hypophysectomy in Chapter 23.
D The preserved superior-based mucoperiosteal nasal flap is now used as lining for the new frontonasal communication. Gauze impregnated with antibiotic ointment is utilized to coapt this flap and extend into the nasal cavity. The gauze is removed in 1 week. An intranasal tube into the frontal sinus (fine polyethylene) is left in place for up to 1 to 3 months, depending on the patient's clinical progress. This intranasal tube is best sutured to the floor of the naris to prevent dislodgement. The short tube or drain through the external incision is removed within 1 week.
THE SINUSES AND MAXilLA
Osteoplastic Approach to the Frontal Sinus (Fig. 5-8) (After Alford, 1964; Beck, 1908; Goodale and Montgomery, 1964) Highpoints 1. Perform a preoperative ophthalmologic evaluation. 2. Use template of frontal sinus cut from radiographs showing Caldwell view (see B). Check the change in size relative to x-ray tube distance from patient. 3. Cosmetic incision: choose eyebrows or coronal hairline. 4. Leave periosteum attached to bone forming anterior wall of frontal sinus. The periosteum acts as a hinge, attaching the bone fragment inferiorly. 5. Bevel bone incision inward toward sinus and make it slightly smaller than the x-ray template. 6. If mucous membrane is hopelessly diseased, it should be removed completely and meticulously using a power-driven bur. The mucosa of the nasa frontal duct-if patent-is better left intact. If duct is obstructed, then remove mucous membrane. 7. If the major portion of the mucous membrane is normal (e.g., in an osteoma), the mucous membrane of the sinus and nasa frontal duct should be carefully preserved. 8. Do not shave the eyebrows, because they may not regenerate. 9. Do not enter the anterior cranial fossa. 10. Preoperatively order culture and sensitivity testing in the presence of infection. 11. Perform a temporary tarsorrhaphy-optional-during pregnancy. 12. Bilateral approach is more common (see G and H).
Anatomy of Frontonasal Duct The frontal sinus drains into the nasal cavity via the nasa frontal duct, into the semilunar hiatus, and then into a groove termed the infundibulum, which lies between the bulla of the ethmoid bone and the uncinate process. It then communicates with the middle meatus. Variations can occur (see Hollinshead's Anatomy for Surgeons, volume 1, page 262). Details relative to the anatomy of the lateral wall of the right nasal cavity along with the nasofrontal duct are described and depicted in Figure 6-1. A The incision may be just above or below the eyebrows, as shown. The upper incision is slightly curved.
B A superior-based skin flap is developed consisting of all layers of tissue down to the periosteum. The periosteum is left attached to the underlying bone. A template of the left frontal sinus containing an osteoma has previously been cut, slightly smaller; from the Caldwell view and has been gas sterilized. The template is placed over the frontal sinus, and an incision is made through the periosteum along the superior, medial, and lateral edges. The inferior edge is left intact, forming the hinge for the anterior frontal sinus bone window. Preservation of the periosteum along the inferior edge is most important, because this is the source of blood supply to the periosteal bone flap. C The line of incision through the periosteum is slightly widened with a narrow elevator to allow free access for the saw blade. With a Stryker sagittal plane saw, a cut is made and beveled slightly inward and downward. This protects the edges forming the boundaries of the sinus and later on supports the bone flap when it is returned. The dotted line indicates the'hinge of intact periosteum and the line of fracture of the bone-periosteum flap. Additional bone is transected on the edges of the dotted line for a distance of a few millimeters inferiorly through the supraorbital rim. D With the use of an osteotome along the cut edges, the bone periosteum flap is elevated and fractured along its inferior margin. E The flap of bone and periosteum is reflected downward, exposing the pathologic change in the frontal sinus, which in this case is an osteoma. The osteoma is removed, revealing the major portion of mucous membrane to be intact and normal. The mucous membrane is left undisturbed; the nasofrontal duct is left inviolate. If the pathologic change consists of chronic sinusitis with diseased mucous membrane, all mucous membrane is meticulously removed. Small spurs of bone are leveled off with a bur, destroying any minute infolding of mucous membrane. The operation microscope can be of help. Too much time spent at this stage cannot be criticized. Preserve the mucous membrane of the nasofrontal duct if the duct is patent. If the duct is obstructed anywhere along its course from the frontal sinus to the infundibulum, strip the mucosa very carefully and completely obliterate the duct. The other approach is to stent the duct, removing obstructions. The problem is the removal of all mucous membrane from the sinus wall. This may not be possible. Any remaining mucous membrane in the sinus will be the nidus for future problems. At this point, place an
THE SINUSES AND MAXILLA
FIGURE 5-8
Complications autogenous adipose tissue graft into the sinus cavity and duct remnant to aid in the obliteration; otherwise, perform a transfrontal ethmoidectomy. When the sinus cavity is obliterated with adipose tissue (obtained from the anterior abdominal wall), it is best to remove as much cortical bone as possible from all areas, including the bone flap. This aids in supplying blood to the adipose graft. Continued
• Fracture of the inner wall or table leading to a possible cerebrospinal fluid leak • Fracture of the roof of the orbit • Injury to the inner wall or table during the initial saw cut through the outer table • Air leak into operative area during postoperative period • Recurrent disease
THE SINUSES AND MAXILLA
Osteoplastic Approach to the Frontal Sinus (Continued) (Fig. 5-8) (After Alford, 1964; Beck, 1908; Goodale and Montgomery, 1964) F The flap of bone and the periosteum are returned, 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 chronic sinusitis. This will reduce the unsightly bulge over the diseased frontal sinus. A cutaneous drain is used only in those patients with active infection. G An outline is shown of the extension of the brow incision in bilateral frontal sinus disease. Occasionally, the opposite sinus may be approached through the original exposure by removing the sinus septum. This depends on the extent of disease and the size of the sinus. It is usually more beneficial to use a bilateral approach. H A coronal hairline incision may be preferred in the female patient to avoid the brow incision. In the male patient this may be disastrous if he is bald. Regardless of the skin incision, in the bilateral approach the bone across the nasal process of the frontal bone usually requires transection with saw or chisel. Occasionally, if the infectious disease is limited to one side (e.g., mucocele of the frontal sinus), drainage may be achieved by taking down the septum in the frontal sinus, thus facilitating drainage to the uninvolved side and its nasofrontal duct. There may be more than
one septum between the right and left sides of the frontal sinus. Be sure all septa are removed as thoroughly as possible with a large communicating fenestra. The nasofrontal duct on the uninvolved side must be patent. This can be verified with the instillation of methyl blue dye. This maneuver is controversial, however, and yet it has proved efficacious.
Partial and Radical Maxillectomy Operations involving resection of the maxilla and contiguous structures for carcinoma can be divided into three main types: partial maxillary resection with preservation of the roof and superior portion of the posterior wall of the antrum, total maxillary resection and ethmoidal exenteration with preservation of the globe, and total maxillary resection with ethmoidal exenteration and orbital enucleation. One of the perplexing problems in the surgical treatment of carcinoma of the maxilla is the evaluation of the extent of the neoplasm. This problem is aggravated at times by late diagnosis as well as by concomitant infection. Another problem is the extent of the malignant changes in an inverted papilloma. Inverted papillomata without malignant change can cause bone changes. Hence, the question arises as to the extent of the surgical resection and the frequency of combined therapy with radiation (preferably postoperative). Evaluation of the extent of the neoplasm is done both preoperatively and operatively and follow-up is done for life. The preoperative evaluation includes careful inspection of the nasal cavity, its floor and lateral wall, the nasal septum, and the nasopharynx; the standard paranasal
FIGURE 5-8 Continued
THE SINUSES AND MAXilLA
sinus radiograph, tomograms, CT, and MRI; and radiographic views of the base of the skull. Ophthalmologic consultation may be helpful in ascertaining whether the orbital contents have been invaded. The obvious signs-proptosis and extraocular muscle impairmentleave no doubt that orbital exenteration is necessary, if indeed the lesion is resectable. Occasionally, the first sign of maxillary sinus carcinoma is an enlarged metastatic sub digastric cervical lymph node. A Caldwell-Luc operation is a last resort for diagnosis and is best avoided if an unequivocal histologic diagnosis can be made through an intranasal antrostomy. Regardless, errors have been made by confusing long-standing inflammatory disease with neoplasm. Difficulty can also be encountered in differentiating anaplastic squamous cell carcinoma from large cell lymphoma (formerly classified as reticulum cell sarcoma). This differentiation can be aided by immunostaining. For example: 1. Leukocyte common antigen: positive-lymphoma; negative-most likely not lymphoma 2. Cytokeratin: positive-anaplastic carcinoma Historically, the electron microscope was of some help in this differentiation. In all epidermal tumors there are desmosomes between the outer cell membranes. This feature is somewhat more obvious in squamous cell carcinoma and is absent in large cell lymphoma. Operative evaluation of the extent of disease is described during the following discussion of surgical technique. In view of this additional information relative to the extent of disease, permission for removal of the eye must be obtained in all patients. Another problem in maxillectomy for carcinoma is the fact that when the disease has extended beyond the confines of the antrum, many of the contiguous structures (e.g., the ethmoidal sinus, sphenoidal sinus, cribriform plate, posterior aspect of the maxilla with pterygoid plates, posterior portion of the orbit, and infratemporal fossa) defy uniform en bloc resection. Other extensions that involve the nasal septum and nasal cavity, palate, and skin of the cheek can usually be encompassed with maxillectomy with little difficulty. Extension to the base of the skull and resection is described in Chapter 23. When the lesion is not resectable, chemotherapy and radiation therapy combined with a drainage procedure and removal of grossly involved and necrotic tumor is the best that can be afforded the patient for palliation. At other times the extent of the surgical resection can be more easily modified. For example, if there is gross evidence of disease involving the bony wall at the canine fossa, this area must be widely encompassed, including a portion of the upper lip and possibly the cheek. The same applies to extension into the mucosa
overlying the hard palate. Regardless, this mucosa IS always resected with the hard palate. In the following discussion the indications for radical and partial maxillectomy are reviewed with each description of the surgical technique. Each patient must be individually evaluated and consideration given to palliative resection-usually partial maxillectomy combined with radiotherapy or preoperative induction chemotherapy-to remove offensive necrotic tumor. It is suggested that preoperative chemotherapy be considered in advanced squamous cell carcinoma of the paranasal sinuses following the regimen detailed in Chapter 3. Although neoplasms of the paranasal sinuses were not included in that review, owing to the limited number of patients, nevertheless one would expect similar favorable results. Ohngren, in 1933, divided the maxilla into an anterior inferior portion and a posterior superior portion by drawing an imaginary line from the medial canthus of the eye to the angle of the mandible. He pointed out that lesions arising in the anterior inferior section carried a better prognosis than those in the posterior superior section because the extension of the disease in the latter section "very soon encroached upon the meninges and vascular stems, thereby eliminating every chance of successful therapy." This thesis has withstood the test of time and forms the basis for the decision whether to perform a partial or radical maxillectomy. Yet it must be emphasized that error in management rests with the lesser resection because of the inherent difficulty in the preoperative evaluation of the extent of the disease. Three anecdotal examples are reported demonstrating the place for chemotherapy in the treatment of esthesioneuroblastoma, as well as neuroendocrine carcinoma. Case 1: Esthesioneuroblastoma A 39-year-old white man presented with a stage III tumor primarily involving the right nasal cavity, ethmoidal sinus, and cribriform plate confined to the extradural space. The tumor was deemed to be resectable. Treatment consisted of two preoperative courses of chemotherapy with cyclophosphamide, etoposide, vincristine, and cisplatin. Craniofacial resection was performed. Four years later metastasis was discovered in the right submandibular area and a right radical neck dissection was done. The pathologic report showed four positive nodes (three level I, one level IV). One year later the tumor recurred in the cribriform plate. A secondary craniofacial resection was done that included maxillectomy and orbital enucleation. Three years later there was spread to the temporal lobe. One year later a craniotomy was performed for recurrence followed with gamma knife therapy. The patient received late radiotherapy (5040 rads) but died 9 years after the initial treatment.
THE SINUSES AND MAXILLA
Case 2: Esthesioneuroblastoma, Nonresectable, Stage C A 51-year-old white man presented with a tumor involving the nasopharynx, right orbits, and sphenoidal sinus, destruction of the clivus, and extension to the ethmoidal sinus and nasal cavity and the middle cranial fossa. Radiotherapy was instituted with cobalt 60 (5180 rads). This was done concomitantly with administration of doxorubicin, vincristine, and, subsequently, cyclophosphamide. The maximum dose of doxorubicin was 780 mg. This was followed with treatment with lomustine. There was no evidence of disease after 22 years. Staging followed the Kadish staging system for esthesioneuroblastoma (olfactory neuroblastoma): Stage A-tumor limited to the nasal cavity Stage B-tumor within the nodes and paranasal sinuses Stage C-extending beyond the paranasal sinuses
Case 3: Neuroendocrine Carcinoma, Nonresectable, Stage C A 31-year-old white woman initially presented with an extensive mass in the nasal cavity involving the maxillary sinus and ethmoidal sinus. This was designated a stage IV lesion. There was a 6-cm mass in the right side of the neck. Treatment initially was with surgery following four courses of chemotherapy consisting of cyclophosphamide, cisplatin, etoposide, and vincristine. There was a 100% response of the neck metastasis, as well as no residual disease in the nasal cavity. She subsequently received an autologous stem cell transplantation to the bone marrow and radiotherapy (6000 rads) to the paranasal sinuses and (5040 rads) to the neck. After 7 years there was no evidence of disease. It is interesting to note that in Case 1 the basic principle that was used in the treatment of squamous cell carcinoma (as discussed under preoperative chemotherapy in Chapter 3) was followed with surgery plus radiation. In Case 2 there was control of the nonresectable esthesioneuroblastoma with chemotherapy and radiotherapy and no surgery. Although these examples are anecdotal, nevertheless they point to the importance of a careful evaluation of patients and the treatment depending on stage and
resectability. In any event, this supports the importance of chemotherapy and radiation in the treatment protocol. These data, relative to the long-term survival rates as described, as well as the literature, support the concept of chemotherapy and radiation in these nonresectable tumors, as well as indicating the possibility, especially in the neuroendocrine carcinomas and those of squamous cell origin, of using preoperative chemotherapy followed by surgery and selective radiotherapy (see Chapter 3). These suggestions, of course, deserve much further evaluation as to end results, stretching out beyond the usual 5-year survivals.
Removal or Saving Remainder of Soft Palate After Partial Maxillectomy 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 remaining soft palatal segment. It is hoped that the following guidelines will give direction when the surgeon is faced with this dilemma. Whether to remove the remainder of the soft palate is based on the fact that the sling of the levator veli palatini muscles occupies the bulk of the middle third of the soft palate, moving the soft palate posterosuperiorly during speech and swallowing, to contribute to palatopharyngeal closure. Thus, when only the anterior one third of the soft palate is removed, the remaining two thirds will be functional and should be retained. Conversely, when the anterior two thirds is removed, the remaining posterior third will be a useless, adynamic strand that should be routinely removed. The decision-making problem arises when the anterior third is removed, along with part of the middle third. How much of the middle third must be removed before the remaining part becomes nonfunctional and is best being totally removed? The answer is probably somewhere in the mid middle third, keeping in mind that individual variation is great. This decision is totally in the hands of the surgeon intraoperatively. The shorter the soft palate is in overall length, the more difficult this decision becomes. To err on the conservative side may make prosthetic reconstruction with a speech-aid very difficult.
THE SINUSES AND MAXILLA
Radical Resection of Maxilla With Orbital and Partial Ethmoidal Exenteration (Fig. 5-9) Malignant tumors of the maxillary sinus (antrum of Highmore) amenable to surgical treatment, unless very early and limited, are better handled by a more radical operation than by a limited one because of the intimate and complex relationship of the antrum to the ethmoidal and sphenoidal sinuses as well as to the orbital contents. Hence, the radical resection with orbital and ethmoidal exenteration will be described first. Permission for orbital exenteration should be obtained in virtually all operations for malignant tumors of the antrum. See Chapter 23 for block resections of the ethmoidal sinus with craniofacial resection. Highpoints 1. Antrum is not entered. 2. Orbital contents should be resected with roof of antrum in any extensive carcinoma of maxilla or with involvement of roof of antrum. 3. Resect as much of the ethmoidal sinuses en bloc as possible. Remainder will require curettage. 4. Graft raw surfaces with split-thickness skin. 5. Leave orbital skin defect open to future inspection for early detection of recurrences. 6. Preserve soft palate if levator muscle is intact. 7. Tracheostomy is indicated. Refer to Figures anatomy.
1-1 through
1-6 for radiographic
A A Weber-Dieffenbach (Fergusson) incision is made with an extension into the floor of the nose. The upper lip incision is staggered to minimize postoperative contracture. The vertical line is just medial to the philtrum, and the horizontal line follows the vermilion border. The eyelids are sutured together and are left attached to either the skin flaps or the eye. If an orbital prosthesis is intended, it may be advantageous to remove the lids with the skin flaps. Discuss this option with the maxillofacial prosthodontist (see Chapter 3, pages 161 to 165, Dental and Prosthetic Considerations in Head and Neck Surgery). An incision in the floor of the naris is optional, because the transection of the floor of the nose can be done without this incision. An acute angle of the skin incision is to be avoided near the medial canthus. Resect the skin of the cheek if it is involved. B The bony area resected includes the entire antrum with hard palate and floor of the orbit, lateral orbital rim, body of the zygoma (malar bone), and portion of zygomatic arch (the double dotted lines on the arch indicate the portion of arch excised to facilitate the application of silver clips to the internal maxillary artery performed early in the operation). The internal maxillary artery may be superficial or deep to the external pterygoid muscle or pass between the two heads of the muscle. The ethmoidal labyrinth, anterior wall of sphenoidal sinus, and complete lateral wall of the nasal cavity with all three turbinates are included in the resection. The nasal septum ;s left intact unless the septum is involved. If it is involved, the line of resection through the floor of the nose is on the contralateral 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
B FIGURE 5-9
:tub. of maxilla -'Lat.pterygoid plate
THE SINUSES AND MAXilLA
Radical Resection of Maxilla With Orbital and Partial Ethmoidal Exenteration (Continued) (Fig. 5-9) C Skin flaps are dissected, preserving the orbicularis oris and buccinator muscle in the lateral flap. The remaining facial muscles are for the most part left attached to the anterior wall of the antrum. The incision from the lip is carried along the gingivobuccal sulcusposterolaterally to beyond the maxillary tuberosity. Attachments of the buccinator muscle to the lower edge of the maxilla, extending back to the tuberosity, are transected. The nasal (frontal) process of the maxilla is then sectioned with a chisel or a sagittal plane saw up to the level of the medial canthus of the eye. This area corresponds to the suture line of the maxilla with the frontal bone and serves as a marker for the level of the cribriform plate of the ethmoid-the floor of the anterior cranial fossa. This is the superior level of resection med_ially. D The upper incisor tooth on the side of the resection is removed. A stab wound is made into the nasal cavity at the posterior edge of the hard palate. Through the stab wound a curved clamp is inserted into the nasal cavity, grasping the end of the Gigli saw (Cocke, 1956), which is passed into the nares. If any tooth fragments remain on the edge of the saw cut, these should be removed.
E The hard palate is transected longitudinally through the floor of the right nasal cavity with the Gigli saw. An incision is then carried across the posterior edge of the hard palate (dotted line), separating it from the soft palate. The soft palate is left intact. F The anterior attachment of the masseter muscle has been cleared from the anterior portion of the zygomatic arch. A 2-cm section of the zygomatic arch is excised with a Gigli saw. This opening affords access to the pterygomaxillary fossa and exposure of a portion of the internal maxillary artery, which is then transected between silver clips (see L). G The periosteum is incised around the entire superior, medial, and lateral circumference of the orbit (the inferior segment will be excised with the en bloc resection). Periosteal elevators then elevate the periorbita to the apex of the orbit. With the globe retracted downward and medially, a curved clamp is passed through the inferior orbital fissure to grasp the Gigli saw. Occasionally, a fracture of some thin bone will be required to introduce the clamp. If it is not possible to pass the clamp, the lateral orbital rim is sectioned using a sagittal plane saw.
FIGURE 5-9 Continued
THE SINUSES AND MAXILLA
FIGURE5-9 Continued
H Directing the Gigli saw upward and forward transects the lateral orbital rim. The optic nerve is severed midway between the globe and the optic foramen (dotted line) or as far posterior as indicated. Avoid excessive traction on the optic nerve because it may produce damage to the optic chiasm and subsequent
visual field defects in the opposite eye. The ophthalmic artery, which is medial to the optic nerve, is ligated. Within the fat pad are small vesselsthat should likewise be ligated. Continued
THE SINUSES AND MAXilLA
Radical Resection of Maxilla With Orbital and Partial Ethmoidal Exenteration (Continued) (Fig. 5-9) I A cut is made with a chisel or sagittal plane saw starting at the upper extent of the osteotomy performed in step C. This separates the maxilla from the frontal bone. The chisel is directed slightly downward and inward, hugging the inner aspect of the cribriform plate. This must be performed slowly and carefully to prevent injury to the cribriform plate. The cut extends across the superior margin of the lacrimal bone and through the upper third of the lamina papyracea of the ethmoid to the anterior lateral extent of the sphenoidal sinus. In this manner as much of the ethmoidal labyrinth as possible is removed en bloc with the maxilla. If gross disease has invaded the superior ethmoidal cells or frontal sinus, extension of the operation to include these areas is performed by exposing the dura and anterior cranial fossa. This will require a combined craniofacial resection (see Chapter 23). The use of forehead flaps or free vascularized flaps to close the orbital defect completely is believed unwise, because recur-
rence of disease would be obscured. vascularized flaps is the adequate operative defect.
The argument for coverage of the
The posterolateral attachment of the maxilla is freed in one of two ways. The pterygoid process is transected near its origin from the body and the great wing of the sphenoid bone (Jl). This is accomplished by first sectioning the external and internal pterygoid muscles from the lateral and medial pterygoid plates and then transecting the pterygoid process with angulated rongeurs. The lateral and medial pterygoid plates are prolongations of the pterygoid process. The two plates are joined anterior and superior and open posterior and inferior. Overlying the pterygoid muscle is the main trunk and some branches of the internal maxillary artery. This artery is variable and may pass deep to the external pterygoid muscle or between the two heads of the muscles. These vessels are the source of significant hemorrhage if not individually ligated or occluded with silver clips. This is performed early in the operation by removing a small section of the zygomatic arch (see B), remembering the variable location of the artery.
Pterygomaxillary fissue
Upper head ext. pterygoid m.
Lateral Plate of Pterygoid process of sphenoid . Maxilla
FIGURE 5-9 Continued
THE SINUSES AND MAXILLA'
Deep Temporal a.
Pterygomaxillary fissure
Upper head ext. pteryg. m. Lower head ext. pteryg. m. -Maxilla Internal Maxillary a.
K
L FIGURE 5-9 Continued
The internal carotid artery is vulnerable at the time of sectioning of the pterygoid process. The distance between the internal carotid artery and the posterior edge of the lateral pterygoid plate is approximately 1. 5 em or less. The styloid process overlies the internal carotid artery. The foramen lacerum is located at the base of the medial pterygoid plate. The inferior aspect of the foramen lacerum is filled with a fibrocartilaginous plate, above which passes the internal carotid artery, after it passes through the orifice of the carotid canal. This orifice is posterior to the foramen lacerum.
Complications • Hemorrhage • Cerebrospinal fluid leak • Airway obstruction unless a tracheostomy is performed • Separation of wound between cheek and nose unless a two-layer closure is used
K An alternate method of freeing the posterolateral attachment of the maxilla is by directing a chisel between the pterygoid process and the maxilla. This cut extends into the pterygomaxillary fissure. Again, branches of the internal maxillary artery require ligation. This method is not recommended if there is any suspicion of bone erosion in the posterior wall of the antrum. L The entire specimen is now usually free enough so that the remaining weak attachments of the maxilla deep in the medial aspect of the orbit are broken by rocking the specimen back and forth. If necessary, a chisel may be used gently to cut these attachments. The line of transection extends across the posterior reaches of the posterior ethmoidal air cells, usually removing the anterior wall of the sphenoidal sinus. Continued
THE SINUSES AND MAXILLA
Radical Resection of Maxilla With Orbital and Partial Ethmoidal Exenteration (Continued) (Fig. 5-9) Proximity of this line to the base of the skull and carotid canal is well shown in Figure 1-1. The internal maxillary artery and its branches are shown in this step. Silver clips are utilized to occlude the vessel. This artery is depicted superficial to the external pterygoid muscle but may be deep or pass between the two heads of the muscle (see Fig. 6-7A). The head is tilted backward and sideward in the drawing, thus throwing the zygomatic arch somewhat upward. Exposure of the vessels is facilitated by Langenbeck long retractors. Occasionally, this maneuver fails. This approach also affords evaluation of the extent of disease in the pterygomaxillary space. Additional exposure of this area can be obtained by transecting the base of the coronoid process of the mandible, but this is rarely necessary. M Any remaining cells of the anterior and posterior ethmoidal sinuses are removed with curettage. The curet is used in a downward motion rather than upward to avoid injury to the cribriform plate of the ethmoid. The anterior wall of the sphenoidal sinus, if still intact, is removed with a forward grasping forceps (JansenMiddleton) or back-biting forceps (Hajek or Kerrison) (see Fig. 23-" C to M). Ifthere is a question regarding identity of the sinus-posterior ethmoidal or sphenoidal sinus-place a metal probe in the area and check with an intraoperative radiograph. A large posterior ethmoidal
cell can mimic the sphenoidal sinus. The internal carotid artery is located just lateral to the posterior ethmoidal and sphenoidal sinuses. N After bleeding has been controlled, all bare surfaces both deep in the bony defect and on the undersurface of the skin flap are covered with split-thickness skin.Where possiblethe graft issutured with 4-0 chromic catgut. The remaining opposition is achieved with a pack of absorbent cotton saturated with liquid povidoneiodine (Betadine) or chlortetracycline (Aureomycin)ointment. The cotton must be squeezed almost dry to avoid the Betadine dripping into the larynx and thence into the lungs. Betadine pneumonia can occur.
o
The orbital defect is filled with this type of packing.
P Sutures of 3-0 nylon are used across the palate defect, acting as slings to hold this pack in place. The skin flaps are approximated in two layers throughout. As soon as the skin graft has taken, and certainly within 2 weeks, the first temporary impression is made for the prosthesis. If this is delayed, contractures of the anterior skin flap will occur and hamper proper fitting for the final upper denture. Some prefer the use of an immediate although temporary prosthesis for the palate defect that is made before the surgery. The packing is thus held in place by the prosthesis.
THE SINUSES AND MAXILLA
M
N
o
p
FIGURE 5-9 Continued
THE SINUSES AND MAXilLA
Resection of Maxilla Including the Floor of the Orbit With Preservation of the Globe
• Partial incision dehiscence under one eye. This serves as an excellent port for inspection and insertion of padding.
(Fig. 5-10) This procedure is indicated when there is no erosion of the orbital floor (hence the importance of CT for bone detail and MRI for soft tissue/tumor detail) but the tumor involves somewhat more than half of the contents of the antrum. Permission for orbital exenteration should be obtained, because intraoperative evaluation may disclose extension into the orbit. The technique combines the initial steps of resection of the maxilla with orbital exenteration except that the globe is preserved. The globe is then supported by a temporal muscle flap across the inferior aspect of the globe (Wise and Baker, 1968). The orbicularis oculi muscle is preserved. Steps are shown that modify the basic operation depicted in Figures 5-8F to Hand 5-9. The globe is protected by a temporary tarsorrhaphy or contact lens. The skin has been elevated superiorly to the orbicularis oculi muscle, which is preserved and carefully retracted upward with a Cushing vein retractor.
En-Bloc Resection for Chondrosarcoma A patient with extensive chondrosarcoma of both maxillary antra, both ethmoidal sinuses, and the entire nasal cavity and entire framework had these structures removed en bloc with the cribriform plate (Craniofacial Resection, see Chapter 23). The exposure consisted primarily of a degloving procedure of the skin overlying the maxilla and the nasal framework, thus preserving the overlying skin and also both eyes. A unilateral Weber-Dieffenbach (Fergusson) incision (see Fig. 5-11) was made to facilitate the exposure. All margins were histologically free of disease. Immediate reconstruction consisted of suspending the medial canthal ligaments with stainless steel wire to the frontal bone, and a temporary Steinmann pin (see Fig. 13-29) (panje) was inserted through both malar bones to support the immediate postoperative prosthesis. Dermal grafts were placed to line the bare areas of the flaps. The prosthesis was thus made in an upper and lower portion, the upper portion to fill out the face and skin of the nose, and the lower portion for the lower maxilla and upper teeth (follow-up at 14 years showed no evidence of disease).
Complications • Minimal diplopia and some slight collapse of the nasal bridge, partially corrected with padding over the prosthesis
A Exploration of the floor of the orbit is performed with an incision (dotted line) along the superior aspect of the infraorbital rim. By careful elevation of the periosteum at this point, palpation of the orbital contents is possible. If there is no gross evidence of disease in the orbit, if the floor of the orbit is intact, and if preoperative (T reveals no bone erosion, the floor of the orbit (roof of the antrum) is resected, preserving the globe. B The frontal process and arch of the zygoma are transected with a Gigli saw. The medial attachment of the infraorbital rim is transected with a sagittal plane saw just inferior to the medial canthal ligament. The dotted lines depict the extent of the osseous resection. The central incisor tooth on the involved side is extracted. The osseous transection is through the tooth socket. C With a small malleable or curved retractor, the globe with the orbicularis oculi muscle and periosteum is gently retracted upward. Posteriorly and inferiorly the orbital floor is transected with a curved osteotome. The bony incision can be carried far posteriorly approximately 4 cm from the inferior orbital rim with care not to injure the optic nerve and without entering the antrum. The danger to the optic nerve is greater medially when dissecting the lamina papyracea. D The remaining steps in the procedure are similar to the more radical operation except that the globe is preserved. A temporal muscle flap (X) is then mobilized by separating a 1-cm strip of the muscle from its insertion and attaching this free distal end near the inner canthus of the eye. This attachment can be made to the fascia in the area or through a small hole drilled in the remaining bone on the medial aspect of the orbit. The temporal muscle flap thus forms a sling to support the globe. The medial canthal ligament requires resection when the osseous resection is higher. Then the lateral portion of the medial canthal ligament is later secured to drill holes in the nasal bone. These drill holes are the same site where the temporal is muscle sling is attached. (See Fig. 14-3D to F.) Care is taken not to disrupt the lacrimal sac deep to the medial canthal ligament.
THE SINUSES AND MAXILLA
Superior orbital fissure ,-cr'
Infraorbitai groove Infraorbital foramen
Inferior orbital fissure
B
A
FIGURE 5-10
THE SINUSES AND MAXILLA
Limited Resection of the Maxilla (Fig. 5-") The technique of this procedure follows the basic principles of the radical maxillary resection except that the orbit is left intact and the ethmoidal labyrinth is not removed en bloc but cleared by curettage. Permission for orbital exenteration should be obtained, although the need for this procedure would be unlikely. Highpoints 1. This procedure is indicated mainly in carcinomas involving only the floor of the antrum. 2. A portion, or all, of the floor of the orbit is preserved as well as all the orbital contents. 3. The skin incision is made as close as possible to lower eyelashes-otherwise troublesome edema of lower lid will result. 4. Ethmoidal air cells are removed by curettage. 5. Preserve the soft palate. 6. All raw areas are covered with split-thickness skin.
A After the eyelids are approximated (temporary tarsorrhaphy, see Fig. 11-15), a Weber-Dieffenbach (Fergusson) skin incision is started across the midportion of the upper lip in stepladder fashion to minimize scar contracture. The incision is carried upward in the nasolabial sulcus to the level of the inner canthus and thence horizontally just beneath the eyelashes of the lower lid and beyond the outer canthus. The orbicularis oculi muscle is left intact and preserved at its orbital location. An incision is made in the gingivobuccal fold, and the cheek flap, including the buccinator muscle, is reflected back to the tuberosity of the maxilla. The area resected is schematically represented. This includes the lower two thirds of the maxilla including the juxtaposed hard palate. A Gigli saw is used to transect the hard palate as in Figure 5-9D and E. The nasal process of the maxilla is sectioned with a chisel for a distance of 1.0 to 1.5 cm to the level of the infraorbital rim. B
The inferior turbinate (a separate bone) is thus included in the resected specimen, whereas the superior and middle turbinates, which are part of the ethmoid, are excised as separate fragments after the main specimen is removed. If the t~mor grossly involves the medial wall of the antrum, the middle turbinate and the superior turbinate are removed en bloc with the main specimen. When the tumor involves the septum, the floor of the nose is transected on the contralateral side. The septum is thus removed with the main specimen. If possible, the columella is preserved; otherwise, an anterior strut graft is inserted for support. C The orbicularis oculi muscle is retracted upward. A Stryker saw transects the upper third of the maxilla, preserving most of the infraorbital rim and floor of the orbit. This cut is' extended laterally across the body of the zygoma. The posterolateral attachment of the maxilla is separated from the pterygoid process of the sphenoid bone with a chisel as depicted in Figure 5-9K. The 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 those in the pterygomaxillary fissure, will require ligation. The anterior and posterior ethmoidal sinuses are curetted as in Figure 5-9M, with the same precautions as in an ethmoidectomy (see Fig. 5-3). A split-thickness skin graft is used to line all bare areas (see Fig. 5-9N). D Povidone-iodine (Betadine)- or iodoform-impregnated cotton is used as packing (see Fig. 5-9P). The packing is removed in 7 to 10 days, and a temporary prosthesis is inserted. In 2 weeks the temporary tarsorrhaphy is released.
A more extensive resection of the maxilla can be performed in which the entire maxilla is resected as in Figures 5-8F to H, 5-9, and 5-10, with preservation of the eye. In such procedures, a portion or slip of the temporalis muscle is detached from the coronoid process of the mandible and swung as a sling under the eye for support. The distal end of the muscle is sutured in the region of the inner canthus of the eye.
THE SINUSES AND MAXILLA
c
D FIGURE 5-11
249
250
THE SINUSES AND MAXILLA
Cysts of Maxilla (Fig. 5-12) Odontogenic and developmental fissural or inclusion cysts of the maxilla are shown: radiculardental root or dentoperiosteal; follicular-dentigerous (contains a tooth); nasoalveolar; nasopalatine; and globulomaxillary.
A TO E
Highpoints
1. Preoperative radiographs should be taken to evaluate the extent of bone encroachment. 2. The entire cyst wall must be removed, including a
juxtaposed portion of nasal or antral mucous membrane, if necessary. 3. Teeth are retained if this is compatible with adequate cyst wall removal. Devitalized teeth require root canal treatment. 4. Frozen section should be performed if there is any question regarding a possibility of neoplasm. Resection of odontogenic cysts follows much of the same technique and approach as with the basic Caldwell-Luc operation (see Fig. 5-2). When possible, the juxtaposed, normally located teeth are preserved by dental care. The oroantral communication is closed, and drainage is obtained with an intranasal antrostomy.
THE SINUSES AND MAXILLA
ODONTOGENIC
A
DEVELOPMENTAL
E
FIGURE 5-12
THE SINUSES AND MAXILLA
Excision of Nasoalveolar Cyst (Fig. 5-13) A Cystic swelling is shown at lateral base of right ala nasi and vestibule with partial obstruction of anterior naris. Cavitation of the bone is not present and rarely occurs in these cysts. B An incision is made along a portion of the nasolabial fold forming the lateral base of the ala nasi. If the presenting portion of the cyst were lower, an approach in the alveolar labial gutter could be used. C With blunt and sharp dissection, the presenting wall of the cyst is exposed. If the cyst is extremely large,
aspiration will facilitate easier enucleation without extension of the incision. D A small, curved, blunt-nosed scissors is used to enucleate the cyst, keeping the wall intact. In this patient there was a line of cleavage between the cyst wall and the nasal mucous membrane. The nasal cavity was not entered. If there were no Iine of cleavage, the adherent nasal mucosa would require excision. The wound is closed with 5-0 nylon sutures without drainage. Nasal packing impregnated with an antibiotic ointment may be placed in the vestibule to coapt the elevated nasal mucous membrane to the concavity of the defect.
THE SINUSES AND MAXILLA
A
B
FIGURE 5-13
THE SINUSES AND MAXILLA
Excision of Nasopalatine Duct Cyst (Fig. 5-14) A Depicted is a form of nasopalatine duct cyst presenting as a sinus tract through the hard palate just behind the right medial incisor tooth. This would correspond to the right incisive canal. The cyst presents in the right nasal cavity, displacing the inferior turbinate superiorly, reaching the nasal septum, and causing severe nasal destruction. A 1 An incision is made in the gingivolabial sulcus slightly acrossthe midline transecting the superior labial frenulum. The incision is so placed that sufficient mucous membrane remains on the gingival side to facilitate placement of sutures for closure. The dotted line around the sinus tract indicates the incision to remove the lining of the sinus tract. B With blunt and sharp dissection, the labial flap is elevated, exposing the anterior wall of the cyst. A small probe can be passed through the sinus tract to demonstrate the communication with the cystic cavity. C Cross section shows the location of the sinus tract and cyst with a small blunt curet attempting to separate the mucous membrane of the floor of the nose from the cyst wall. This is not possible posteriorly, and thus juxtaposed nasal mucous membrane and cyst wall are removed together. It is most important that all portions of the cyst wall be excised; otherwise, recur-
rence will most likely take place. Any bone projecting into the nasal cavity is removed with rongeur forceps. D The entire lining of the sinus tract must likewise be removed. This requires an elliptical incision around the sinus tract in the hard palate, with careful curettage along the walls of the defect in the bone. Considerable bleeding may occur from terminal branches of the greater palatine artery or the nasopalatine artery in the tract. Electrocautery is used to control this bleeding. Cautery is also utilized to destroy any possible remaining epithelial elements of cysts and duct. A single suture of 4-0 nylon is placed through the mucous membrane of the hard palate to close the defect, whereas a continuous 4-0 nylon suture closes the gingivolabial incision. Packing of 0.5-inch strip gauze impregnated with antibiotic ointment or nitrofurazone (Furacin) is inserted in the defect in the floor of the nose and brought out through this defect. Additional nasal packing may be required to control any oozing blood. E Shown here is another type of nasopalatine cyst that presents in the roof of the mouth rather than in the nasal cavity. F A palatal flap based posteriorly is elevated with an incision just behind the gingiva, thus preserving the greater palatine vessels.The cyst and wall are resected using much the same technique as for the previous nasopalatine cyst. Closure is with 4-0 nylon and a drain brought out anteriorly, if necessary.
THE SINUSES AND MAXilLA
FIGURE 5-14
THE SINUSES AND MAXilLA
Closure of Oroantral Fistula (Fig. 5-15) Highpoints 1. Small oroantra! fistulae, 1 to 2 mm, usually close spontaneously. Those from 3 to 4 mm are usually successfully closed with a buccal flap (see F). 2. Fistulae 5 mm and larger as well as those of longstanding duration associated with severe sinus disease require a more extensive surgical procedure using a large palatal flap. 3. Adequate sinus surgery with antrostomy is necessary in this latter group. 4. Flaps must be rotated and sutured without tension. 5. The suture line must be well away from the bony defect. 6. All diseased bone must be removed. In large fistulae, the tooth on either side of the fistula is extracted. 7. If an active purulent sinusitis exists, antral washings through an antrostomy with systemic antibiotics are indicated preoperatively. 8. Any projecting bone should be leveled off so that no undue pressure is exerted on the flap.
A The dotted line depicts the diseased edematous mucous membrane to be excised. Because the anteriorly located tooth is close to the fistula, it will be extracted. The solid line on the palate outlines the mucoperiosteal palatal flap based on the greater palatine artery (dotted line). A broad-based buccal flap is also elevated to expose the canine fossa through which a Caldwell-luc operation (see Fig. 5-2) can be performed as indicated. large fistulae over 5 mm usually require this antral surgery, depending, of course, on the antral pathologic change.
B
Frontal section through the fistula shows the diseased mucous membrane extending into the fistula. All this diseased tissue, as well as surrounding osteomyelitis in adjacent bone, is excised. If the bone disease is extensive, adjacent teeth or alveolar ridge is to be removed. The arrow indicates the position of the Caldwell-luc approach to the antrum through which diseased mucous membrane is removed. If the oroantral defect is extremely large, a Caldwell-Luc exposure may not be necessary, because access to the antrum may be through the fistula defect. An intranasal antrostomy (see Fig. 5-1) is performed into the inferior meatus. This is enlarged if considerable sinus disease is present. C The palatal flap is elevated, preserving the greater palatine artery. The buccal flap is turned upward to
expose the canine fossa when the Caldwell-Luc procedure is deemed necessary. The tooth anterior to the fistula has been extracted, and diseased bone and mucous membrane have been excised.
Cl
Following the technique of Proctor (1969), a bone plug may be fitted into the bony defect when it is large (0.5 to 2.5 em). The bone plug is taken from the iliac crest and consists only of cancellous bone, the hard cortical bone having been discarded. The bone plug is tapered and shaped to fit the defect. It is tapped into the fistula. Any protruding portion of the bone plug is removed so that it is flush with the surrounding bone.
D The palatal flap is rotated across the defect without tension. The suture line must rest on sound bone and not cross the fistula. If tension occurs posteriorly at the second molar tooth, this unfortunately is removed. The donor site on the palate may be allowed to granulate, or, if objectionably large, grafted with free dermis or epidermis. E The frontal section depicts the palatal flap closure with suture lines well away from the fistula. The locations of the Caldwell-Luc operation and the intranasal antrostomy are shown on the lateral and medial wall of the antrum, respectively. A rubber drain is through the intranasal antrostomy. F With smaller fistulae (under 5 mm in diameter), buccal flap is advanced to cover the fistula. Care must be taken not to injure Stensen's duct in the mobilization of the flap. G The frontal section shows the buccal flap in position. An intranasal antrostomy has been performed. A disadvantage of the buccal flap is that it crosses the buccogingival gutter and partially obliterates it-a possible source of trouble with denture-wearing patients. However, this flap will stretch in time. In the immediate postoperative period, the patient must not wear his or her denture because this would place undue tension and pressure on the flap. Another disadvantage is the possible tension placed on this flap with motion of the lips and cheek. Usually no dressing is used in either procedure; however, with large palatal flaps, cotton soaked with nitrofurazone and secured to surrounding teeth may be used if the flap appears to buckle or separate from the underlying bone. The intranasal antrostomy drain is likewise optional. Antibiotics are used.
THE SINUSES AND MAXILLA
c
FIGURE5-15
25&
TH£ ~INU~£~ AND MAXILLA
ENDOSCOPIC SINUS SURGERY
without removal of the maxillary lining. Prior to 15 to 20 years ago this patient would have been treated by a Caldwell-Luc approach with removal of the entire sinus lining and inferior meatus antrostomy. However, it has been recognized more recently that when the critical pathways are opened and decompressed, the lining will heal and does not need to be removed. The patient shown in Figure 5-16 was treated by endoscopic partial ethmoidectomy and middle meatus maxillary antrostomy with complete resolution of the opacification and of the patient's preoperative symptoms.
Keith F. Clark Highlights
1. Safe and effective endoscopic sinus surgery requires practice and a thorough knowledge of intranasal, sinus, and perisinus anatomy that can only be gained through study, cadaver dissection, and mentorsupervised surgical training. 2. Thorough treatment with medications, including a long course of a broad-spectrum antibiotic, corticosteroid sprays, decongestants, antihistamines, and treatment of underlying conditions such as allergy, elimination of smoking, and so on, should be attempted before sinus surgery is undertaken. 3. CT provides required detailed information about extent of disease, anatomic relationships, distortions, and abnormalities. Scans using I-mm cuts can be aligned with the patient in the operating room using a computer. Computerized, image-guided technology provides the surgeon with the ability to accurately locate any anatomic location touched in the patient on the CT scan. lt can be particularly useful in revision cases when there is loss or distortion of anatomic landmarks. 4. Endoscopic sinus surgery techniques have largely replaced external approaches including the CaldwellLuc procedure. Today we have an understanding of the physiology of the sinuses, particularly with respect to patterns of ciliary flow, and a better understanding of the anatomy through the availability of CT. In addition, the endoscopic equipment and techniques have allowed significant improvement in success rates and the possibility of better healing through mucosal preservation. Consider Figure 5-16, which illustrates the results of a preoperative CT scan (A) demonstrating maxillary disease and a postoperative CT scan (B) taken after endoscopic middle meatus maxillary antrostomy, showing resolution of maxillary disease
A
Indications
The indications for the endoscopic approach are similar to those for other intranasal and external approaches and in general include: • • • • • •
Recurrent acute sinusitis Chronic sinusitis Allergic fungal sinusitis Chronic hypertrophic rhinosinusitis (polyps) Antrochoanal polyp Mucoceles in any sinus
As surgeons have become proficient with endoscopic techniques many other procedures are being done endoscopically, including: • Septoplasty • Drainage of periorbital abscess via ethmoidectomy • Control of epistaxis including sphenopalatine artery ligation • Closure of cerebrospinal fluid leak • Transsphenoidal hypophysectomy • Orbital decompression • Dacryocystorhinostomy • Resection of intranasal tumors • Repair of choanal atresia
B
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. FIGURE 5-16
THE SINUSES AND MAXILLA
Complications (Not Restricted to Endoscopic Approaches) • Intranasal bleeding • Synechiae formation • Stenosis and obstruction of sinus ostium with recurrence of disease • Lateralization of middle turbinate • Obliteration of frontal recess with persistent or de novo frontal disease • Mucocele formation, especially in the frontal sinus • Orbital emphysema • Epiphora • Anosmia or hyposmia • Persistent or recurrent sinus disease • Severe arterial hemorrhage • Orbital hematoma • Diplopia • Visual loss or blindness • Cerebrospinal fluid leak • Intracranial bleeding • Stroke • Death Technique-General Preoperative
Several preoperative considerations are important to improve the intraoperative conditions, including treatment with antibiotics, avoidance of topical decongestant sprays, and treatment with topical or systemic corticosteroids, especially in the case of allergy, fungal sinusitis, or the presence of polyps. Anticoagulants, aspirin, and other nonsteroidal anti-inflammatory agents should be discontinued well in advance of the surgical procedure. Surgical Planning
extensive injection may be necessary and can include transpalatal sphenopalatine block. Recommended anesthetic is 1% lidocaine with 1:100,000 epinephrine to cause vasoconstriction and provide postoperative comfort. Holding Endoscopes
The endoscope should be held between the thumb and forefinger and embraced with the other fingers while resting the hand or fingertips on the patient's nose or cheek. The scope is held as close to tlje lighted end as possible, and the viewing end is supported by the surgeon's periorbital structures. All light cords and camera wiring are directed against the surgeon's chest and then back to lie across the patient's chest. The scope should be placed in the nasal vestibule first to view the caudal septum. Then the dissecting instrument held in the other hand is passed into view and the scope and dissecting instrument advanced together deeper into the nasal passage. Thus, the scope follows the instrument into place. A gauze pad moistened with antifogging solution is placed near the patient's nose to wipe away blood and prevent fogging. The position of the hand on the scope can serve as a depth gauge for rapid cleaning of the endoscope tip and quick replacement of the scope to the same depth each time. A common mistake is to hold the scope near the viewing
TABLE 5-1 Variations
Surgically Important Anatomic
Frontal Sinus
Supraorbital ethmoidal cells High frontal recess ethmoidal cells Narrow frontal sinus ostium Atelectaticfrontal sinuses Ethmoidal Sinus
A thorough understanding of the operative technique, identification of landmarks intraoperatively, and the identification of anatomic variants (Table 5-1) seen on endoscopic examination and/or a CT scan are critical. Anesthesia
Endoscopic surgery can be performed under local or general anesthesia. In the preoperative holding area, it is helpful to decongest the nose with a topical decongestant such as oxymetazoline. The face is draped with the eyes exposed to enhance the surgeon's ability to recognize intraoperative orbital hematoma. Local anesthetic is injected to the inferior turbinate, at the anterior attachment of the middle turbinate, and at the region of the uncinate process. During awake sedation, more
Concha bullosa Paradoxicallybent middle turbinate Infraorbital ethmoidal cells Mediallydownsloping skull base with low medial lamella of cribriform plate Dehiscence of lamina papyracea or skull base Maxillary
Sinus
Lateralization of the uncinate process Maxillaryatelectasis Infraorbital ethmoidal cells Accessoryostium Sphenoidal Sinus
Onodi cells (sphenoethmoidal cells) overriding the sphenoidal sinus Projection of carotid artery and optic nerve into the sphenoidal sinus
THE SINUSES AND MAXilLA end, which leaves the scope unstabilized against the patient's nose. Uncinectomy
There are several methods of performing the unci nectomy, which is the first step before antrostomy and ethmoidectomy. Some surgeons advocate minimal excision at the midpoint whereas others remove the entire uncinate. The uncinate process can be viewed on the lateral nasal wall under the middle turbinate. It has a semilunar-shaped anterior attachment and posterior free edge. Its attachment superiorly is anterior and lies under the leading edge of the middle turbinate attachment. As one follows the attachment inferiorly, it curves and moves posteriorly. The incision in the uncinate is made at the concave region of the attachment approximately 4 mm anterior to its posterior leading edge. The poste-
Uncinate
Sickle knife
FIGURE 5-18
Backbiting forceps.
rior leading edge forms the hiatus semilunaris. The uncinate can be removed by cutting its attachment with a sickle knife beginning at the midpoint (Fig. 5-17). One feels the cut through the mucosa, bone, and another layer of mucosa into the free space lateral to the uncinate, which is the infundibulum. The knife pierces through the three layers and is moved medially, and the surgeon views the space of the infundibulum, confirming the proper position. The knife is then swept superiorly and inferiorly in the semilunar direction described. The remaining attachments superiorly and inferiorly are then removed with a Takahashi or Wilde-Blakesley forceps. The back-biting instrument (Fig. 5-18) can also be used to bite away the uncinate in a piecemeal fashion with the remnants then removed using a suctiondebrider. Once the uncinate has been removed the maxillary antrostomy and then ethmoidectomy can be performed.
Middle turbinate
Accessory ostium
Ethmoid bulla
Middle turbinate FIGURE5-17
Uncinectomy.
FIGURE 5-19
Maxillary antrostomy.
THE SINUSES AND MAXilLA
the curved suction through the membranous ostium inferiorly to avoid penetrating the lamina papyracea and entering the orbit. Another common mistake is to pass the suction too superiorly between the bony orbital floor and the sinus mucosa. Thus the sinus mucosa is stripped from the roof without actually entering the sinus cavity. The location of the lacrimal system duct and sac is just anterior to the natural ostium. Overly aggressive removal with the back-biting instrument can lead to postoperative epiphora or other lacrimal system complications. Ethmoidectomy
Middle meatus antrostomy FIGURE5-20
Maxillary antrostomy.
Maxillary Antrostomy (Figs. 5-19 and 5-20)
Use the 3D-degree endoscope. The natural ostium of the maxillary sinus lies lateral to the uncinate process in an anterior and medial location within the infundibulum. It usually can be visualized after uncinectomy; if not, it can be palpated with a curved suction. It should be widened by removing anterior and inferior membranous and bony fontanel with a back-biting forceps or debrider. Occasionally, an accessory ostium is seen more posteriorly in the membranous fontanel, which can mislead the surgeon into thinking antrostomy is unnecessary. The natural ostium must be identified and opened because ciliary flow is directed toward the ostium and good function through the accessory ostium alone is not likely. Care should be taken during palpation of an obscured natural ostium to pass the curve suction just above the attachment of the inferior turbinate directing
Use the O-degreeendoscope. It is not necessary to remove the middle turbinate. Avoid traumatizing the middle turbinate during the ethmoidectomy (see Battered Middle Turbinate Syndrome, later). Ethmoidectomy begins by identifying the ethmoid bulla and opening it inferiorly and medially. The ethmoidectomy can be done with forceps, but there is a tendency to strip the mucosal lining, causing delayed healing. It is preferred to use the suction debrider device, which will more precisely remove the septa and open into air cells without stripping the lining. Aim for removal of all bony septa where disease is present while sparing mucosa. The dissection begins inferiorly and medially and proceeds superiorly and laterally using the middle turbinate and its attachment, the ethmoidal fovea (roof) and the lamina papyracea as limits of the dissection. The lamina papyracea extends in the vertical plane from the membranous fontanel at the level of the maxillary antrum. The fovea is recognized by being denser, more yellowish colored bone. It can be sloped or flat or a combination as shown in Figure 5-21. The fovea must not be violated or a cerebrospinal fluid leak and likely meningitis or other more serious central complications can occur. A partial or anterior ethmoidectomy involves cleaning the frontal recess area, exposing the anterior fovea of
Sloped ethmoid roof Flat ethmoid roof
A FIGURE 5-21
Ethmoidectomy.
THE SINUSES AND MAXILLA the ethmoidal sinus, and extending posteriorly to the ground lamella of the middle turbinate. A total ethmoidectomy includes removal of the ground lamella to open into the posterior ethmoid cell. Pitfalls during ethmoidectomy mainly relate to penetration of the lamina papyracea, in which case a surgeon must recognize the difference between mucosal thickening in the sinuses and adipose tissue of the orbit. Bleeding usually occurs diffusely but can be profuse in the region of the sphenopalatine arteries inferiorly and laterally near the sphenoid natural ostium, as well as the anterior ethmoidal artery in the posterosuperior aspect of the frontal recess. The fovea is most likely to be injured in the region of the anterior ethmoidal artery, at the junction between the posterior ethmoidal and the sphenoidal sinus and along the attachment of the middle turbinate. Anywhere along the fovea is at risk. The medial lamella of the cribriform plate, which is medial to the middle turbinate, should never be traumatized or anosmia or cerebrospinal fluid leak will ensue. Sphenoidotomy
(Fig. 5-22)
Use the D-degree endoscope. The sphenoidal sinus can be approached from the ethmoidal sinus once the total ethmoidectomy is completed, by examining the region in the inferomedial posterior ethmoidal sinus using the point above the lower edge of the middle turbinate as a landmark. The sphenoidal opening can be palpated by placing a suction tip 7 em from the nasal sill at an angle of 3D degrees. The posterior wall of the sphenoidal sinus is 9 em from the nasal sill. Once the natural 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
widened by removing inferior and medial bone. Only overhanging bone should be removed from the superior and lateral aspect, and this is done very carefully. It is important to avoid sharp instrumentation of the sphenoidal contents, because it is possible to injure the carotid artery or the optic nerve. In addition, preoperative CT should be evaluated for the presence of an overriding posterior ethmoidal cell, which makes the likelihood of an exposed optic nerve greater. It is not necessary to perform ethmoidectomy to perform a sphenoidotomy. The sphenoidotomy can also be done directly through the nose by gently fracturing the inferior turbinate and the posteroinferior aspect of the middle turbinate and then identifying the natural ostium by palpation or direct visualization. The ostium can then be widened as described. Frontal Sinusotomy (Figs. 5-23 to 5-25)
Use the 3D-degree endoscope. The curved suction with a large diameter curve is very useful for palpating the frontal recess area. It can be used to gently displace ethmoidal septa in the frontal recess, which then can be removed with a suction ctebrider, curved curet, giraffe forceps, or up-biting forceps. The 3D-degree sinus endoscope allows easy visualization of the frontal foramen, which should be exposed without denuding mucosa from bone. Various instruments are available, including giraffe forceps, curved curets, and probes. The frontal sinus and foramen anatomy can be evaluated preoperatively with C1. There are situations when a very small opening could be made, in which case it is best
Frontal Foramen
Sphenoid ostium
Septum
Curved Suction FIGURE5-22
Sphenoidotomy.
FIGURE5-23
Frontal sinusotomy.
THE SINUSES AND MAXilLA
Narrow frontal foramen
A
B FIGURE 5-24
to avoid direct instrumentation of the area. On other occasions, a very large frontal foramen can be identified, in which case a large opening can be made that will remain patent. The frontal sinusotomy is one of the more difficult techniques in endoscopic sinus surgery, and it is the most likely site for postoperative stenosis and persistent sinus disease after endoscopic surgery. Transillumination of the frontal sinus is an excellent method of determining that one has actually opened the frontal sinus. Bright transillumination will only occur when the frontal sinus is illuminated directly. If there is a persistent high anterior ethmoidal cell, there will be very minimal, if any, transillumination. This high ethmoidal cell can be recognized on the CT scan and certainly more easily identified using computer image-guided technology. Surgical Pitfalls Battered Middle Turbinate Syndrome (Fig. 5-26) Lateralization of the middle turbinate with associated obstruction of the maxillary, ethmoidal, and frontal sinuses is a common postoperative problem that can be prevented by avoiding trauma to the turbinate mucosa and/or fracture of the turbinate attachment. The middle
FIGURE5-25
Post-op frontal foramen
Frontal sinusotomy.
Frontal sinusotomy.
turbinate should be left undisturbed. It should not be fractured. It is not usually necessary to trim it. There are occasions when the inferior horizontal segment is very large and the anterior portion can be removed. In addition, a concha bullosa, or aerated middle turbinate, should be treated by removal of the lateral wall. This is done using scissors, but care should be taken to avoid fracturing the attachment of the turbinate. If the turbinate is removed because it has become diseased or is partially removed for exposure, the attachment should be left in place as a future landmark. The medial attachment of the middle turbinate is the medial extent of the ethmoidectomy. It is easy to injure the cribriform area, and this can more likely occur if this landmark is lost. Should the turbinate become fractured and flaccid, it will undoubtedly lateralize and should be held medially by a method that will allow at least 1 month of stabilization against the septum. This can be done with a transfixion suture through the septum, 3- to 4-week stenting, or scarification of the turbinate to the septum. Remember, middle turbinectomy does not guarantee frontal recess patency. Cerebrospinal Fluid Leak Cerebrospinal fluid leak is a known complication of ethmoidectomy and is best recognized and repaired at the time it occurs.
FIGURE 5-26
Battered middle turbinate syndrome.
264
THE SINUSES AND MAXILLA
Orbital Complications
Orbital complications include intraorbital hemorrhage, injury to the extraocular muscles, visual disturbance, and blindness. These are best avoided by recognizing the lamina papyracea and avoiding lateral dissection in the posterior ethmoidal and sphenoidal sinuses. Orbital swelling after surgery with ecchymosis is suggestive of orbital hemorrhage and possible hematoma. It should be recognized early in the operating room or in the recovery room and treated quickly with ophthalmologic consultation and possible decompression with lateral canthotomy. If orbital fat is exposed, it can be recognized by its appearance as yellow soft fat. This can be confirmed by feeling or seeing subtle eye movement when the exposed fat is gently palpated with an instrument. One can also see movement of the fat when the eye is gently palpated. If fat should become exposed or protrude into the ethmoidal cavity, simply leave it alone and avoid this area. Postoperatively the patient may experience mild eye pain or mild ecchymosis. He or she should refrain from nose blowing for several days to avoid orbital emphysema. Bleeding
Preoperative treatment with corticosteroids is helpful to decrease hemorrhage in cases of diffuse polyps. Injection of 1 % lidocaine with 1:100,000 epinephrine into mucosa, including polyps, is also helpful. The suction debrider device is an excellent way of being able to complete an extensive procedure that would have been very difficult in the past using forceps alone. Suction cautery can be used to control the occasional bleeding that occurs from the sphenopalatine branches, which will often bleed after sphenoidotomy and when the dissection disturbs one of these vessels in the inferolateral wall of the posterior ethmoidal sinus. Packing is usually unnecessary after endoscopic sinus surgery. At the end of the procedure, cotto no ids moistened with oxymetazoline can be placed in the ethmoidal frontal recess and maxillary antral openings. Once the patient is extubated and awake enough to cough, swallow, and protect the airway from secretions, this packing is removed and it is very unusual to see significant further bleeding. Should additional packing be necessary, it can be done with gauze or Merocel packs made specifically for endoscopic sinus surgery. BIBLIOGRAPHY Alford BR: Osteoplastic approach to the frontal sinus for osteoma. Arch Otolaryngol 80:16-21, 1964. Appelblatt NH, McClatchey KD: Olfactory neuroblastoma: A retrospective clinicopathologic study. Head Neck Surg 5:108-113,1982. Applebaum EL, Desaum NM: Primary empty sella syndrome with CSF rhinorrhea. JAMA 244:1606-1608,1980.
Arlen M, Tollefsen HR, Huvos AG, Marcove RC: Chondrosarcoma of the head and neck. Am J Surg 120:456-460, 1970. Bartkowski SB, Stypulkowska J, Stachura J, et al: Malignant tumors of the maxilla. J Maxillofac Surg 14:301-350, 1986. Bateman GH: Personal communication, 1960. Bateman GH: Technique of hypophysectomy. Presented at the Transactions of the American Academy of Ophthalmology and Otolaryngology, Chicago, 1961. Bateman GH: Trans-sphenoidal hypophysectomy. Otolaryngol Clin North Am 4:205-215, 1971. Beck JC: A new method of external frontal sinus operation without deformity. JAMA 51:454-455, 1908. Bhattacharyya N, Thornton AF, Joseph MP, et al: Successful treatment of esthesioneuroblastoma and neuroendocrine carcinoma with combined chemotherapy and proton radiation. Arch Otolaryngol Head Neck Surg 123:34-40, 1997. Bordley JE, Bischofberger W: Osteomyelitis of the frontal bone. Laryngoscope 77:1234-1244,1967. Bosley WR: Osteoplastic obliteration of the frontal sinuses: A review of 100 cases. Laryngoscope 82:1463-1475, 1972. Brownson RJ, Ogura JH: Primary carcinoma of the frontal sinus. Laryngoscope 81:71-89, 1971. Catlin FI, Cluff LE, Reynolds RC:The bacteriology of acute and chronic sinusitis. South Med J 58:1497-1502,1965. Chandler JR: Iatrogenic cerebrospinal rhinorrhea. nans Am Acad Ophthalmol Otolaryngol 74:576-584, 1970. Chandler JR, Langenbrunne OJ, Stevens ER:The pathogenesis of orbital complications in acute sinusitis. Laryngoscope 80:1414-1428,1970. Chiari 0: Zur Kasuistik der Erkrankungen der Unterkieferspeicheldriise. Wien Klin Wochenschr 25:1562-1567,19]2. Cocke EW: Use of Gigli saw in resection of the superior maxilla. Presented at James Ewing Society Meeting, New York, April 1956. Cocke EW Jr, Braund RR: Superior maxillary resection. In Cooper P (ed): The Craft of Surgery, 2nd ed. Boston, Little, Brown, 1971. Conley J, Baker DC: Hypoglossal facial nerve anastomosis for reinnervation of the paralyzed face. Plast Reconstr Surg 63-72, 1979. Dokianakis GS, Helidonis E, Karamitsos D, Papazoglou G: Use of a new mucoperiosteal flap from the upper lateral nasal wall in frontal sinus surgery. Otolaryngol Head Neck Surg 89:912-916,1981. Donald PJ: The tenacity of the frontal sinus mucosa. Otolaryngol Head Neck Surg 87:557-566, 1979. Donald PJ: Frontal sinus ablation by cranialization. Arch Otolaryngol 108:142-146, 1982. Fenton RA: Radical treatment of the ethmoid: Intranasal. Ann Otol Rhinal Laryngol 38:913-930, 1929. Fracchia AA, Farrow JH, Miller TR, et al: Hypophysectomy as compared with adrenalectomy in the treatment of advanced carcinoma of the breast. Surg Gynecol Obstet 133:241-246, 1971. Freedman HM, Kern EB: Complications
of intranasal ethmoidectomy:
A review of 1,000 consecutive operations. Laryngoscope 89:421-432, 1979. Gallagher TM, Boles R: Symposium: Treatment of malignancies of paranasal
sinuses:
I. Carcinoma
of
the
maxillary
antrum.
Laryngoscope 80:924-932, 1970. Gass HH, Klein S: Transethmoidal drainage and arrest of craniopharyngioma by Zenker's solution. Acta Neurochir (Wien) 17:196-203, 1967. Gatti WM, Mason JH, Kosmala RL: Fibrocementoma of the maxilla. Arch OtolaryngoI84:114, ]966. Goodale RL, Montgomery WW: Technical advances in osteoplastic frontal sinusectomy. Arch Otolaryngol 79:522-529, 1964. Grayhack JT: Adrenalectomy and hypophysectomy for carcinoma of the prostate. JAMA 210:1075-1076, 1969. Hamberger CA, Hammer G, Notlen G, Sjogren B: Transantrosphenoidal hypophysectomy. Arch Otolaryngol 74:2-8, 1961. Harner SG, Newell RC:Treatment of frontal osteomyelitis. Laryngoscope 79:1281-1294,1969.
THE SINUSES AND MAXILLA
Hiranandani LH, Kamdar HH: Treatment of chronic oro-antral fistula by complete palatal flap. J Laryngol 75:744-752, 196!. Hiranandani LH, Chandra 0, Melgiri RD, Hiranandani NL: Aberrant salivary tumors. J Laryngol 80:564-570, ] 966. Hollinshead WH: Anatomy for Surgeons. New York, Hoeber-Harper, 1954, vall, p 262. Jesse RH: Preoperative versus postoperative radiation in the treatment of squamous carcinoma of the paranasal sinuses. Am J Surg
110:552-556, ] 965. Kane AM, Lore JM: Meningoencephalocele of the paranasal sinuses. Laryngoscope 85:2087-209], ]975. Kennedy DW, Zinreich SJ, Johns ME: Functional endoscopic sinus surgery. In Goldman J (ed): The Principles and Practice of Rhinology. New York, John Wiley & Sons, ]987. Kennedy DW, Zinreich SJ, Rosenbaum A, et al: Functional endoscopic sinus surgery: Theory and diagnosis. Arch Otolaryngollll:576-582, 1985. Kennedy DW, Zinreich SJ, Shaalan H, et al: Endoscopic middle meatal antrostomy theory, technique and patency. Laryngoscope 97 (Suppl 43):]-9, 1987. Kimmich HM: Radical palliative surgery about the orbit. Arch Otolaryngol 94:338-346, 197!. Kirchner FT, Toledo PS, Robison JT: Modified osteoplastic approach to the frontal bone, sinuses, and/or the orbit. Laryngoscope 77:]706-]713,1967. Koegel L Jr, Levine HI, Waldman SR: Paraganglioma of the sphenoid sinus appearing as labile hypertension. Otolaryngol Head Neck Surg 90:704-707, ]982. Kurohara SS, Webster JH, Ellis F, et al: Role of radiation therapy and of surgery in the management of localized epidermoid carcinoma of the maxillary sinus. AJR Am J Roentgenol 114:35-42, ]972. Lewis JS: Sarcoma of the nasal cavity and paranasal
sinuses.
Ann
010178:778, ]969. Loeb HW: Operative Surgery of the Nose, Throat and Ear. St. Louis, CV Mosby, 1917, vol II. Lore JM: Diseases of the maxillary sinus and their relationship to the oral cavity. Laryngoscope 48:724-737, 1938. Lore JM Jr: Partial and radical maxillectomy. Ololaryngol Clin North Am 9:255-267, 1976. Lore JM Jr: Esthesioneuroblastoma. In Pochedly E (ed): Neuroblastoma. Philadelphia, Elsevier Science, 1983. Lynch RC: The technique of a radical frontal sinus operation which has given me the best results. Laryngoscope 3]:1-5, ]92!. Macbeth R: Caldwell-Luc operation 1952-]966. Arch Otolaryngol 87:630-636, ]968. Manace ED, Goldman JL: Acinic cell carcinoma of the paranasal sinuses.
Presented
at Meeting
of Eastern Section
of American
Laryngologic Rhinologic and Otologic Society, Paradise Island, Nassau, January] 97!. Marchetta FC, Sako K, Mattick WL, Stinziano GD: Squamous cell carcinoma of the maxillary antrum. Am J Surg 118:805-807, ]969. Martinson FD, Alii AF, Clark BM: Aspergilloma of the ethmoid. J Laryngol 84:857-861, 1970. Merrick RE, Rhone DP, Chilis TJ: Malignant fibrous histiocytoma of the maxillary sinus. Arch OtolaryngoI106:365-367, ]980. Messerklinger W: Endoscopy of the Nose. Baltimore, Urban & Schwarzenberg, 1978. Messerklinger
W: Recurring rhinosinusitis:
Endoscopic
diagnosis and
surgery. Read before the 13th World Congress of Otorhinolaryngology, Miami, May 30, ]985. Messerklinger W: New dimensions in diagnosis and therapy of sinusitis. International Congress Series 680: New Dimensions in Head and
Neck Surgery. Amsterdam, Elsevier Science, ] 985. Montgomery
WW: Symposium
on surgery
of the nasal
sinuses.
Otolaryngol Clin North Am 4:97-126, ] 97!. Mosher HP: Symposium on the ethmoid: The surgical anatomy of the ethmoidal labyrinth. Ann Otol Rhinal Laryngol 38:869-90], 1929.
Niho S, Niho M, Niho K: Decompression of the optic canal by the trans ethmoidal route and decompression of the superior orbital fissure. Can J Ophthalmol 5:22-40, 1970. Otty JH: Exploration of the sphenoid sinus. In Rob C, Smith R (eds): Operative Surgery: Eye, Ear, Nose and Throat. Philadelphia, FA Davis, 1958. Pastore PN: Mucormycosis of the maxillary sinus and diabetes mellitus. South Med J 60:1164-1167, ]967. Pedersen RA, noost BT, Schramm VL: Carotid-cavernous sinus fistula after external ethmoid-sphenoid surgery. Arch Otolaryngol 107: 307-309, ]98!. Proctor B: Bone graft closure of large or persistent oromaxillary fistula. Laryngoscope 79:822-826, 1969. Rafla S: Mucous gland tumors of paranasal sinuses. Cancer 24: 683-69], ] 969. Ritter FN: A clinical and anatomical study of the various techniques of irrigation of the maxillary sinus. Laryngoscope 87:2]5-223, 1977. Ritter FN: Surgical
anatomy
of the paranasal
sinuses.
Instruction
Section. Trans Am Acad Ophthalmol Otolaryngol, ]970. Roca AN, Smith J, Jing B: Osteosarcoma and parosteal osteogenic sarcoma of the maxilla and mandible: Study of 20 cases. Am J Clin Pathol 54:625-636, ] 970. Ross DE: Radical en bloc ethmoidectomy for cancer. Surg Gynecol Obstet 108:109-114, 1959. Sachs ME, Conley J: Intraoral masseter muscle transposition: Use with reconstruction of regional facial paralysis. Arch Otolaryngol 108:397-400, 1982. Saunders WH, Miglets A: Surgical techniques for eradicating far advanced
carcinoma
of the orbital-ethmoid
and maxillary
areas.
Trans Am Acad Ophthalmol Otolaryngol 71:426-431, ]967. Schmitz GL, Peters R, Lehman RH: Thorium induced carcinoma of the maxillary sinus. Presented before the Wisconsin Otolaryngological Society, February 1969. Schuknecht HF: The surgical management of carcinoma of the paranasal sinuses. Laryngoscope 61:874-890, 195!. Sisson GA: Modern management of malignancies of the maxilla. Proceedings of Ninth International Oto-Rhino-Laryngology Congress, Mexico, 1969. Sisson GA: Symposium-Paranasal
sinuses: III. Discussion
and sum-
mary. Laryngoscope 80:945-953, 1970. Sisson GA, Johnson NE, Amiri CS: Cancer of the maxillary sinus. Ann Otol 72:1050, ]963. Smith AT:Acute and chronic sphenoid and ethmoid sinus disease. In Maloney WH (ed): Otolaryngology. Hagerstown, MD, Harper & Row, 1969, vol III. Smith HW: Cystic lesions of the maxilla. Arch Otolaryngol 88: 426-435, ]968. Smith RR, Klopp CT, Williams JM: Surgical treatment of cancer of the frontal sinus and adjacent areas. Cancer 7:991,1954. Sobul SM, Wood B, Levine H: An approach to total maxillectomy with emphasis on orbital preservation. Plast Reconstr Surg 69: 945-948, 1982. Sofferman RA, Smith RO, English GM: Albers-Schonberg's disease (osteopetrosis):
A case
with
osteomyelitis
of
the
maxilla.
Laryngoscope 81:36-46, ]97!. Tabb HG: Carcinoma of the antrum: An analysis of 60 cases with special reference to primary surgical extirpation. Laryngoscope 67:269, ]957. Tabb HG, Barranco SJ: Cancer of the maxillary sinus: An analysis of 108 cases. Laryngoscope 8]:818-827, 197!. Thompson IN, Niccole MW, Wong E, et al: Blindness following frontal sinus irrigation. Arch Ololaryngol 106:358-360, 1980. Turnbull FM: An antro-ethmosphenoidal operation. Arch Otolaryngol 9:271-28],1929. Van Alyea OE: Maxillary sinus. In Jackson C, Jackson CL (eds): Diseases of the Nose, Throat and Ear, 2nd ed. Philadelphia, WB Saunders, ]959.
THE SINUSES AND MAXilLA
Ward PH, Alley C, Owen R: Monostotic fibrous dysplasia of the maxilla. Laryngoscope 79:1295-1306, 1969. Weymuller EA, Reardon FJ, Nash D: A comparison of treatment modalities in carcinoma of the maxillary antrum. Arch Otolaryngol 106:625-629, 1980. Wilder LW, Beyer CK, Smith B, Conley JJ: Ocular findings following radical maxilleclOmy. Trans Am Acad Ophthalmol Otolaryngol 75:797-801, 1971.
Wise RA, Baker HW: Surgery of the Head and Neck, 3rd ed. Chicago, Year Book Medical, 1968. Worsoe-Petersen J: Colloid carcinoma of the nasal cavity and sinuses. Arch Otolaryngol 82:181-185,1965. Zappia JJ, Carroll WR, Wolf GT, et al: Olfactory neuroblaslOma: The results of modern treatment approaches at the University of Michigan. Head Neck 15:190-196, 1993.
6
THE NOSE AND THE NASOPHARYNX
Anatomy of the Lateral Wall of the Right Nasal Cavity (Fig. 6-1) The pathogenesis of sinusitis and its mechanism of spread can best be understood if the anatomy of the lateral wall of the nose is thoroughly reviewed. See Figures 1-1 to 1-7, especially Figure 1-3. Pratt and Pratt's description (1924) is excellent: Uncinate Process "The process (processus uncinatus) is a long, thin, scimitar-shaped bone (accessory turbinate) attached high up just under the anterior superior attachment of the middle turbinate. It lies at an angle of about 45 degrees with the lateral wall, with the anterior edge touching the lacrimal bone. At its upper beginning it follows the contour of the nasal process of the maxillary bone but soon curves backward, following and just under the edge of the middle turbinate. It terminates about in the middle of the hiatus maxillaris and gives the bony hand-shaped frame that supports the membrane, which covers the opening. "Near the posterior end of the process and partly covered by it, is located the ostium maxillaris. It is from this point, which is the lower end of the infundibulum ethmoidalis, that the antrum is evaginated. "The fingerlike projections at the end of the uncinate process articulate with the ethmoid process of the inferior turbinate and portions of the lateral wall. These portions of membrane, which lie between the fingers of the uncinate process, are known as the nasal fontanelle, and when these membranous walls are broken, form the accessory ostia of the maxillary sinuses. The accessory ostia of the maxillary sinuses always open into the middle meatus, while the true ostium opens in the floor of the infundibulum ethmoidalis. Any secretion from the antrum must pass through the hiatus semilunaris to reach the middle meatus if it passes through the natural ostium. The posterior superior surface of the uncinate process forms the anterior inferior wall of the infundibulum ethmoidalis, while its curved posteroinferior thin edge forms one margin of the hiatus semilunaris, the bulla ethmoidalis forming the other.
Bulla Ethmoidalis "The bulla ethmoidalis is first noticed as a swelling just posteriorly to the uncinate process which curves around its anterior border by three furrows from which are evaginated the cells which afterward occupy it. The bleb-like protuberance projects medially, leaving an under-shelving in its contact with the lateral wall. It is this under-shelving space lying under the edge of both the bulla and the uncinate process and follows the complete contour of the bone that is known as the infundibulum ethmoidalis. "These bulla cells which compose the bulla ethmoidalis open into the bulla recess which is one of the bulla furrows and from there into the middle meatus. The ostia, being in the superior part of the cells, do not give gravity drainage and these cells are frequently affected and often show polypoid degeneration. Infundibulum
Ethmoidalis
"Owing to the definition given the hiatus semilunaris and the infundibulum ethmoidalis by the Basle Commission in 1895, there has been great confusion in describing these spaces. The infundibulum ethmoidalis is the space on the bony lateral wall of the nose extending from the lower end of the frontonasal duct to the ostium of the maxillary sinus. It is bounded laterally by the lacrimal bone and the mesial wall of the maxillary sinus, anteroinferiorly by the uncinate process, and posterior-superiorly by the bulla. It communicates with the middle meatus, by a semilunar-shaped opening, formed by the sharp edge of the uncinate process with the bulla ethmoidalis, which is known as the hiatus semilunaris. At the lower end of the infundibulum ethmoidalis is evaginated the sinus maxillaris, while its upper end may terminate blindly or in an anterior ethmoidal cell. This anterior ethmoidal cell may develop into the frontal sinus and when this takes place, we have direct communication from the frontal sinus to the maxillary sinus. A number of anterior ethmoidal cells empty in an indirect way, into the infundibulum ethmoidalis which would allow any discharge from such a cell to run down the infundibulum into the sinus maxillaris. This 53 per cent explains some of the reasons why the antrum acts as a reservoir for a suppurating
267
THE NOSE AND THE NASOPHARYNX
Anatomy of the Lateral Wall of the Right Nasal Cavity (Continued) (Fig. 6-1) ethmoidal or frontal sinusitis. In order for the antrum to act as a reservoir, it is necessary that there be either an extremely large ostium or an accessory ostium to allow the air to escape as the discharge enters. An accessory ostium of the maxillary sinus is present in 42 per cent of adult cases. The infundibulum ethmoidalis acts as a draining trench, protected by bony walls, so is not easily compressed, and thus keeps open many cells, the ostia of which would otherwise be closed during inflammations. The drainage by the infundibulum may account for the absence of vacuum headache when the nose is apparently completely closed by congestion. At birth the lateral wall has all the markings and cells of the adult but on a smaller scale."
A The dotted line and arrow demonstrate the course of the frontal sinus duct (nasofrontal duct), one of the
more common types of the frontal sinus. This empties into the middle meatus, medial to the hiatus semilunaris. Above this hiatus is the bulla of the ethmoid, which contains the middle ethmoidal cells, which drain through the bulla or near the bulla. The short solid arrow depicts the location of the ostium of the maxillary sinus into the middle meatus. The nasal lacrimal duct opens into the anterior portion of the inferior meatus. The sphenoidal sinus opening is usually near the superior anterior wall of the sinus, depicted by the long solid arrow. B Another common type of drainage of the frontal sinus is by an ostium that opens directly into the nasal cavity. Disease of the anterior ethmoidal cells may impinge on this ostium and may be the cause of obstruction of the ostium, leading to frontal sinusitis as well as blockage of the natural ostium of the antrumthe ostial meatus complex.
THE NOSE AND THE NASOPHARYNX
MIDDLE TURBINATE BULLA ETHMOID HIATUS SEMILUNARIS
FRONTAL SINUS DUCT
SPHENOID SINUS OPENING SUP. TURBINATE
NASAL LACRIMAL DUC
EUSTACHIAN TUBE
FIGURE 6-1
THE NOSE AND THE NASOPHARYNX
Anatomy
of Epistaxis (Fig. 6-2) (After Koh et aI., 2000; Montgomery, 1971 )
Epistaxis can be either a very minor or a very major problem. The most common area in children and young adults is anteriorly on the septum (Kiesselbach or Little area) and is the easiest controlled (see Fig. 6-3E and F). The more complicated areas are posterior and superior, both on the lateral wall of the nose and the septum in older adults (see Fig. 6-3). The important factors in the control of epistaxis are etiology, location, and management. Etiology A. Local disease 1. Crusting and ulceration 2. Nose picking 3. Infection 4. Neoplasms a. Malignant neoplasms b. Juvenile nasopharyngeal fibromas c. Angiomas d. Metastatic renal cell carcinoma to the paranasal sinuses and/or nasal cavity. Massive epistaxis can occur. If feasible, resection of the metastatic lesion may be the treatment of choice. 5. Trauma 6. Foreign body B. Generalized disorders and disease 1. Arteriosclerosis-hypertension 2. Rheumatic heart disease 3. Blood dyscrasia and associated diseases a. Anemia b. Polycythemia vera c. Thrombocytopenia purpura d. Hemophilia 4. Leukemia 5. Familialtelangiectasia (Rendu-Osler-Weberdisease) 6. Hepatic diseases 7. Chronic nephritis 8. Vicarious menstruation 9. Atmospheric pressure changes (e.g., scuba divers; caisson disease) 10. Generalized infectious diseases 11. "Stigmata"? Location Exact determination of the bleeding site must be made, if at all possible, to facilitate direct attack. Occasionally, a submucous resection (see Fig. 6-12) or septoplasty (see Figs. 6-13 and 6-14) is necessary to visualize the site. Often under such circumstances these procedures
will achieve control of the hemorrhage. Lateral rhinotomy may be necessary especially in familial telangiectasia to insert a dermal graft for septal dermoplasty (see Fig. 6-6) (Saunders, 1960). 1. 2. 3. 4.
Cauterization Nasal packing-anterior, posterior, or both Submucosa resection or septoplasty Ligation of arteries a. Ethmoid arteries, anterior and posterior b. Internal maxillary and sphenopalatine arteries c. External carotid artery rarely controls epistaxis. 5. Septal dermoplasty-removal of offending mucosa and application of a dermal graft rather than splitthickness epidermis . 6. Basic care of severe hemorrhage-frequency and selection depends on degree of severity of blood loss. a. Vital signs-every 1 to 2 hours b. Hemoglobin and hematocrit determination, one to three times per day c. Blood transfusion d. Central venous pressure e. Blood volume f. Venous cutdown or intracatheter in vein g. Blood urea nitrogen determination-elevation is result of swallowing and absorbing blood. 7. Embolization of branches of external carotid artery-hazard of hemiplegia and facial palsy
Angiography-Digital
Subtraction
This is seldom necessary but is of distinct use in persistent and refractory epistaxis to determine feeding vessels as well as recurrent epistaxis after unsuccessful arterial ligation. Obtain true lateral and anteroposterior views (Koh et aI., 2000). Angiography usually requires selective external carotid artery with internal maxillary artery arteriogram and then an internal carotid artery arteriogram with visualization of the ophthalmic artery and its anterior and posterior ethmoidal branches. A bilateral . angiogram is ideal but may have to be staged, depending on find-ings and patient tolerance. Complications of possible stroke and blindness must be explained to the patient. Complications • Shock • Aspiration of blood with airway obstruction causing respiratory arrest and then cardiac arrest. Never have patient keep the head back. 1f bleeding is to occur, let it run out of the nose rather than down the pharynx and into the larynx. Oversedation can be the cause of this complication. • Death
THE NOSE AND THE NASOPHARYNX
SUPERIOR
271
ANT ETHMOID
~
OPHTHALMIC
_..••
(SPHENOPALATINE)
_INT.
_
INTCAROTID
POST
SEPTAL WALL
(POSTNASAL) NASOPALATINE (POSTSEPTAL)
ANT. ETHMOID
-
__
NASOPALATINE
OPHTHALMIC .•• SPHENOPALATINE -
-
DESCENDING_INTMAX. PALATINE
GREATER'"
PALATINE (KIESSELBACHI L1TILE AREA)
A
•
o
INT.CAROTID INTMAX.
EXT..CAROTID -
EXT..CAROTID
FACIAL MAX-) -
EXT.CAROTID
..-
SUP.LABIAL
SUPERIOR
ANT ETHMOID POST
_
OPHTHALMIC.~"'_----_
INT.CAROTID
POSTERIOR
SPHENOPALATINE (POSTLATNASAL)
INT MAX.
EXT.CAROTID
(I ANTERIOR
B
EXT..CAROTID
SEPTAL BR.
FIGURE
Axiom
Treat all cases of severe epistaxis as a serious problem.
NASAL SA.
•
.•.•
FACIAL
~(EXT.
MAX _
•••
'lI(
EXT.CAROTID
(EXT..MAX.)
6-2
There are numerous anastomoses of all these vessels,
both intranasal and extranasal, as well as bilateral anastomoses; other contributors to this are the occipital and
superficial temporal arteries. Hemorrhage from the internal A
Anatomy of septal vessels.
B Anatomy of vessels on lateral wall of nose.
maxillary artery can steal blood from the intracranial circulation via backflow from the middle meningeal artery. Theoretically, a steal of blood could also occur via the external carotid artery from the internal carotid artery.
THE NOSE AND THE NASOPHARYNX
Anterior and Posterior Packing for Epistaxis (Fig. 6-3) Highpoints I. Attempt to locate bleeding site by cleansing nasal passages with cotton-tipped applicator dipped in solution of cocaine 10%, or tetracaine 2 %, and a vasoconstrictor. 2. Anterior septal vessels (Kiesselbach's plexus) are the most common site. 3. In the absence of hypertension, bleeding at this common site is usually controlled with a pledget of cotton gauze soaked with cocaine or tetracaine and a vasoconstrictor. If bleeding persists from this location, cauterization with either a silver nitrate stick or electrocautery is performed (see Fig. 6-3E). Anterior packing (see Fig. 6-3F) may also be necessary. 4. Fatal hemorrhage is very rare, especially in hypertension, if meticulous care is given. 5. Epistaxis in hypertension is looked on as a fortunate safety valve mechanism, provided the patient's vital signs are monitored carefully. 6. Aspiration and swallowing of blood should be avoided. If oozing persists, allow blood to run from anterior nares with head flexed forward. Oversedation is strongly condemned because of the danger of aspiration, respiratory obstruction, and death. For the same reason the patient must not be restrained. 7. Ligation of one or both external carotid arteries is occasionally necessary. 8. Occlusion of anterior ethmoidal, posterior ethmoidal (see Fig. 6-4), or internal maxillary arteries (see Fig. 6-7) with silver locking clips may be necessary. 9. Ligation of the common carotid or internal carotid artery is neither necessary nor justified. 10. Nasal packing of any type should be accompanied
by systemic antibiotics. Strip gauze one-half inch, impregnated with an antibiotic ointment, is ideal. n. Occasionally in persistent epistaxis (e.g., in familial telangiectasia), an arteriogram may be helpful. Collateral blood supply has been demonstrated via the vertebral artery and the occipital artery into the internal maxillary artery in a patient with external carotid artery ligation. 12. A nasal mucous membrane dermoplasty (excision of diseased mucous membrane and coverage with dermal graft) may be required in familial telangiectasia (see Fig. 6-6). 13. All packing should be impregnated with antibiotic ointment plus systemic antibiotics for normal flora and gram-negative bacilli. Posterior Packing
A Topical anesthesia may be applied to the nasal mucosa. A small rubber catheter (No. 10 French), to which an l8-inch length of soft-bodied string is tied, is inserted into one naris. The forward end is grasped with a small sponge stick and pulled out through the mouth, leaving the string in the nasal cavity and mouth. This maneuver is repeated through the other naris. B The oral ends of the string are then secured to a prearranged roll of gauze impregnated with antibiotic ointment to which is tied a third section of string.
C Steady traction is then applied to the nasal ends of the strings and, with the index finger of the opposite hand, the roll of gauze is firmly directed into the nasopharynx. The third string protrudes from the corner of the mouth. Continued
THE NOSE AND THE NASOPHARYNX
B
FIGURE 6-3
THE NOSE AND THE NASOPHARYNX
Anterior and Posterior Packing for Epistaxis (Continued) (Fig. 6-3) Complications
• Persistent hemorrhage leading to hypovolemic shock and death • Aspiration of blood passing down through nasopharynx. Oversedation may well be a contributing factor to this avoidable complication, which has caused death. • Elevation of blood urea nitrogen from absorption of ingested blood • Any other complication resulting from hypovolemic shock (e.g., myocardial infarction, kidney shut-down) • Decrease in arterial P02 and an increase in Pe02 • Decreased pulmonary compliance • Synergistic effect of hypoxia and hypercarbia with preexisting obstructive lung disease may well account for sudden death in prolonged nasal packing • Nasal septal mucosal excoriation • Necrosis of the alar naris and columella and/or the palate from sutures, tape, or "string" or tubing related to the packing • Infection secondary to gram-negative bacilli • Toxic shock syndrome. Treatment is removal of the nasal packing and culture and treatment with antibiotics. Suggested antibiotics are intravenous methicillin sodium or cefazolin while awaiting the sensitivities from the nasal culture of the nasal packing and nasal cavity. • Obstructive sleep apnea D The two nasal ends of the string are tied securely over a small cushion of gauze or dental roll across the columella. The oral string is loosely taped to the cheek. This latter string facilitates easy removal of the posterior pack. When this equipment is not available, a Foleycatheter is inserted through one naris. When the tip has passed the nasopharynx, the bag is inflated and pulled forward
into the posterior naris. The catheter is secured with folded gauze tied at the anterior naris. Dl The Stevens nasal balloon with or without a built-in breathing tube can also be used. Its use is similar to that of the Foley catheter. Other devices are commercially available (e.g., "Epistat" manufactured by Xomed, which accomplishes both posterior and anterior tamponade). At times these various balloon devices fail in severe bleeding, and the gauze packing is able to control the bleeding. Conuol of Anrerior Hemo"hage
E Cauterization of the anterior septal vessels is done after initial control with topical application of cocaine 10%, or tetracaine 2%, and a vasoconstrictor. Either silver nitrate (stick or 50% to 100% solution) or electrocautery is used as the agent. F When anterior nasal packing is necessary, one-half inch gauze impregnated with antibiotic ointment is placed in horizontal layers. In this manner more complete and uniform pressure is obtained or selective pressure at one level is obtained by simply raising or lowering the packing. This latter technique leaves a small air passage for respiration. Systemic antibiotics are used with any type of nasal packing. Nasal Endoscopy and Cauterization
Currently, most clinicians prefer endoscopic examination of the nasal cavity, under general anesthesia, direct visualization of the bleeding vessel(s), and electrocauterization. This approach avoids the discomfort and morbidity associated with nasal packing, particularly posterior nasal packing, and considerably shortens hospitalization time.
THE NOSE AND THE NASOPHARYNX
FIGURE 6-3 Continued
THE NOSE AND THE NASOPHARYNX
Ligation of Ethmoidal Arteries (Fig. 6-4) Indications
• Epistaxis superiorly (above the middle turbinate) (see Fig. 6-2) • Perform concomitantly with internal maxillary artery ligation if unable to ascertain region of bleeding. Highpoints
1. Avoid injury to the medial canthal ligament and the lacrimal sac below and the trochlea of the superior oblique muscle above. If this ligament is sectioned, careful repair is necessary. The trochlea may be elevated with the periosteum if additional exposure is necessary. 2. Subperiosteal dissection is necessary. 3. Avoid injury to the globe and optic nerve. 4. Do not fracture the thin lamina papyracea of the ethmoid bone. 5. Control all bleeding meticulously-postoperative intraorbital hemorrhage could damage the optic nerve by pressure. 6. Ligate both anterior and posterior ethmoid arteries. 7. Use of the operating microscope facilitates improved illumination and magnification.
8.
Digital subtraction angiography (arterial) or standard
artertography may be of help, A Depicted is the anatomy of the origin and relationships of the anterior and posterior ethmoidal arteries
as they arise from the ophthalmic artery, which is the first branch of the internal carotid artery (see Figs. 1-1 to 1-6 for bony relationships). The excellent articles by Weddell and colleagues (1946) and Kirchner and coworkers (1961) refer to the details of the surgical anatomy of these vessels. An important relationship is the proximity of the posterior ethmoidal artery to the optic nerve, which "entering at a small angle with the medial orbital wall, lies only 1 or 2 mm from the point at which the posterior ethmoid[al] artery leaves the orbital soft tissue to enter the foramen" (Kirchner et aI., 1961). The posterior ethmoidal artery usuallyapproaches its foramen at a 90-degree angle to the bone. The posterior ethmoidal foramen is between 4 to 7 mm in 84% of the skulls from the optic foramen. Hence, the admonition of caution if electrocautery is used to obliterate this vessel. It must be applied meticulously to the bony foramen with retraction of the orbital contents. Silverlocking clips are preferred. The distance relationships depicted on the illustration are from Kirchner, but he hastens to emphasize that there are such variations that these distances may be of little help to the surgeon. The anterior ethmoidal artery is usually the larger, but the reverse can be true. One or the other vessel may be absent. Occasionally, there may be three ethmoidal arteries. B
An anterolateral view of the anatomy of the medial
bony wall of the orbit shows the more typical location
of the foramina of the anterior and posterior ethmoidal arteries in the region of the frontoethmoidal suture line. Continued
THE NOSE AND THE NASOPHARYNX
CRISTA GALLI FRONTAL SINUS FRONTOMAXILLOLACRIMAL SUP. OBLIQUE M.
13-18MM
1
CRIBRIFORM
SUTURE
PLATE
ANT. ETHMOID A. SUP. RECTUS M. MEDIAL RECTUS M. POST. ETHMOID A.
10-13MM! OPTIC N. LACRIMALA.
4-7MM
OPHTHALMIC
A.
A
FRONTOMAXILLOLACRIMAL SUTURE OPTIC FORAMEN FRONTAL PROCESS MAXILLARY BONE
LACRIMAL FOSSA ANGULAR A.
ORBITAL PLATE OF MAXILLARY BONE
WabniQ B FIGURE 6-4
277
THE NOSE AND THE NASOPHARYNX
Ligation of Ethmoidal Arteries (Continued) (Fig. 6-4) The relationship of the medial canthal ligament and the lacrimal sac to the region of the surgical approach is depicted in Figure 11-12B. The trochlea is a fibrocartilaginous pulley through which the tendon of the superior oblique muscle passes. The stippled area is a portion of the lacrimal bone and the lamina papyracea whereas the diagonally lined area is the frontal process of the maxillary bone and the juxtaposed nasal bone. These are areas resected in an external ethmoidectomy (Fig. 5-4B).
Complications • Hematoma • Optic nerve damage
C A temporary tarsorrhaphy may be performed. A slightly curved incision about 3 cm in length is made as depicted, extending more above the medial canthal ligament than below it. Branches of the angular vessel will require ligation. This artery anastomoses with the dorsal nasal branch of the ophthalmic artery. D The periosteum is incised and elevated above the medial canthal ligament, avoiding the lacrimal sac
below and the trochlear above. This exposes the suture line (vertical) between the frontal (nasal) process of the maxilla and the lacrimal bone and the suture line (horizontal) between the orbital plate of the frontal bone and the lamina papyracea of the ethmoid bone. Microsurgical spatulas are ideal for periosteal elevation posteriorly. A suitable self-retaining retractor with interchangeable slatted and solid blades (Luongo) is inserted. If necessary, a small malleable retractor can also be used to retract the periosteum and the globe laterally. Following the frontoethmoid suture line, the anterior ethmoidal artery is identified. Silver clips using the House hemostatic clip instrument (Storz) are placed proximally and distally-if possible, two on each side-and the vessel is transected. This is necessary to facilitate deeper exposure of the posterior ethmoidal artery, which is then simply occluded with one or two silver clips. Care is taken not to dislodge the silver clips on the ends of the transected anterior ethmoidal artery during the maneuver. At this point extreme care is exercised to avoid injury to the optic nerve (see Fig. 6-4A). When hemostasis is incomplete, bipolar electrocautery can be used for small vessels if extreme care is taken not to injure the optic nerve nor any other contents of the orbit (best to avoid cautery of posterior artery); the wound is closed with a drain (portion of rubber band).
LACRIMAL SAC
c
D FIGURE 6-4 Continued
THE NOSE AND THE NASOPHARYNX
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 the external ethmoidectomy was used to resect this suspicious area as well as clip the feeding vessel that existed through the cribriform plate (Sobie and Loft'). The accompanying anteroposterior left carotid angiogram (DSA, arterial route) demonstrates a concentration of dye (circled) just inferior to the cribriform plate in a patient with recurrent, severe, life-threatening epistaxis. (Angiogram courtesy of Dr. David Rowland, Director of Radiology, Sisters Hospital of Buffalo,
In the unusual event that bilateral ligation of the anterior and posterior ethmoidal vessels as well as internal maxillary arteries fails to control hemorrhage high in the nasal cavity, an external ethmoidectomy may be necessary (see Fig. 5-4). The extent of the osseous resection of the lacrimal bone to the frontal process of the maxillary bone and the nasal bone for the approach to the vessels perforating the cribriform plate depends on whether the location of the bleeding site is anterior or posterior. Preoperative digital subtraction angiogra-
New York.)
FIGURE 6-5
THE NOSE AND THE NASOPHARYNX
Septal Dermoplasty (Fig. 6-6) (After Saunders, 1960) Indication
• Repeated epistaxis is secondary to familial telangiectasia (Rendu-Osler-Weber disease). This disease is systemic with possible bleeding from any epithelial or mucosal surface including the gastrointestinal tract. Cardiac failure secondary to anemia must be carefully evaluated and managed before any surgical intervention. Highpoints
I. Remove entire mucous membrane in area to be treated, leaving intact the underlying perichondrium or periosteum, which will serve as the source of blood supply to the graft. 2. If there is any question regarding the viability of the septal cartilage from use of electrocautery, it may be wiser to stage a procedure on the opposite side to avoid perforation. 3. Remove as much of diseased area as possible from one side-this usually includes mucous membrane not only on the septum but also on the lateral wall of the nose, including turbinates. 4. Give adequate exposure. 5. Avoid aspiration of blood; if performed under general anesthesia, pack hypopharynx in addition to using a cuffed endotracheal tube, because the bleeding may be profuse. 6. The nasal packing (packing impregnated with antibiotic ointment) must be carefully inserted so as not to disrupt the graft. The use of a Teflon splint against the graft and sutured in place accomplishes this protection. 7. Blood transfusions may well require washed packed red cells rather than whole blood and/or the use of fresh-frozen plasma. 8. Provide therapy with systemic antibiotics for the normal nasal flora as well as gram-negative bacilli.
• Septal perforation • Atrophic rhinitis with varying degrees of crusting A Depicted is a lateral rhinotomy (see Fig. 6-32), which affords adequate exposure of the nasal septum and a portion of the lateral wall of the nasal cavity. The lateral rhinotomy usually does not require osteotomy. The dotted line outlines area of mucous membrane excised. Allthe mucous membrane must be excised so that no islands remain under the skin graft. A sharp ring curet can be used to remove inaccessible mucosa and at the same time preserve the perichondrium. The perichondrium is preserved. Bleeding is usually copious and is controlled with electrocautery. Care must be taken not to perforate the nasal septum. A1 Because it is quite impractical to place sutures completely around the edges of the mucosal defects on the skin graft, the grafts are merely sutured anteriorly using 5-0 continuous nylon or absorbable suture material. The grafts are then folded in over the defects on the septum and lateral wall of the nose, leaving excess graft posteriorly. This will slough off in due time. One-half-inch gauze packing impregnated with antibiotic ointment is carefully and loosely placed within the nasal cavity separating the two grafts, medially and laterally. Teflon splints are utilized alongside the septum (see Fig. 6-131 to L).
B Frontal section through the nasal cavity shows the location of the skin graft. Both split-thickness epidermal and dermal grafts have been utilized, more recently the latter. Although not proven, it is believed that the dermal grafts may possibly assume some of the morphologic characteristics of mucosa in the nose as they do in the oral cavity and pharynx. One caution would be the possible adherence of the dermal grafts on the septum and the turbinate to one another. Hence, packing or splint (see Fig. 6-131) should be maintained until epithelialization of the dermis occurs. Another possible criticismwould be the increased thickness of the dermal graft over the epidermal graft, thus compromising the nasal airway.
Complications
• Recurrent epistaxis • Cardiac failure: danger of overtransfusion during surgery, postoperative tachycardia, and auricular fibrillation • Graft failure
The nasolabial incision for the lateral rhinotomy is closed in layers. There must be no bleeding at the close of the operation. Ligation of internal maxillary and/or ethmoidal arteries may be necessary (see Figs. 6-4 and 6-7B to D).
THE NOSE AND THE NASOPHARYNX
I. SPLIT THICKNESS 1
OR
I DERMAL GRAFT
FIGURE 6-6
THE NOSE AND THE NASOPHARYNX
Ligation of Internal Maxillary Artery (Fig. 6-7)
a. Sphenopalatine (posterior lateral nasal) b. Posterior nasal (nasopalatine; posterior septal)
Indications • Epistaxis posteriorly (from the sphenopalatine artery and its nasopalatine branch) (see Fig. 6-2) or any epistaxis refractory to nasal packing, especially prolonged packing • Recurrent epistaxis • Often performed concomitantly with ethmoidal artery ligation (see Fig. 6-4) Part I
The branches of the third part are those involved in the transantral ligation for the control of epistaxis, specifically the terminal medial branch forming the sphenopalatine and the posterior nasal arteries and the descending palatine. There are anastomoses with the internal carotid (via ethmoidals and ophthalmic), other external carotid branches (via facial), other branches of the maxillary artery (via buccinator), and crossed anastomoses with vessels of contralateral side (via sphenopalatine). Hence, there is the obvious difficulty of controlling persistent epistaxis and often the necessity of performing
bilateral
multiple
ligations
of not
(Medial to mandible)
only the maxHiary artery branches but also the bilateral
I. Deep auricular
ethmoidal arteries. In one patient (with familial telangiectasia) who previously had bilateral external carotid
artery ligations as well as ethmoidal and sphenopala-
2.
Anterior tympanic 3. Middle meningeal 4. Inferior alveolar
(and accessory
meningeal)
Part II (Relationship deep or superficial muscle-all muscular branches) 1. Masseteric 2. Deep temporal 3. Buccinator
to external
pterygoid
(2)
4. External and internal
Pterygopalatine part lies against posterolateral aspect of maxilla and passes in a plane lying between two heads of external pterygoid muscle to enter pterygopalatine fossa (lateral portion).
alveolar
B. Anterior 1. Infraorbital 2. Descending palatine rior) a. Greater palatine b. Lesser palatine
(somewhat
C. Posterior 1. Pharyngeal 2. Branch to foramen rotundum canal 3. Medial and superior
would also demonstrate any significant variant of the internal carotid, which is extremely rare, as shown by Quain (1844), in which the branch to the foramen rotundum and the accessory meningeal arteries substituted for the internal carotid artery.
Highpoints
pterygoid
Part III
A. Lateral 1. Posterior superior
tine artery ligations, an angiogram performed via the superficial temporal artery revealed anastomoses of a branch of the maxillary artery with the vertebral artery via the occipital artery. It is in such situations that an angiogram is of help. A common carotid arteriogram
medial and infe-
and to the pterygoid
1. Check anatomy and size of antrum with radiographs. A markedly small antrum will require removal of lateral inferior wall of the antrum for exposure (see Fig. 6-70). The average size of an antrum is 23 mm wide, 33 mm high, and 34 mm deep (Schaeffer, 1920). 2. Be cognizant of proximity of internal carotid artery. 3. Related nerves lie in a deeper plane and should easily be avoided. 4. Take care not to dissect too high and enter the orbit-this may occur with the smaller antrum. 5. At least occlude the terminal medial branch forming the sphenopalatine and posterior nasal arteries and the anterior branch forming the descending palatine. Ideally, at least three sites should be occluded, as depicted in C, as well as the main trunk of part III of the maxillary artery. 6. A portion of the orbital process of the palatine bone should be removed for access to the terminal branch of the maxillary artery forming the sphenopalatine and posterior nasal arteries. 7. Use locking clips or multiple clips and transect vessels when possible.
THE NOSEAND THE NASOPHARYNX
PART I
PART II
283
PART III
POSTERIOR PHARYNGEAL PTERYGOID CANAL FORAMEN { ROTUNDUM EXT. PTERYGOID M. SUP. HEAD INF. HEAD
MEDIAL & SUPERIOR SPHENOPALATINE POSTERIOR NASAL
MIDDLE MENINGEAL AND ACCESSORY A.
LATERAL
POST.
A
{
SUP.
ALVEOLAR
FIGURE 6-7
8. Do not use oxidized cellulose or any other material capable of expansion if packing the antrum. Expansion of packing can cause pressure and result in blindness and/or total ophthalmoplegia.
A Depicted is the basic anatomy of the internal maxillary artery (now known as simply the maxillary artery, whereas the external maxillary artery is known as the facial artery) (see Figs. ,-, to '-7 for bony rela-
The approach to the antrum is a Caldwell-Luc operation (see Fig. 5-2) with a large opening. Take care not
tionships). The maxillary artery may be either superior (anterior) to the external pterygoid muscle or deep to
to injure the infraorbital nerve and preserve as much of the lining mucosa as possible to cover the surgical defect. Cocaine 10%, oxymetazoline (Afrin), or phenylephrine (Neo-Synephrine) (check with the anesthesiologist regarding side effects of any general anesthetic agent, e.g., halothane) is applied to the antral mucosa to decrease bleeding. General endotracheal anesthesia is provided with the patient in semi-Fowler's position so that the direction to the posterior wall of the antrum is toward the inferior aspect, thus avoiding any injury to the orbit.
the muscle or pass between the superior and inferior heads of the muscle. This main terminal branch of the external carotid artery (along with the superficial temporal artery) is of prime concern to the surgeon. It is divided into three parts. There may be some confusion regarding terminology, and alternate names are in brackets. Continued
THE NOSE AND THE NASOPHARYNX
Ligation of Internal Maxillary Artery (Continued) (Fig. 6-7)
At times the main trunk of the internal maxillary artery enters the operative area from the inferior aspect. Minimally, three sites are occluded with clips and, if possible, the intervening vessels are transected. It is important to occlude the maxillary artery proximally (1) as well as distally (2), where the vessel continues on to divide into the sphenopalatine and posterior nasal branches and the descending palatine artery (3), to prevent retrograde flow. If additional small vessels are apparent, these, too, should be occluded because of the crossed anastomoses. In other variants of the maxillary artery, multiple clips are utilized again. It may not be possible to identify each branch by name. It is adequate to occlude them all. Avoid the sensory nerve to the palate, which accompanies the descending palatine artery. If bleeding occurs during the procedure, the antrum is packed and then re-explored. All related nerve structures are usually deep to the vessels and easily avoided.
Complications • Facial numbness • Intolerance to extremes of heat and cold over the distribution of the infraorbital nerve • Pain • Blindness and ophthalmoplegia with the use oxidized cellulose packing • Infection extending into pterygomaxillary space
of
B An inferiorly or laterally based mucoperiosteal flap is then elevated and reflected from the posterior wall of the antrum. With the use of the operating microscope with 300-mm lens, 0.6 magnification setting, and angulated eyepiece the thin inferior posterior wall of the antrum is removed with a bur or curet. This opening
is then enlarged
superiorly
with fine back-
biting Kerrison forceps and hooks. The bone removal is continued
D
upward to resect a portion of the orbital
secondary operations,
process of the palatine bone (see Fig. 6-4D) (Pearson et aI.,
1969).
a somewhat
different dissection
of the antrum is performed:
This may require additional use of a bur,
and this exposes foramen.
If the antrum is small or the patient is undergoing
the region
of the sphenopalatine
Take care with the patient's
head and neck
1. Remove
the lateral inferior wall of the antrum,
if necessary,
terior wall of the antrum too high. If it is too high and
Caldwell-Luc
medial, one can enter the ethmoidal
heads of the external pterygoid muscle. The maxillary
not to make the opening
sinus; if it is too
communicating opening,
this exposure
and
in the pos-
hyperextended
with the
expose the upper and lower
artery may lie over the lower head or pass between
high and lateral, one can enter the orbit.
the two heads or may cross the muscles in a vertical The vessels may be just beneath the periosteum and are thus in jeopardy during the removal of the bony posterior wall. Extreme care must be exercised to avoid lacerating a vessel. If this does occur, the area must be packed.
The procedure
if the vessel cannot
may have to be terminated
be clipped.
At times removal
portion of the lateral wall of the antrum internal maxillary artery proximally sure to place a clip proximally.
of a
to expose the
may afford expo-
C The posterior layer of periosteum is then opened using a fine instrument or electroscalpel. This exposes adipose tissue, which is teased forward, exposing some of the branches of the third part of the maxillary artery. A small Mixter forceps as well as a nerve hook is of aid in this dissection. Small forward grasping forceps are advantageous for removing adipose tissue. Depicted is a rather typical configuration (after Pearson et aI., 1969).
direction. All branches of the vessel are then occluded with clips. It may be possible to pass a silk ligature around the main trunk of the maxillary artery (part III) using a fine Mixter clamp. 2. Ligation of the maxillary artery will then be lateral and posterior
3.
to the antrum.
Be careful not to enter the orbit.
After hemostasis is ensured, the posterior mucoperiosteal flap is replaced. An antral window is usually not required unless antral packing is necessary. The packing should be strip gauze impregnated with antibiotic ointment and applied very loosely to avoid any pressure that might be transmitted to the optic nerve. Do not use oxidized cellulose or any material capable of expansion. The Caldwell-Luc incision is closed with continuous 4-0 nylon without drainage. If there is difficulty in locating the maxillary artery, the technique described in Figure 6-70 can be helpful.
THE NOSE AND THE NASOPHARYNX
UPPER HEAD
LOWER HEAD
D
INT. PTERYGOID M.
FIGURE 6-7 Continued
285
THE NOSE AND THE NASOPHARYNX
Removal of Nasal and Nasopharyngeal Polyps (Fig. 6-8) Highpoints
1. Use topical tetracaine 2%, or cocaine 10%, with or without a vasoconstrictor, for anesthesia. 2. Usually more polyps will become visualized after removal of initial polyps. 3. Suspect polypoid disease in sinuses and some type of allergic background. 4. Most polyps tend to recur. 5. Do not confuse a polypoid turbinate with a true polyp. Do not remove part or all of middle turbinate. 6. In infants a nasal glioma may simulate an innocent polyp (see Fig. 6-34). 7. Do not confuse an angiofibroma with a nasopharyngeal polyp. 8. Be cognizant of other lesions in the nasopharynx and nasal cavity: glioma (infants, see Fig. 6-34), meningiomas, chordomas, Thornwaldt's bursa, Rathke pouch remnant with pituitary gland (see Craniofacial Approach in Chapter 23). "In the median line of the adenoid, especially in adults, you will often find an opening leading upward and backward to a cavity commonly known as the pharyngeal bursa, or Thornwaldt's bursa. Mellinger, who has investigated it extensively in adults, has found it frequently present, deep and often in a state of chronic inflammation. In some instances pus pockets were found and a chronic inflammation of the adenoid, even though small, was clearly evident. Emerson has also reported similar affections, which are commonly known as Thornwaldt's Disease" (Barnhill, 1937). 9. Refer to nasopharyngoscopy, Chapter 4. Flexible and rigid telescopes are a great aid in the evaluation of lesions not only of the nasopharynx but also of the nasal cavity. Complications
• Hemorrhage
• Aspiration of blood or, conceivably, polyps, causing respiratory embarrassment • Septic shock syndrome following any nasal packing • Disaster if lesion is other than nasal polyp that arises intracranially A A nasal polyp snare is slipped around the polyp under direct vision through a nasal speculum. B The snare is tightened only after it is worked up to the base of the pedicle. If possible, the snare is not completely closed, thus not completely transecting the pedicle. At this point, the snare has a firm grip on the pedicle; snare and polyp are removed together. If the pedicle is completely transected, a bayonet forceps or duckbill forceps (Watson-Williams) is used to remove the free polyp. If it is inaccessible, the patient is asked to blow the nose gently and this will expel the polyp. C Some large posterior polyps presenting in the nasopharynx cannot be encircled with a snare alone. D A grasping forceps through the mouth is used to introduce the dependent portion of the polyp into the loop of the snare. Gentle traction on both instruments works the snare upward to the pedicle. E When the snare meets resistance, it is at the base of the pedicle; it is then completely closed. This severs the pedicle completely and the polyp is removed orally using the grasping forceps.
Smaller polyps and remnants are removed with punch forceps. Extension of polypoid disease into the sinuses may require sinus surgery. Refer to uncapping of ethmoids, ethmoidectomy, antral window, and Caldwell-Luc operations. All polyps and, for that matter, all tissue must be submitted for histologic examination at all times.
THE NOSE AND THE NASOPHARYNX
FIGURE 6-8
287
THE NOSE AND THE NASOPHARYNX
Transpalatlne Exposure of the Nasopharynx and the Sphenoidal Sinus (Fig. 6-9) Indications
• Removal of large benign and locally invasive lesions (juvenile angiofibroma); nasopharyngeal chordoma • Exposure for surgical correction of posterior choanal atresia • Diagnostic exploration when other methods have failed • If lesion extends beyond confine of nasopharynx, another approach or combination of approaches is necessary. • An alternate approach to the sphenoidal sinus (see
2.
3. 4.
5.
p.228). Alternate
6.
Techniques
1. Most benign pedunculated lesions in the nasopharynx can be removed with nasal snare (see Fig. 6-8). 2. Posterior choanal atresia also can be surgically treated via the nasal cavity with or without the operating mIcroscope.
Highpoints
1. Never biopsy a lesion in the office that is suggestive of being an angiofibroma. 2. A mucoperiosteal hard palate flap is used. 3. Remove and discard the major portion of the bone of the hard palate. 4. Preserve the greater palatine arteries bilaterally. Elevate the vessels and nerves with a mucoperiosteal hard palate flap. 5. Safeguard as much mucous membrane as possible (e.g., along floor of nose, septum, vomer, and palatal crest). If the lesion is malignant, the mucous membrane is removed with the lesion. 6. Additional exposure can be achieved by mobilization of the greater palatine vessels by removing surrounding bone. 7. Flexible and rigid telescopes are a great aid in evaluation of lesions in the nasopharynx. Additional Criteria and Characteristics Juvenile Angiofibroma
of
1. External carotid arteriogram (digital subtraction)
is helpful in delineating feeder vessels that are usually the internal maxillary and ascending pharyngeal arteries. Although uncommon in this
invasive test, stroke is possible if the dye reaches the intracranial circulation; the complications must be explained to the patient. Do not perform a selective vertebral arteriogram. It can result in basilar artery syndrome and adds no useful information. Tumor can extend into the orbit, any paranasal sinus, pterygomaxillary space, nasal cavity, or temporal fossa and involve the foramen of the skull and extend intracranially. Bleeding is usually profuse-have up to 12 units of blood available. The use of hormones such as estrogens as definitive treatment has not been proved to be of value. A computed tomographic scan with enhancement is mandatory in the evaluation of the extent of tumor. Temporary occlusion of the external carotid artery. The vessel should not be permanently ligated, because subsequent arteriograms to evaluate recurrence will then be quite difficult to perform. However, such an arteriogram can be
performed with permanent ligation through a catheter in the superficial temporal artery. 7. A transpalatine approach is usually preferred. The pterygomaxillary space can be reached via this approach. The combination of trans maxillary and lateral rhinotomy approaches may be necessary, depending on the extent of the tumor behind the antrum (Pressman, 1962). Lateral rhinotomy can be performed via an extended Caldwell-Luc approach. This can be performed without an external facial incision (see Fig. 6-10). 8. Cryosurgery has been utilized in conjunction with this surgical procedure to reduce the size of the tumor and to reduce the hemorrhage, but late hemorrhage has occurred. 9. Radiation therapy is not advised unless absolutely necessary because of the subsequent danger of malignant change. Hypotensive anesthesia, although used by some surgeons, carries too great a risk. 10. Some of these tumors are very friable, others are very firm. If at all possible, they should be removed intact rather than piecemeal. This requires careful blunt dissection. 11. If the tumor is large and bleeds profusely, external carotid artery ligation can be attempted, but by and large this has not proved useful. The better approach would be to ligate the internal maxillary artery via a transantral approach. In addition this trans antral approach will give additional exposure
THE NOSE AND THE NASOPHARYNX
to the larger tumors that extend into the antrum, behind the antrum into the lining of the antrum, or further into the pharyngomaxillary space as well as the sphenoidal sinus. The author's technique is to perform a transantralligation of the internal maxillary artery as the initial step, depending on the findings of digital subtraction angiography (arterial). 12. Infratemporal or infrazygomatic swelling indicates further spread of the tumor. Intracranial spread must also be evaluated before any surgical approach. Chemotherapy has been reported for nonresectable intracranial extension. 13. Consider the use of fresh-frozen plasma after 4 to 6 units of blood transfusion.
14. Magnetic resonance imaging may prove to be of help in the evaluation of the extent of the tumor.
Complications • Naso-oral fistula, especially at the anterior portion • Related specifically to angiofibroma: profuse hemorrhage during and following surgery • Incomplete removal or recurrence; neurologic sequelae from vertebral arteriogram-possibly due to blood flow stasis from catheter in vertebral artery or bolus of the radiopaque material • Rhinism
THE NOSE AND THE NASOPHARYNX
Transpalatine Exposure of the Nasopharynx and the Sphenoidal Sinus (Continued) (Fig. 6-9) A Anatomy of the palate and outline of the palatal flap. The incision is made parallel to the gingival margin, leaving enough mucous membrane on the gingival side for placement of closure sutures. The anterior extent of the incision should be within 1 cm of the bases of the upper incisors. The important greater palatine arteries are depicted. A vertical incision in the soft palate is of no help for exposure.
Al
Cross-sectional view depicting blood supply.
and along the anterior tonsillar pillar, is necessary.Care must be taken not to injure the thin nasal mucous membrane on the contralateral side, especially when a Bovie cutting current is used. C The palatal flap is retracted and the hard palate removed with rongeur forceps. The hard palate found directly under the incision should be left intact so that the closure has underlying intact bone. The mucous membrane along the floor of the nasal cavity is left intact, if possible. In angiofibroma, the hard palate and mucous membrane may be eroded. Occasionally, the greater palatine artery can be sacrificed on one side if the integrity of all the vesselson the contralateral side is preserved. These include the lesser palatine artery and branches of the ascending palatine artery (see A). In these instances, on the contralateral side, extension of the incision is not made nor the flap developed.
B The palatal flap, including the periosteum, is mobilized with the aid of an elevator. The vesselsand nerves are within the flap. The crucial point is at the site of emergence from the greater palatine foramen, which is juxtaposed to the third molar region. To facilitate further retraction of the palatal flap, the posteromedial wall of the greater palatine foramen and canal can be removed to give more length to the greater palatine artery. In addition, the tensor veli palatini muscle can be sectioned or the hamulus of the pterygoid bone
the lesion extends. Laterally, this incision may be lengthened to reach the anterior angle of the eustachian tube. If the lesion is an angiofibroma, care should be taken to avoid trauma to the tumor and its feeding vessels.
fractured. The incision, extended behind the third molar
Continued
D A transverse incision through the mucous membrane of the floor of the nose is made as far anterior as
THE NOSE AND THE NASOPHARYNX
LESSER PALATINE ASCENDING PALATINE
t
,.j
D FIGURE 6-9
291
THE NOSE AND THE NASOPHARYNX
Transpalatine Exposure of the Nasopharynx and the Sphenoidal Sinus (Continued) (Fig. 6-9)
F The lesion is resected by sharp and blunt dissection. Depending on the histology, there may be profuse bleeding. If this is the case, pressure with gauze, suction, or cauterization may be necessary. Complete hemostasis is achieved after total removal of the tumor. If necessary, the septum or the posterior portion of the inferior turbinate can be excised.
If the angiofibroma extends into the pterygomaxillary space with a presenting mass in the cheek, exposure can be gained through an incision in the buccal sulcus (after Sardana, 1965). Profuse hemorrhage will likely occur from the internal maxillary artery, which will require occlusion with clips. If the angiofibroma extends into or arises in the antrum, a Caldwell-Luc (see Fig. 5-2) approach is ideal both for removal of the antral tumor as well as ligation of the internal maxillary artery. The latter is performed first. With communication into the nasal cavity and the nasopharynx and/or sphenoidal sinus the Denker (see Fig. 6-lD) type operation is the procedure of choice.
G
the need
resection.
H, I Anterior and posterior packing has been inserted depending on the hemostasis necessary. Closure consists of the best possible approximation of the mucous membrane of the floor of the nose. The palatal flap is sutured with 4-0 nylon to the gingival mucous membrane. Care in closure is important to avoid oronasal fistula formation.
The canine fossa incision is extended across the midline, thus obviating type incision.
The completed
for a Weber-Fergusson
J
E Depicted is a tumor arising from the left posterior nasal cavity and the left side of the nasopharynx. The
If pressure is required to maintain the palatal flap in position, this is achieved by securing gauze or cotton soaked in liquid antibiotic or nitrofurazone (Furacin) ointment with cross sutures of 3-0 nylon passed around the teeth. When this is bulky and there is any question
septum is displaced to the right and the turbinate
of postoperative
to
indicated.
the left.
F
FIGURE 6-9 Continued
bleeding,
an elective tracheostomy
is
THE NOSE AND THE NASOPHARYNX
G
J
FIGURE 6-9 Continued
THE NOSE AND THE NASOPHARYNX
Transmaxillary Approach to Nasopharynx and Base of the Skull (Fig. 6-10) (Modified Denker) Following the basic technique of a Caldwell-Luc antrotomy (see Fig. 5-2), the cheek flap is further elevated to expose the lateral wall of the antrum and a portion of the zygoma by extending the gingivobuccal incision line and the midline. The vertical nasolabial portion of the Weber-Dieffenbach incision (see Fig. 5-9A-F) may very rarely be necessary for the additional exposure. The major portion of the bony anterior wall and a portion of the lateral wall of the antrum is removed depending on the exposure necessary. The lateral bony transection approximates the zygoma-maxillary suture line. The infraorbital rim, infraorbital nerve, and floor of the orbit are all preserved.
The medial wall of the antrum is removed, exposing the middle turbinate above and the nasal septum farther medially. The middle turbinate can be removed, thus exenterating the ethmoidal sinus. Care is taken not to enter the orbital floor or the medial wall of the orbit. This exposure thus leads to the nasopharynx and to the sella turcica via the sphenoidal sinus. As the procedure is extended posteriorly, the posterior ethmoidal sinus becomes narrower. Hence the exenteration of any posterior ethmoidal cells must be medial and not lateral to avoid injury to the internal carotid artery and the optic nerve (see Figs. 1-2, 1-3, and 1-7). The internal carotid artery may not be covered with bone as it traverses the sphenoidal sinus; 20% to 30% of cases have bony dehiscence over the internal carotid artery in the sphenoidal sinus. In addition, the superior extent of the posterior ethmoidal sinus may be above the level of the cribriform plate.
MIDDLE TURBINATE NASAL SEPTUM
FIGURE 6-10
THE NOSE AND THE NASOPHARYNX
Posterior Choanal Atresia (Fig. 6-11) (After Beinfield, 1961 and 1965) Newborn and Young Children Highpoints
1. Bilateral choanal atresia is usually an airway emergency (the newborn usually breathes through the nose). Use an oropharyngeal airway until the infant is brought to the operating room. 2. Extreme care is needed not to injure the spinal cord between the axis and the atlas. 3. Extreme care is needed not to injure the base of the skull. 4. Mark instrument-curet and sound-from tip along shank to a distance of 4.4 em. This will indicate the distance of the posterior pharyngeal wall to the edge of the anterior nares along the floor of the nose. A safe distance more superiorly is reduced to 3.2 em.
29S
S. The atresia can be unilateral or bilateral; it can be bony or simply membranous. 6. General oral endotracheal anesthesia is preferred, supplemented with topical cocaine 10% and a vasoconstrictor. 7. Postoperative care is important to keep indwelling tubes patent. 8. Other congenital anomalies may be present. Described is the technique for bony atresia. Membranous atresia is treated in basically the same fashion, eliminating the steps for removal of the bony portion. Yet with membranous atresia, a certain degree of bony stenosis can be present and this requires the steps referable to bony atresia. Diagnosis is made by the inability to pass a nasopharyngeal catheter. Contrast material instilled in the nasal cavity with radiographs can be used to confirm the diagnosis. This is especially useful in older children and adults in whom the differential diagnosis may involve benign and malignant neoplasms.
THE NOSE AND THE NASOPHARYNX
Older Children and Adults
Posterior Choanal Atresia (Continued) (Fig. 6-11) (After Beinfield, 1961 and 1965) A Using either a No. 8 urethral sound or a No. 2 Lempert type mastoid curet, an initial opening is made through the nasal mucous membrane overlying the bony wall itself. The shank of the instrument is marked 3.2 cm and 4.4 cm from the tip to avoid injury to the posterior pharyngeal wall, spinal cord, or base of the skull. Keep the instrument along the floor of the nose. Depicted is the use of the urethral sound. This is performed with the sense of touch. Direct vision is virtually impossible during this maneuver. A1 Technique of utilization of the mastoid curet. It must only be made in a downward direction. 8 If the posterior mucous membrane flap cannot be safely perforated as depicted with the urethral sound, a cruciate incision with a No. 11 or suitable ear knife is made (Bl). 81 Using an ear speculum and the operating microscope, visualization can be obtained and the incision made with a suitable microsurgery ear knife. After the
The technique used at the older ages usually is that of a transpalatine approach (see Fig. 6-9). In addition to the diagnostic measures described under infants, nasopharyngoscopy is routine. After exposure of the posterior choanal region via the transpalatine approach, the bony wall forming the atresia is excised. The posterior end of the nasal septum may require resection. Depicted in this plate is the midline incision; in Figure 6-9A to D is the palatal flap incision. Highpoints
1. Avoid injury to the pterygopalatine and posterior palatine canals. 2. Preserve as much nasal and juxtaposed mucous membrane as possible, using this retained tissue to line the raw edges of the resulting bone. Complications • • • • •
Cerebrospinal fluid leak Meningitis Hydrocephalus Pressure necrosis of anterior nares rim or columella Postoperative plug of indwelling tubes
opening is established, its diameter is increased by
• Extrusion of tubes
gradually using larger diameter urethral sounds up to
• Late stenosis • Regurgitation of feedings into nasopharynx-usually
size No.16, No. 18, or No. 20 French. Continued
transient • Aspiration of feedings. If this persists, an associated neuromuscular deficiency may exist-cricopharyngeus myotomy has been tried in one patient without success.
THE NOSE AND THE NASOPHARYNX
4.4cm
/
A
FIGURE 6-11
THE NOSE AND THE NASOPHARYNX
Posterior Choanal Atresia (Continued) (Fig. 6-11) (After Beinfield, 1961 and 1965) C A rubber catheter is then passed through the nose and retrieved through the mouth. A section of silicone rubber tube (No. 16 French) measuring 4.0 to 4.5 cm in length is then sutured to the distal end of the catheter. The inferior aspect of the distal end (posterior end) of the silicone rubber tube is transected obliquely to increase the size of the lumen and also to prevent the end of the tube from being obstructed by the posterior nasopharyngeal wall. Then the tube is pulled into place by withdrawing the catheter. Ideally, this maneuver pulls the posterior mucous membrane edges into the newly formed posterior nares. D If bilateral, the same procedure is performed on the opposite side. Both tubes are sutured together with 4-0 nylon across the anterior portion of the columella with suitable padding of the columella to prevent pressure necrosis. Neosporin (polymyxin B/neomycin/ bacitracin) or chlortetracycline (iodoform) ointment is used liberally at this juncture and continued postoperatively. The presenting end (anterior) of the tube is lodged just within the alar rim to minimize necrosis of the rim. This end of the tube must be carefully observed so that it is not obstructed by the alar rim.
Postoperatively, ultrasonic mist and meticulous nursing care with suctioning of the tubes are mandatory. Gavage feeding may be necessary for days or weeks. The tubes are left in place from 3 to 8 weeks, depending on the healing progress. E After the posterior portion of the hard palate has been exposed and the soft palate mucosa incised and a cleavage plane developed between the mucosa and palatal muscles (see Fig. 6-9A to D), the bony portion of the hard palate is removed, as depicted by the dotted lines. The underlying mucoperiosteum should be preserved to form flaps. F The bony atresia has been excised and the mucoperiosteal flaps formed. A Silastic tube is shown on one side, with the flap on its inferior aspect. These flaps are so placed to aid in lining the new choana, which helps in the prevention of subsequent stenosis. G The palatine incision is then closed. The tubes can be secured anteriorly as in the infant or with throughand-through sutures of nylon at the columella end of the septum. The postoperative care of the tubes should be meticulous. They are left in place for about 1 month's time.
THE NOSE AND THE NASOPHARYNX
D
E
G FIGURE 6-11 Continued
THE NOSE AND THE NASOPHARYNX
Submucous Resection of Nasal Septum (Fig. 6-12) Highpoints I. 2. 3. 4.
Subperichondrial plane of separation is necessary. Leave adequate support dorsally and distally. Avoid fracture of cribriform plate of ethmoid. Secondary procedures on septum are difficult; hence, perform a complete operation at the first sitting. S. Be certain that there is no impingement of the orifice of the nasofrontal duct by the deviated septum. Anterior portion of middle turbinate may require resection. Comment
Some surgeons are of the belief that this standard submucous resection of the nasal septum should be replaced by septoplasty (see Figs. 6-13 and 6-14). It appears that each procedure has its merits and indications and that more often than not an operation combining both techniques is ideal. Complications • Saddleback deformity. This may occur many years later. • Septal hematoma • Collapse of nasal tip and columella • Nasal obstruction-incomplete resection • Mucosal tear-if feasible repair with fine chromic catgut. Teflon splints will likewise aid in coapting mucosa. • Toxic shock syndrome-following any nasal packing (see p. 274) • Septal perforation. If troublesome, a Silas tic button may be used. • Cartilage and bone may have "memory" to return to original deformed position.
A, AlAn incision using either a No. 15 blade or a No. 66 Beaver blade is made 12 to 16 mm from the distal end of the septum using the index finger in the opposite naris as support. The incision extends through mucosa and perichondrium but not through cartilage. B, B1 With a small curet or curved elevator with the concavity facing medially, the white glistening cartilage is exposed. This marks the correct subperichondrial plane of separation of the mucoperichondrium. Again, the index finger in the opposite naris lends support to initiate this step. C, C1 Elevation of the mucoperichondrium and mucoperiosteum is then completed by carefully hugging the cartilage and bone. At times this blunt separation fails at an old fracture site or ridge. Sharp dissection may be necessary. Care must be taken not to puncture or to tear the mucoperichondrium and mucoperiosteum. This may occur owing to infolding of the mucosa into a previous fracture of bone or cartilage. Sharp dissection may be necessary at this point (see Fig. 6-13Al). Take care when using suction, because the suction tip can easily tear the mucosa. If a tear does occur, satisfactory healing usually takes place if the mucosa on the opposite side is intact. D, D1 The cartilage is then incised through the original incision. Extreme caution is necessary to avoid a counter incision in the opposite perichondrium. The index finger is an excellent guard, for as soon as the knife blade reaches the perichondrium it may be felt. If the mucoperichondrium is cut, the defect should be sutured, along with the main incision on the opposite side; otherwise, a perforation may persist. E, E1 Using the small curet or curved elevator with the concavity facing the midline, the perichon-drium and periosteum are elevated in the same way as on the left side. Elevation of the mucoperichondrium and mucoperiosteum should extend beyond the deviated area to be resected.
Continued
THE NOSE AND THE NASOPHARYNX
FIGURE 6-12
THE NOSE AND THE NASOPHARYNX
Submucous Resection of Nasal Septum (Continued) (Fig. 6-12) F In preparation for the Ballenger swivel knife, a small cut is made with scissors at the superior edge of the incised cartilage. G, G 1 The swivel knife is placed at this cut straddling the cartilage. Before the knife is pushed backward and upward, make certain that no portion of mucoperichondrium or mucoperiosteum is caught on the edge of the knife. The knife is then advanced to the bony septum and follows this junction downward to the vomer bone and then anteriorly. The freed cartilage is removed with forceps. H Cartilage-cutting forceps (McCoy) or duckbill forceps (Watson-Williams) allow for the removal of any remaining cartilage as well as portions of the perpendicular plate of the ethmoid and vomer. A portion of septum 12 to 16 mm wide must be left dorsally to support the bridge of the nose. When removing the deviated portion of the perpendicular plate of the ethmoid, the cribriform plate of the ethmoid must not be injured. Proper use of the bone forceps is necessary. Fragments are not avulsed; small complete bits are 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 . forceps, because the mucoperiosteum may be adherent in several areas and require sharp separation. A Jansen-Middleton spoon-shaped biting double-action forceps is also excellent for this stage. I Inferiorly, portions of a broadened vomer or ridge are difficult to remove with forceps. Decussation of the periosteum and perichondrium at this point is best separated by sharp dissection (see Fig. 6-13Al). An open, sharp, ring curet placed posteriorly and drawn forward
often removes this bone and cartilage. Again, one must be certain that no mucoperiosteum is adherent.
J
Occasionally, an osteotome is necessary to remove a thick bony ridge along the base of the septum. A free septal cartilage graft is then reinserted to support the anterior portion of the septum so further support is given the dorsum of the nose. Anterior to the dotted line is the critical area for support; posterior to the dotted line no support is necessary (Tardy et aI., 1985). A septal cartilage graft can be added to the anterior area. The septal flaps are coapted and the incision approximated with 4-0 nylon. Two techniques are available:
K A specially designed (Lore, Sr.) septal hollow needle with suture material already threaded is inserted as depicted. The free posterior end is grasped with forceps, and the needle is withdrawn. L
The knot is tied anteriorly.
M If such a needle is not available, the incision and anterior portion of the septum are approximated with one or two through-and-through sutures. In each case, a portion of the anterior cartilage strut is included in the suture. These sutures are removed in 3 to 7 days.
Teflon splints are now used routinely (see Fig. 6-131 and L) to coapt the flaps and to control bleeding. Onehalf inch gauze impregnated with antibiotic ointment is inserted in both nares to add support to approximate the flaps. This packing is removed the following day. If the flaps appear to separate-this will not occur if the Teflon splints (see Fig. 6-13) or the septal needle has been used-the packing may be reinserted. Johnson (1971) reports the use of small suction catheters inserted under the septal flaps. These are connected to suction, thus removing serum and approximating the flaps.
THE NOSE AND THE NASOPHARYNX
J wab~ FIGURE 6-12 Continued
THE NOSE AND THE NASOPHARYNX
Septoplasty Type I (Fig. 6-13) soft and soft the
(After Gorney, 1962) Highpoints 1. Prime indications are external nasal deformity due to deviated septum and dislocated columella. Some surgeons have substituted septoplasty for the classical submucous resection. 2. Complete mobilization of all deformed cartilage-do not depend on stents and sutures to correct deformity. 3. Precise realignment and bone have a 4. 5.
6. 7. 8.
of mobilized
cartilage.
Cartilage
memory to return to their original
deformed position! Provide adequate cartilaginous support for tip and bridge of the nose. Wherever possible, leave a portion of mucoperichondrium attached to mobilized cartilage to ensure complete viability of cartilage. A rhinoplasty is necessary if part of the deformity is caused by displacement of the bony framework. Study Figure 6-13G because it is very important. Suture the base of the caudal supporting strut of cartilage to the anterior nasal spine with buried 5-0 nylon (see Fig. 6-13M and N).
A An incision is made along the dotted caudal end of the deviated septum.
line at the
A 1 If an inferior obstructing septal ridge is present, it will often consist of both cartilage and bone. The perichondrium and periosteum decussate at the point where cartilage meets bone. This prevents the elevation of the mucoperichondrium and mucoperiosteum by blunt dissection with the elevator (nasal freer). Hence, sharp dissection is necessary, as depicted along the dotted lines. The deviated bone is removed with the osteotome at the site of the solid horizontal line. The deviated septum is shown, causing the external nasal deformity. The dotted line depicts a portion of the alar cartilage, which may require excision depending on an associated tip deformity. In similar fashion a portion of the upper lateral nasal cartilage may require excision (see Fig. 6-14M and N). B
C The caudal end of the septum is exposed. Unilateral or bilateral tunnels can be developed for additional exposure. Cl The incision commences on the left side of the caudal end of the septum. The initial separation of the
tissue from the septum requires sharp dissection may be difficult. Take care not to fragment the tissue. This may be made on the right side when deviation is to the right.
D The dotted lines depict the extent of the of the mucoperichondrium. It will be noted mucoperichondrium is not elevated from the of the most caudal portion (1) of the septum
elevation that the right side to ensure
viability of this most important section of the nasal septum. The next section of cartilage (2) may be swung into alignment with complete mobilization or be excised or be used as a free graft. If it is swung into alignment, a vertical strip of cartilage between section 2 must be excised to prevent overriding sections of cartilage. If section 3 is deviated, is removed as in a standard submucous the nasal septum. Another method of correcting a twisted lage is depicted in Figure 6-1 3pl and Pll.
1 and section of the two this portion resection of septal carti-
E Lateral view depicting the comparable sections of cartilage corresponding to D. The inferior and superior incisions mobilizing the septal cartilage depend on the type and extent of deviation. The solid line on the superior portion of cartilage (section 1) refers to the incisions between the lateral nasal cartilages and the septum. Details of this are in G and H. These incisions extend posteriorly only as far as is necessary to free the caudal section 1 so that it will realign in the midline. These incisions may be made with scissors as depicted or with a No. 11 blade knife. If made with scissors, the mucosa is elevated and preserved. If there is any ques-tion of stability, a suture is placed as in H, with reposi-tioning of the relationship of the septal cartilage to the lateral nasal cartilage as depicted. It is at this stage that a portion of the alar cartilage may require excision as outlined in B. All sections of cartilage must be freely mobile for realignment. Adequate support along the most caudal end (section 1 and section 2) and the bridge of the nose must be ensured. If a simultaneous or second-stage rhinoplasty is performed, these dic-tums are most important. By and large a one-stage septorhinoplasty rather than a twostage procedure is preferred (Tardy et aI., 1985). F At the close of the operation, realignment of the nasal septum must be independent of any packing or splints or sutures. These supports are used mainly for immobilization and prevention of hematomas, much as a plaster cast is used in the treatment of Colles' fracture (i.e., immobilization but not reduction). Depicted is the use of Teflon splints to achieve this
THE NOSE AND THE NASOPHARYNX
A
CI
3,
I
D
!
F
G
H FIGURE 6-13
immobilization. They are secured in position with through-and-through 4-0 nylon sutures. Details of the use of these splints are shown in Figure 6-131 to L.
degree of caudal external deformity; otherwise, the septal cartilage will most likely assume its original deviated position days or weeks postoperatively.
G Incision is made between the lateral nasal cartilage and the septum. This step is most important with any
H
Suture supporting repositioned cartilages.
Continued
THE NOSE AND THE NASOPHARYNX
Septoplasty Type I (Continued) (Fig. 6-13) (Gorney, 1962) Teflon Splint I Outline of a typical Teflon splint cut to size of patient's nasal cavity after the technique of Johnson. The Teflon is from 0.022 (less than 1 mm) to 0.034 inch (about 1 mm) in thickness; the holes are made with an ordinary leather or paper punch. The holes are optional and are usually omitted. A smooth lateral bend at the caudal inferior end of the splint is made with a clamp. This prevents the base of the caudal end from cutting into the soft tissue (see also Fig. 6-13L). Pink dental wax as well as Silastic may also be used.
J
To prevent overriding of the sections of cartilage, especially when no splint is used, a 4-0 nylon suture can be placed as depicted following the technique of Wright.
K, L Details of placement of the Teflon splint. Also shown is another variety of cartilaginous sutures that help prevent overriding of sections of cartilage. A ring curet can be used to set the knot when the suture is placed deep in the nasal cavity (Johnson, 1971). Or, the tip of the needle can be inserted into the turbinate after it passes through the septum to localize the needle. The needle tip is then removed from the turbinate. Because there is usually no bleeding with the use of splints, intranasal packing is not necessary. The splints may be left in place for up to 2 weeks. Care must be exercised to avoid any pressure points along the edges of the splint. A suitable surgical ointment is applied to the splints at the time of insertion and postoperatively along the free presenting edges, especially at the inferior (base) aspect of the columella. These splints should protrude several millimeters distally beyond the columella. This will prevent undue pressure on the mucoperichondrium of the nasal septum. The sutures should not be tight. They should
be relatively loose, and their purpose is mainly just to hold the splints in position as far as dislodging them posteriorly is concerned. One surgeon has reported slough of the mucoperichondrium following the use of splints. This may have been the result of excess pressure due to tight sutures. Correction of Septal Cartilage and Anterior Nasal Spine Deformity
M When the inferior portion of the caudal end of the septum is overriding the anterior nasal spine or maxillary crest, fixation of the realigned septal cartilage is necessary. This is achieved by drilling a hole using a sturdy Keith needle through the spine or crest. Exposure is either through an existing incision with a tunnel at the base of the spine and the floor of the node or through a sublabial incision. N Fixation of the cartilage to the spine or crest is then secured with a buried 4-0 or 5-0 nylon suture.
o When the septum is arched in its superior-inferior axis at the caudal end, the mucoperichondrium being elevated, a section of cartilage is removed. The septal nasal spine relationship is corrected. If the normal V-shaped approximation is absent and this becomes necessary to maintain the position of the cartilage, the spine is reconstructed in V fashion. P
A 4-0 or 5-0 nylon suture is buried beneath the mucosa for fixation. A Teflon splint is usually necessary to maintain the superior and inferior sections of the nasal septum.
Pl Numerous types of deformities can occur at the region of the anterior nasal spine. Depicted is a deviated caudal end of the cartilage resting on a ridge of the spine. This ridge (hatched area) can be removed and the base of the caudal end of the septum then sutured to the main portion of the nasal spine as depicted in steps M and N. A wedge of cartilage is excised from the nasal septum to facilitate its realignment to the spine. Continued
THE NOSE AND THE NASOPHARYNX
TEFLON SPLINT
J
K pili
!!
M
N
o FIGURE6-13 Continued
p
pi
307
THE NOSE AND THE NASOPHARYNX
Septoplasty
Type I (Continued)
Composite Lateral View of Reconstructed Septum
(Fig. 6-13) (Gorney, 1962) Other deformities can occur where the anterior nasal spine is not located in the midline. Several methods can be used to correct this deformity. One is to take the base of the caudal end of the septum and to suture it to the medial side of the anterior nasal spine. This will realign the caudal end of the septum in the midline. Another method is to move the entire nasal spine in the midline and to secure it in position with buried 5-0 or
4-0 nylon sutures, The correction of this deformity may require a sublabial incision. If the nasolabial angle is too obtuse, then an inferior edge of the nasal spine along with the juxtaposed base of the caudal end of the septum can be removed; this will decrease the nasolabial angle. Various other types of modifications may be necessary at this area of the septoplasty. Detailed descriptions of all the various types of modifications and corrections are virtually impossible here, because they can be so numerous. Ingenuity and use of the described basic techniques can, for the most part, correct these deformities. Consideration must be given in realigning the base of the caudal end of the supporting strut in that the posterior aspect of this strut must likewise be very carefully realigned, because at a later date this portion of the cartilage may assume its original deviated position.
P2 An cartilage from the made on
alternate method for correction of septal (Fry) involves removing wedges of cartilage convex surface while interposing incisions are the concave surface.
P3 The straightened cartilage. The problem with any corrective surgery of cartilage is the "memory" of cartilage, which has a tendency to cause the cartilage to return to its original deformed position. Intact mucoperichondrium contributes to this "memory." Teflon splints may be of aid in preventing this complication.
Occasionally,the deviated caudal end of the septum resists all the previously described techniques. In such circumstances an incision through the cartilage bridge at point X is made to straighten the caudal end of the septum. This incision may be made through only the cartilage or, if the mucoperichondrium is not elevated in this area, the incision may be made through the mucoperichondrium on one side. Ifthe cartilage edges are very loose, a suture of buried 4-0 nylon is used to Q
prevent overriding as shown in the illustration. Shown also isthe suture through the inferior edge of the caudal strut and the anterior nasal spine. To lend additional support, a cartilage graft from the removed or mobilized septum is placed as depicted. Teflon splints are used to maintain the position during the healing period. Closure of the wounds is similar to that illustrated in Figure 6-12F to M. It is important to excise any bulky soft tissue at the columella (see Fig. 6-14C). Another incision at point Y may be necessary to further realign a deformed nasal septum. Suture is usually not feasible, but if feasible it does have the advantage of preventing misalignment of the dorsum of the nose. With such cartilaginous incisions, a simultaneous rhinoplasty may not be advisable. A septal crushing mold or clamp can also be utilized to re-form severely deviated cartilage before the cartilage is reinserted as a free graft.
R The stippled area depicts the bilateral tunnels that are formed at the base of the nasal septum, elevating the mucoperiosteum from the nasal spine as well as the floor of the nose. This elevation can then be carried along the cartilaginous septum. The approach to developing these tunnels can be either through the nares or by exposing the floor of the nose and nasal spine via an incision along the alveolar labial groove elevating the lip.
THE NOSE AND THE NASOPHARYNX
CARTILAGE GRAFT
R
Q I
FIGURE 6-13 Continued
THE NOSE AND THE NASOPHARYNX
Septoplasty
Type II (Fig. 6-14)
Occasionally, external nasal deformity is due solely or primarily to a severely deviated septum. Correction depends on realignment of the septum. If there is associated bony deformity in the adult, it is corrected by the usual rhinoplasty (see Figs. 6-15 and 6-16). Highpoints 1. Complete mobilization of the deviated septum is obtained. 2. Preservation of as much cartilage as possible is done. 3. If possible, mucoperichondrium is left at least partially attached to one side of the mobilized septal cartilage. Complications • • • • •
Saddleback deformity (may occur many years later) Septal hematoma Collapse of nasal tip and columella Nasal obstruction-incomplete resection Mucosal tear-if feasible repair with fine chromic catgut. Teflon splints will likewise aid in coapting mucosa. • Toxic shock syndrome-following any nasal packing (see p. 274) • Septal perforation-if troublesome, a Silas tic button 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.
A The external nasal deformity is due to a deviated septum. B, C The usual incision for a submucous resection is made followed by elevation of mucoperichondrium on the left side (see Fig. 6-12A to E). It is important to excise any excess soft tissue (C, point X) to reduce bulk. D A small right-angle knife is inserted under the elevated mucoperichondrium to the point of angulation of the septum. The cartilage is then transected along the dotted line leaving a narrow bridge of cartilage intact along the upper border (X). Partial incision of the narrow ridge of cartilage may be required at a later stage to permit the anterior portion of the septal cartilage to be swung and maintained in the midline. The base of the cartilage must likewise be transected along the dotted line. If the nasal spine and/or base of the vomer bone is significantly off center, this may require correction with a chisel (see Fig. 6-14]). Fixation of the anterior spine is then necessary. E Through the incision in the cartilage, the mucoperichondrium is elevated posteriorly on the opposite side if there is a posterior deviation that is causing obstruction.
Continued
THE NOSE AND THE NASOPHARYNX
Bony septum
Mucoperichondrium
Medial crura of alar cartilages
c
D FIGURE 6-14
THE NOSE AND THE NASOPHARYNX
Septoplasty
Type II (Continued)
(Fig. 6-14) F, G For a posterior deviation, a Ballenger swivel knife is used to remove the cartilaginous obstruction, whereas a McCoy forceps is used to remove the thin bony obstruction. Thicker bone requires the use of JansenMiddleton spoon-shaped forceps. H, I Using sharp and blunt dissection, the anterior portion of the septum and columella are mobilized at
the base down to the anterior nasal spine.
J
This anterior section of cartilage is then transected along its base. Tunnels are usually necessary for exposure. Occasionally, a sublabial approach is used. If a prominent bony ridge is present, this may require mobilization with a small curved chisel. The hinged anterior (lower) septal cartilage is then swung into the midline. If sufficient mobilization at the base has been done, the cartilage will stay in position. More than likely, however, the mucoperichondrium on the right side of the septum at the columella will pull the hinged cartilage out of line. This will require fixa-
tion of the cartilage with buried 4-0 or 5-0 nylon, as illustrated in Figure 6-13J to R.
THE NOSE AND THE NASOPHARYNX
FIGURE 6-14 Continued
THE NOSE AND THE NASOPHARYNX
Septoplasty
Type II (Continued)
(Fig. 6-14) K If this is the case, this mucoperichondrium will require partial elevation through a separate incision on the right side. This incision is made slightly more distally than its counter incision on the opposite side. An alternate step, which is preferred if the deviation of the anterior portion of septal cartilage is very severe, is the transfixion incision depicted in E and F of the standard rhinoplasty (see Fig. 6-15). If the transfixion incision is used, elevation of the mucoperichondrium on the right side of the anterior deviated portion of septum is performed through this incision. Hence, the additional incision depicted in K is.not necessary.With such severe deviation, additional elevation of the mucous membrane along the floor of the nose on the right side will be advantageous.
L The anterior septal cartilage is now swung into position. If the deviation is severe, the attachments of the lateral cartilages to the septum will require transection (Ll) with the use of a No. 11 blade knife (see Fig. 6-13G and H). M, N A triangular section along the medial edge of the left lateral nasal cartilage may require removal if it overlaps the newly aligned septum.
o
Transfixion sutures are placed anteriorly. The incisions in the septum, if gaping, are approximated with nylon. Packing of nitrofurazone-soaked or antibioticsoaked one-half inch gauze is inserted, and an external molded aluminum splint with sponge rubber or dental compound mold is used for support.
THE NOSE AND THE NASOPHARYNX
N
FIGURE 6-14 Continued
315
THE NOSE AND THE NASOPHARYNX
Rhinoplasty (Figs. 6-15 and 6-16) H/ghpo/nts
1. Perform subperichondrial and subperiosteal elevation for cartilage and bone to be either modified or excised. Elevation of periosteum (or perichondrium) should be minimal-limited to areas where bone (or cartilage) is to be removed or transected (Tardy et aI., 1985). 2. Excise the osteocartilaginous hump. Plan a nasal profile angle at the glabella (nasal dorsal profile) between 25 and 36 degrees (30 degrees is ideal). Be conservative in excising the hump. Removal of excessive hump is very difficult to correct. 3. When shortening the septum, if this is necessary, be certain that a careful estimate is made regarding the amount of septum excised. 4. When changing the nasolabial angle, be certain that the exact configuration of cartilage excised matches the correction desired (usually 90 degrees but can be up to 120 degrees). 5. Bilateral osteotomy of the nasal processes of the maxillae is done as close as possible to their bases or origins. 6. "Outfracture" the lateral bony walls before final shaping. 7. Be conservative in excision of any cartilage forming or supporting the nasal tip. 8. Preoperative photographs must be in the operating room with a careful analysis of deformity and a planned method of correction. 9. It is important to correct even a moderate deviation of the septum as a one-stage procedure (Tardy et al., 1985). This deviation of the septum may be a significant contribution to the external nasal deformity. The posterior portion of the septum can be removed; the anterior portion should be preserved! Basic Surgical Technique
At the present time there are a number of books solely dedicated to rhinoplasty that are recommended for "fine tuning" as well as other approaches.
A A schematic drawing shows the deformity of the hump along the bridge of the nose with the anatomic features of the osteocartilaginous framework superimposed. The dotted lines represent the lines of the saw cuts through bone and the incisions through cartilage, which also indicate Tardy and colleagues' (1985) modification of the osteotomies: "The majority of lateral osteotomies are best initiated on the ascending (frontal) process of the maxilla just at or above superior margin of the inferior turbinate" (see Fig. 6-16B), using an osteotome. A1 Depicted are the relationships of the cartilages forming the columella. B An incision is made intranasally between the lateral and alar cartilage bilaterally using a No. 11 blade knife. The incision is carried upward to start the separation of the lateral cartilage from its perichondrium. C This separation of cartilage and perichondrium is continued using a Joseph knife up to the nasal bone. At this level the tip of the knife raises the periosteum from the nasal bone. Minimal elevation of periosteum should be done, because intact periosteum acts as a splint (Tardy et aI., 1985). D A periosteal elevator (McKenty) is then inserted in the same plane, and the periosteum is elevated to the upper suture line of the nasal bone and to the midline. The only exception here might be in the case of an exceptionally large hump in which the overlying periosteum is removed with the hump to prevent regeneration of excess bone. Continued
THE NOSE AND THE NASOPHARYNX
, ,( "
NASAL FRONTAL SUTURE LINE Nasal bone
Excised hump
" Alar cartilage LATERAL CRUS
A
ALAR CARTILAGE MEDIAL CRUS
ALAR CARTILAGE LATERAL CRUS
SEPTUM
c
FIGURE 6-15
THE NOSE AND THE NASOPHARYNX
Rhinoplasty (Continued) (Figs. 6-15 and 6-16) E After the preceding steps are repeated on the opposite side, a button end knife initiates the so-called transfixion incision, which runs along the dorsal and distal borders of the septum. To commence this incision, a curved button end knife may be more adaptable. In either case, the knife is inserted in the original intercartilaginous incision on one side reaching and lying in the subperiosteal plane over the bony hump. The knife is then brought downward over the dorsum of the septum, thus transecting the attachment of the septum along its dorsal margin. When the knife reaches the level of the opposite intercartilaginous incision, the instrument is advanced through this incision and extended to the septal tip or angle. At this point the direction changes almost at a right angle, hugging the lower or distal margin of the septum. The apices of both nares are not retracted upward as in F so that the membranous distal end of the septum is placed on the stretch. In this manner the knife can follow the plane between the membranous and cartilaginous portions
H The bony hump is then sawed through from one side to another. This requires a saw cut from the opposite side. Both nasal bones and the dorsum of the septum are cut in this manner. The hump usually still has lower attachments of the lateral and septal cartilages that are not cut with the saw. A small curve button end knife is used to sever these attachments in a manner similar to its use in F.An osteotome may also be used to separate higher attachments. The hump is then removed with a clamp. An alternate method of removing the hump is with a chisel. Remember to be conservative in the amount of hump removed. It is very difficult to correct an overaggressive hump removal. I A sharp rasp is used to smooth any rough areas along the bony edges as well as to round the outer (dotted) edges of the cut surfaces of the nasal bones (11). The rasp must be used in single downward strokes and after each stroke the rasp should be cleaned of all bony fragments. Additional bone is removed at the nasal dorsal angle (glabella). This step is very important to avoid a "straight line" effect. At times this may be overlooked because of soft tissue edema.
of the septum, leaving the membranous septum caudad with the columella.
J
F
any irregularities of the lower portion of the incision that involves the septal and lateral cartilages. This may
The lower portion of this transfixion incision is
completed with a No.
11
blade knife or scissors down
The small curved button end knife is used to correct
require the use of scissors. It is important that following the use of the rasp and the button end knife all
to the anterior nasal spine.
fragments of bone and cartilage are removed; other-
G
A long narrow retractor (Aufricht)
exposes the
subperiosteal plane for the bayonet saw, which will be inserted through the intercartilaginous incision. Care must be taken not to injure or dull the teeth on the saw, at the same time avoiding entanglement with soft tissue.
wise, they may serve as a nidus for regeneration of bone and cartilage.
Continued
THE NOSE AND THE NASOPHARYNX
J
H
FIGURE 6-15 Continued
319
THE NOSE AND THE NASOPHARYNX
Rhinoplasty (Continued) (Figs. 6-15 and 6-1 6) K Any remaining attachments of the lateral cartilages to the septum are transected with scissors close to the septum. L The distal or lower margin of the septum is now delivered into one naris and a triangular section of cartilage with overlying mucoperichondrium is excised with scissors. The shape of this excised section depends on the relationship of the nasolabial angle (90 degrees). It is important to evaluate carefully the amount of shortening necessary to correct the existing deformity. This may be done by raising the tip along a fixed ruler and measuring the distance between the two points. Remember that excising an extra amount of the distal margin of the septum is nO assurance of a properly raised tip; it is catastrophic if too much is excised. L1 The septal angle or tip of the septum is then rounded with a No. 15 blade knife. A small section of mucoperichondrium is also trimmed back from this angle to prevent any untoward bulkiness at the tip.
A schematic drawing shows the portion of the lateral cartilage excised in the previous step. Again do not shorten this cartilage any more than is necessary. It is usually necessary to excise two triangular wedges of bone, one on either side of the septum at its juncture with the nasal bones. This step may be done at this stage of the operation or concomitantly with the "outfracturing" of the lateral bony nasal wall (see Ml
Fig. 6-15U).
N Using a narrow osteotome, a cut is made close to the septum. A saw can likewise be used to prepare for the fracture.
o
With the same osteotome, another cut is made close to the edge of the nasal bone. In such fashion, a wedge of bone is, one hopes, outlined and freed. (This wedge of bone is removed with a hemostat. The same procedure is performed on the opposite side.) P
The two wedges of bone are removed.
Q To expose the nasal (anterior) process of the
M As the tip is raised and the nOse shortened, there is usually a protrusion of the lower end of the lateral
maxilla for the lateral osteotomy, an incision is made in the pyriform recess that lies at the inferior margin of the nasal process. This incision is so directed that it 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
K
p
Q FIGURE6-15 Continued
THE NOSE AND THE NASOPHARYNX
Rhinoplasty
(Continued) (Figs. 6-15 and 6-16) R First a Joseph knife and then a periosteal elevator is inserted through the incision in the pyriform recess, and the periosteum is elevated along the base of the nasal (frontal) process of the maxilla up to its suture line with the frontal bone at the region of the inner canthus of the eye. This tunnel is as close to the base or origin of the nasal process as possible except that superiorly it is anterior enough so that the medial palpebral ligament is not detached. This ligament is attached to the nasal (frontal) process of the maxilla in front of the lacrimal groove. S Using a narrow retractor or curved saw protector, the bayonet saw is inserted through the subperiosteal tunnel. This is done with the same care as depicted in G when the saw was inserted for excision of the hump. T Keeping as close to the base or origin of the nasal (frontal) process of the maxilla as possible, this bone is sawed through at right angles to the body of the maxilla. An attempt is made to remove the "sawdust" 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. 6-16B to D). U The next step consists of the "outfracturing" of these two lateral bony frames, each consisting of the nasal bone and nasal process of the maxilla. This maneuver aids in the ultimate narrowing of the nasal bridge, because it usually establishes a clean fracture line along the region of the suture line between this lateral frame and the frontal bone. The outfracturing is accomplished by the insertion of an osteotome between the septum and the nasal bone. Several slight taps on the osteotome are made and then, using the septum as a fulcrum, the osteotome is moved laterally, thus pushing the nasal bones outward. Beware of a greenstick fracture. Some surgeons do not outfracture. V The lateral nasal frame on each side, which is now quite mobile, is fractured inward by pressure with the operator's thumbs. If mobility is incomplete on one side or the other, a Walsham nasal forceps or heavy
needle holder is used to grasp this lateral nasal frame and "outfracture" it again. The "infracturing" is repeated. The bridge of the nose is again evaluated for any rough or sharp edges, which now may be rounded to a pleasing contour. W Before the transfixion sutures are placed, evaluation of the hanging septum is made. This consists of an excessively deep columella made up of folds of skin and broad medial crura of the alar cartilages. An elliptical section of both skin and cartilage is excised as depicted by the dotted lines. The two transfixion sutures of 3-0 nylon are then inserted, being certain that there is good coaptation of the septal angle with the cartilages of the tip. These are through-and-through sutures joining the septum with mucoperichondrium and columella with skin. They are usually staggered so that when they are tied they will tend to raise the columella and thence the tip. A problem may arise with an eventually dropped tip after these sutures are removed. To minimize this complication, buried sutures of 6-0 nylon can be placed. These sutures are not removed.
Rhinoplasty Dressing X Nasal packing of one-half inch strip gauze impregnated with an antibiotic ointment or liquid nitrofurazone is then gently and rather loosely inserted into the nose. A small plastic tube can then be inserted along the floor of the nose on each side for breathing purposes. Some surgeons eliminate any intranasal packing. The skin is cleansed with hydrogen peroxide and water, dried, and then coated with tincture of benzoin or povidone-iodine (Betadine). Narrow strips of adhesive are then applied with one or two strips placed around the tip and the superior portion of the columella and then pinched at the tip (see Fig. 6-17D). Y A thin layer of lint, cottonoid material, or Telfa is placed over this adhesive dressing. Then a splint composed of a dental mold compound or soft malleable metal is used as an additional external protection. This external splint is held in place with adhesive strips as shown. Five to 7 days later, the splint is removed.
THE NOSE AND THE NASOPHARYNX
v
1/
1
/
I
I x
y FIGURE 6-15 Continued
.
323
THE NOSE AND THE NASOPHARYNX
Rhinoplasty
(Continued) (See Fig. 6-16)
perform the lateral osteotomy. As the osteotomy proceeds upward to the lacrimal groove it is curved anteriorly (dotted line). No guard is used on the osteotome. Thus, trauma and bleeding are reduced. The osteotome is sharpened before each operation. He prefers the 2-mm osteotome. Depicted is the relationship of the lacrimal groove (the site of the lacrimal sac) to the osteotomy. Although the proximity is striking, evidence of any significant and lasting damage has not been substantiated (Flowers and Anderson, 1968).
Complications • • • •
Dropped tip Broad nasal base Prominent nasal or dorsal frontal angle Saddleback deformity
Alternate Techniques of Rhinoplasty
A
Removal of the dorsal hump,
C Another technique for lateral osteotomy of a small power -d riven Seltzer saw.
especially if small,
can be performed entirely with an osteotome along the dotted line. A Hilger guarded osteotome is ideal for this purpose. Deepening of the nasofrontal angle at the glabella can also be achieved by use of an osteotome along the solid line.
D
is the use
Close-up of Seltzer saw.
E Cross section of correct (1) and incorrect (2) planes for the lateral osteotomy. The horizontal osteotomy facilitates support for the transected bone. The arrow shows the lack of support for the transected bone when the osteotomy is oblique.
B The lateral osteotomy can be accomplished with a guarded osteotome inserted in the pyriform recess. Tardy uses a micro-osteotome (2 to 3 mm wide) to
B
c
D
FIGURE 6-16
THE NOSE AND THE NASOPHARYNX
Correction of Broad Nasal Tip (Conservative Method) (Fig. 6-' 7) Highpoints 1. Elevate perichondrium on both surfaces of medial portion of lateral crura of alar cartilage to be excised. 2. Excise cartilage along medial and upper edges of lateral crura. 3. Be conservative in amount of cartilage excised. 4. The anterior or rim incision (1 in B) must be made at the free margin of the lateral crus and not at the margin of the nares.
A The dotted lines enclose the medial and upper portion of the lateral crus to be excised. B Three incisions are made in the roof of the vestibule. The posterior incision (2) is the intercartilaginous incision between the lateral and alar cartilages as done in
the standard rhinoplasty. The anterior incision (1) is along the lower margin of the alar cartilage and is known as the rim incision. The cartilage between these two incisions is separated subperichondrially on both surfaces. The medial incision (3) is made close to the septum and carried through the alar cartilage. External finger pressure over the alar cartilage aids in exposure and helps deliver the alar cartilage into the incision. During this maneuver, the cartilage is "turned upside down." C The medial and upper edges of the lateral crus of the alar cartilage are trimmed very conservatively. It is much safer to excise too little rather than too much cartilage; otherwise, a pinched tip will result. The same procedure is repeated on the opposite side. D Supportive narrow strip adhesive is utilized to coapt the cartilages by pinching the adhesive with a clamp.
/
D FIGURE 6-17
THE NOSE AND THE NASOPHARYNX
Augmentation
of Dorsum of Nose
(After Tardy et al., 1985) Probably the best source of material to correct a "saddleback" nose and other deficiencies of the dorsum and lateral portion of the nose is a section of the auricular cartilage. This section is the cavum between the antihelix and the crus helicis (see Fig. 12-12A). The cavum with perichondrium and some attached soft tissue can be removed through either an anterior or posterior approach (see Fig. 12-30, E, and G and Fig. 3-7). The important point to remember in the harvest of the cartilage is to preserve the entire antihelix and its superior and inferior support as well as the blood supply of the mobilized skin flap. If the patient is a child, at least one layer of perichondrium is left at the donor site. The cartilage and perichondrium and soft tissue thus removed are best not morselized. The appropriate shape and size is chosen in its natural form to augment the nasal deformity. A pocket is made in the nasal dorsum or lateral portion of the nose just large enough to facilitate the cartilage graft. The patient should be informed that the cartilage will be mobile and that this mobility is of no concern. The resulting scar on the auricle will barely be perceptible.
Additional Nasal Tip Procedures (Fig. 6-18) Highpoints
1. These are the same as under the conservative method (see Figs. 6-17 and 6-18). 2. If the dome of the lateral crus or the underlying perichondrium and skin of the vestibule are cut through completely, extreme care must be taken to prevent overriding of the cut edges of the cartilage. Complications • Pinched tip • Narrowed nares causing airway obstruction • Distortion and twisting of columella
A As in the previous conservative method, two initial incisions (Safian, 1935) are made. The anterior or rim incision (1) along the edge of the free margin of the lateral crus extending to the medial crus must not be along the extreme edge of the nares; otherwise, this soft tissue will contract and form a pinched or notched area. Another posterior incision (2) is the intercartilaginous incision (between the upper or posterior edge of the lateral crus of the alar cartilage and the quadrilateral or upper lateral cartilage). This is the same incision made in the standard rhinoplasty.
B
Using straight or angulated scissors, the soft tissue is separated subperichondrially along the outside, presenting portion of the dome of the lateral crus and of the medial crus of the alar cartilage. The locations of the initial incisions are shown and numbered as in A. C The dome is exposed. This is the site of the incision for resection of a portion of the cartilage. Again, it is emphasized that conservation of cartilage is recommended, because if too much cartilage is excised, a pinched tip will result, which is impossible to correct. Several modifications can be performed. D Depicted is a complete transection through the dome and underlying perichondrium and vestibular skin. The desired amount of cartilage and underlying soft tissue is then excised along the dotted line. This technique is indicated mainly in very broad and bulbous
tips. Care must be taken so that there is no subsequent overriding of the cut ends of the cartilage or displacement of either the medial or lateral crura. This error may cause distortion of the columella.
E A less radical type of cartilage incision is made as depicted. Here, the underlying soft tissue is neither incised nor excised. It will be noted that the cartilage excised is along the posterior or upper border of the cartilage, with a small rim of cartilage left intact along the anterior or lower border (rim) of the cartilage. F Depicted is the amount of cartilage excised according to Brown and McDowell (1958). G Depicted is the amount of cartilage excised according to Goldman (1952) and Fomon (1960).
THE NOSE AND THE NASOPHARYNX
B
c
EXCISED CARTILAGE
WabritU F
G FIGURE 6-18
327
THE NOSE AND THE NASOPHARYNX
Columellar Graft for Collapsed Nasal Tip (Fig. 6-19) There are two main causes of a collapsed nasal tip . Type I is entirely due to lack of septal support and is associated with a retracted columella. The second type is due to a congenitally shortened columella associated with lack of septal support. In either case a columellar cartilage graft is necessary. Columellar grafts are also used in total and subtotal nasal reconstruction. The technique of obtaining a section of costochondral cartilage is shown in Figure 3-5.
Type I Highpoints
1. Graft is autogenous cartilage or bone. Autogenous cartilage is preferred. 2. Place graft anterior to medial crura of alar cartilages. 3. Cartilage graft may have layer of perichondrium attached. This, however, may cause warping. Gibson shapes cartilage grafts by trimming equal portions on each side of the graft. Type II Highpoints
1. Lengthen skin of columella.
2. The cartilage graft should have a layer of perichondrium attached. This is controversial.
A Through an incision made anterior to the medial crura of the alar cartilages, a tunnel is developed down to and anterior to the anterior nasal spine. The tunnel is extended upward into the bulk of the nasal tip but not so far that the end of the cartilage graft will be noticed subcutaneously. B A thin strut of cartilage with attached perichondrium is then inserted in this tunnel. An anchor mattress suture of 4-0 nylon is placed through the base of the graft and brought out through the skin of the columella. This suture is tied over a small rubber or plastic bootie. The lateral incision is approximated with fine sutures.
Complications
• • • •
Absorption and/or warping of cartilage or bone graft Rejection of Silastic graft Dislocation of any type of graft Pressure on skin causing skin necrosis C Collapsed nasal tip due to congenitally short columella. During previous surgery, the septum was shortened in an attempt to correct the deformity. There is an associated lack of cartilaginous support. D Skin incisions to lengthen the skin of the columella and expose the area for a cartilage graft. E The soft tissue of the columella is freed and reflected upward. The medial crura of the alar cartilages are included in this columellar flap. The distal end of the septum is exposed if present. F After a tunnel is opened down to and anterior to the anterior nasal spine, a slit-like pocket is made in the bulk of the nasal tip. An anchor suture of 4-0 chromic catgut or 5-0 nylon secures the upper end of the cartilage graft. This suture is buried and remains. G Additional sutures of 4-0 or 5-0 chromic catgut are placed to support the graft. These sutures grasp a portion of the perichondrium of the septal cartilage on either side. They straddle the graft but are not placed through the graft. H Two or three of these straddling sutures are utilized. They are entirely buried and remain. I The lateral margins of the upper lip defect are first approximated with deep sutures of 4-0 or 5-0 chromic catgut. The skin is closed with 5-0 nylon. The usual rhinoplasty splint and nasal packing with nitrofurazone (Furacin) strip gauze are used. The upper lip is best immobilized with adhesive, and the patient should be kept on liquids until healing occurs.
After any graft, primary healing may be delayed. The patient should be kept on antibiotics and liquids with the upper lip immobilized. Secondary healing occurs usually within 7 to 10 days.
THE NOSE AND THE NASOPHARYNX
A
, I
J
c
F
H
FIGURE 6-19
THE NOSE AND THE NASOPHARYNX
Nares and Columella Procedures (Fig. 6-20)
G Approximation of the baseand side of the columella is shown. At times the entire lip may require revision.
Correction of Bulbous and Flattened Nasal Tip Correction of Pinched Naris A
An ellipse of skin and subcutaneous tissue is excised.
B Closure is done with fine nylon. Lengthening of Skin of Columella C Using the principle of conversion of a V incision into a Y closure, the skin of the columella is lengthened. The entire tip of the nose may require mobilization by a transfixion incision as in a rhinoplasty (see Fig. 6-15E). Further support may necessitate the use of a cartilage strut. D The upper columella flap is raised, and all skin edges are approximated with fine nylon. Shortening of Columella E The skin of the entire columella is mobilized by a through-and-through incision. A small section of skin is excised, and the skin margins are approximated. Narrowing
a Flared Naris
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.
H This deformity is corrected by a simple Z-plasty. The lower edge of the ala is freed while a flap is developed in the nasolabial fold. I The ala exchanges places with the nasolabial flap. One or two deep sutures help secure the ala. The skin margins are then approximated. Straightening
a Slanted Columella
J
This deformity is usually associated with the socalled harelip nose, in which case a complete rhinoplasty is necessary.The skin of the columella, however, is corrected by utilization of a Z-plasty. The upper flap is in line with the slanted columella, whereas the lower flap is placed so that its right margin is to the right of center. In this manner, when the flaps are exchanged, there is a tendency toward slight overcorrection. K The flaps are exchanged approximated.
and skin margins
For enlargement of nares with Z-plasty see Figure 6-31G to I.
THE NOSE AND THE NASOPHARYNX
B
F
G
H
FIGURE 6-20
331
THE NOSE AND THE NASOPHARYNX
Nasofacial
and Nasolabial
Flaps
(Fig. 6-21)
D
The skin is approximated
with 5-0 nylon.
E
A skin incision is made as outlined.
Highpoints (Also see Figs. 6-22 and 6-23)
1. Skin on the nose is so fixed and inelastic that simple closure is virtually impossible. Rotating or advanced flap or skin graft is necessary. 2. Rotating flaps include same adipose tissue. A For lesions in the nasofacial sulcus, advanced flaps usually suffice. A wide elliptical incision is carried down to the periosteum or perichondrium, and the lesion is excised. B
The angular artery and vein are separately ligated.
C The lateral skin flap is widely undermined. If closure is still difficult, the lower portion of the lateral flap is advanced upward, as depicted by the arrow. The dogear at the superior margin is excised (dotted triangle). Several deep sutures are placed as shown in the inset (e1).
F The lesion has been excised, and the rotating flap is swung toward the defect. The lateral border of the donor site is mobilized. This facilitates closure of the donor site. Any dog-ear (X) at the superior margin of the donor site is excised. G Several deep sutures of 5-0 white silk or catgut are used. The skin is approximated with 5-0 nylon. A dogear at Y may require excision. H If the lesion is somewhat larger and lower on the nose, the reverse type of rotating flap is used. X and Y refer to dog-ears that may require excision. I The technique is identical to the preceding procedure. X and Y refer to dog-ears excised. The reader is referred to geometry Flap, Chapter 3, page 104.
of the Rhombic
THE NOSE AND THE NASOPHARYNX
o
FIGURE 6-21
333
THE NOSE AND THE NASOPHARYNX
Septal Flap for External Nasal Defect (Fig. 6-22) Through-and-through defects, surgical or traumatic, of the external nasal framework can be reconstructed in a number of ways: forehead flaps (see Figs. 6-29 and 8-12), sickle or scalping flaps (see Fig. 6-29), local turnin flaps (see Fig. 6-30), and arm flaps (see Fig. 6-27). The choice depends on a number of factors, such as size and location of defect and age of patient. In the older patient some type of forehead or scalp flap is preferred, whereas in the younger patient the use of a forehead flap is hardly justifiable because of the residual cosmetic deformity of the forehead. In the elderly an arm flap is contraindicated because of the danger of deltoid bursitis (supraspinatus tendonitis). Depicted is a septal flap that avoids both of the previous criticisms. The septal flap, however, results in a permanent septal perforation that is associated with crusting, bleeding, and possible chronic ulcerations along the margins of the perforation.
Highpoints 1. Use a full-thickness flap. 2. Leave adequate support along the bridge of nose and at the columella. 3. A second stage utilizes a full-thickness skin graft or local flap.
A Shown is a full-thickness defect of the external nasal framework. The dotted lines represent the area to be trimmed or excised. B Superior-based septal cartilage flap, including both sides of the mucoperichondrium.
C Cross-sectional view depicting the superior-based septal flap. The edges of the defect are trimmed along the dotted lines. D The flap is swung into the defect and sutured into position. The coapting edges of the flap are denuded of mucous membrane to facilitate adequate approximation to the edges of the defect. At a later stage the remaining portion of mucous membrane externally (but not the perichondrium) is excised and a full-thickness graft from the retroauricular region is applied over the perichondrium (see Fig. 6-25A to D). External covering can also be achieved with a rotation flap as described in E and F. E Superior-based nasolabial flap is elevated and rotated into defect. A cheek flap formed by an incision along the nasolabial fold is mobilized to close the donor site. Any resulting dog-ear (X) is excised. The distal end of the nasolabial flap may require excision, depending on the extent of the deformity. If a lesion is to be excised, a cotton-tipped applicator inserted into the nasal cavity will aid in affording counter pressure during the excision. F The completed closure using 5-0 nylon interrupted sutures. This procedure is well suited for non-through-andthrough defects resulting from excision of basal cell carcinoma of the skin. Through-and-through defects can also be closed with a nasolabial flap. The inner aspect of the flap can be lined with buccal mucosa or septal cartilage flap. Other modifications of this flap are depicted in Figure 6-21.
THE NOSE AND THE NASOPHARYNX
PERPENDICULAR PLATE OF THE ETHMOID
c
FIGURE 6-22
THE NOSE AND THE NASOPHARYNX
Nasolabial Flap (Fig. 6-23) Highpoints 1. Through-and-through excision is necessary of all malignant lesions. 2. Nasolabial turn-in flap forms inner nasal lining and skin covering. 3. If there is any question regarding adequate circulation, the operation is performed in stages. When the carcinoma of the columella is more extensive, then there is concern regarding the covering and masking of the resected area with a flap. The reconstruction can be achieved by a prosthetic replacement (see the section of Chapter 3 on maxillofacial prostheses by David Casey). The prosthesis can be easily removed and the operation site examined for any early recurrence. For additional surgery relative to carcinoma of nasal septum, see Figure 6-32.
Excision and Reconstruction of Ala Nasi A Note outline of skin incision for resection of the lateral portion of the ala nasi and nasolabial turn-in flap. The complete thickness of the ala nasi is resected along with a portion of the alar cartilage. The width of the turn-in flap should be slightly wider than the defect, especially at the site where it is folded on itself. When the nasolabial flap is elevated and folded, if there is any question regarding adequate circulation a delay is effected by returning the flap to its own bed for 10 to 14 days. The edges of the alar defect are closed by approximation of the inner nasal lining to the skin edges. B The nasolabial flap is turned in and folded on itself with the approximation of its raw surface. One or more sutures are placed within the nares to secure the end of the flap to its own base. Through-and-through sutures or a two-layer closure is used to approximate the edges.
C If the flap is large, a through-and-through mattress suture is placed in the middle of the flap over a rubber or plastic bootie. This type of suture, if the flap is made sufficiently wide, will tend to roll the fold in, simulating the natural roll of the ala nasi. The nasolabial donor site is closed in two layers by advancement of the cheek. Nitrofurazone-soaked cotton is firmly packed in the naris for support and pressure. External pressure is achieved with similar material. Another modification is the splitting of the distal end of the flap: one portion will form the ala nasi, and the other portion will close a defect of the floor of the nose or the upper lip (Krizek and Robson, 1973).
Excision and Reconstruction of Columella D The columella has been resected for a small localized squamous cell carcinoma. A long superior-based nasolabial flap has been elevated similar to that depicted in Figure 9-8 and partially rotated to replace the resected columella. The skin of the flap has formed the left side of the defect, whereas a split- or full-thickness skin graft has covered the bare side of the flap. This is the right side of the reconstructed columella. A cartilage strut placed either primarily or secondarily (see Fig. 6-19) may be necessary, depending on the amount of septum removed. The skin graft at the base of the flap serves as a temporary dressing that is excised when the flap is transected in several weeks' time. E The completed reconstruction is shown. The unutilized portion of the flap has been returned to the donor site. The donor site can barely be visualized if the flap has followed the natural skin folds comparable to the contralateral side.
A large nasolabial flap based inferiorly can be brought through a stab wound in the cheek to reconstruct portions of the floor of the mouth. The problem in this type of reconstruction is that if the patient has a full set of teeth, the teeth in fact may impair the blood supply to the flap.
THE NOSE AND THE NASOPHARYNX
o
E FIGURE 6-23
THE NOSE AND THE NASOPHARYNX
Resection of Tumor of Tip of Nose (Fig. 6-24) Most lesions in the region of the nasal tip can be excised, and the defect can be covered with a full-thickness skin graft (see Fig. 6-25). Highpoints 1. This technique is lesions in patients nasal tip. 2. Underlying cartilage 3. Closure follows the and shortening of Fig. 6-15A to Q).
adaptable for moderately large with a drooping or elongated can be excised. technique of nasal tip elevation the nose as in rhinoplasty (see
A The area excised is depicted by the oval incision. Underlying cartilage can be excised if necessary.
B An incision is made intra nasally between the lateral (upper) and alar cartilages bilaterally using a No. 11 blade knife. The incision is carried upward to start the separation of the lateral cartilage from its perichondrium. C The separation of the lateral cartilage from its perichondrium is continued using a Joseph knife up to the nasal bone. The lateral extent of the resected area is shown by the dotted line.
A No. 11 blade knife is inserted between the distal end of the septum and the columella, thus making a through-and-through incision that is extended downward to the base of the columella. E The distal end of the septum is delivered into the left naris, and a triangular section of septal cartilage with overlying mucoperichondrium is excised with scissors. This shortens the nose and raises the nasal tip, thus facilitating closure of the defect. F As the tip is raised and the nose is shortened, there is usually a protrusion of the lower end of the lateral cartilage through the intercartilaginous incision. This is excised. If the attachment of the lateral cartilages to the septum inhibits the raising of the tip, these attachments are transected (see Fig. 6-15K). G Two or three transfixion sutures of 3-0 or 4-0 nylon are utilized to approximate the columella to the distal end of the septum. These are placed in staggered fashion so as to raise the nasal tip. H The skin incision is then closed with fine nylon sutures. I If skin closure is under too much tension, a superior nasal flap is elevated with the excision of a triangle (Burow's triangle) of skin bilaterally.
J D After the previous steps are completed, on the 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.
The completed closure is shown with the superiorbased nasal flap pulled downward.
B
A FIGURE 6-24
THE NOSE AND THE NASOPHARYNX
\IIi
\uf >
c
D E
G
J
FIGURE 6-24 Continued
339
THE NOSE AND THE NASOPHARYNX
Resection and Reconstruction of Tumor of the Superior Dorsum of the Nose
The donor site defect is closed primarily by undermining the posterior skin border.
When the lesion is higher on the midportion of the dorsum, the reconstruction can be accomplished by using the rhombic geometric principles as depicted in Chapter 3 under Rhombic Flap, page 140. When the defect is large, an inferior-based midline forehead flap can be utilized (see Fig. 8-12).
B The lesion is then excised. If it is thought to be malignant, biopsy may be bypassed, with wide excision done as a primary procedure. In such cases deep excision and frozen section are mandatory. A stay suture rather than a forceps is used for traction. Absolute hemostasis is necessary.
Full-Thickness Graft to Nose (Fig. 6-25)
C The full-thickness graft is secured with 5-0 nylon with moderate tension on the graft. At least four of these sutures are left long to be used to hold the dressing in place. No incisions are made in the graft.
Indications • Basal cell carcinoma of the nose • Large benign skin lesions • Skin loss from trauma Highpoints 1. Take graft first when lesion is basal cell carcinoma. 2. Excise to perichondrium when lesion is basal cell carcinoma. 3. Use a pressure dressing. 4. Avoid use of forceps on graft. 5. More radical excision is usually necessary in squamous cell carcinoma.
A After determination of the size of the defect using an outline of methylene blue (alcohol solution), a fullthickness layer of skin is excised from the retroauricular region. All adipose tissue is removed from the graft.
D After all serum and blood are gently extruded from beneath the graft, a cotton pressure dressing is applied. The long sutures are tied over the dressing. The cotton has been previously soaked in liquid antibiotic or nitrofurazone ointment surgical dressing, the excess liquid having been pressed out and the cotton molded to the appropriate size and shape. The first dressing is done in 7 to 10 days. E TO G The same technique is used as the previous procedure. The excision is carried down to the periosteum when the lesion is basal cell carcinoma. If the tumor has reached the periosteum, then the periosteum is removed; If squamous cell carcinoma, then wider resection with the periosteum; if squamous cell carcinoma involves the periosteum, then the underlying bone is resected (see the section in Chapter 3 on bone imaging and pathology). For composite
graft from ear to nose, see Figure 6-26.
THE NOSE AND THE NASOPHARYNX
c
D
FIGURE 6-25
THE NOSE AND THE NASOPHARYNX
Composite Graft From Ear to Nose (Fig. 6-26) Highpoints 1. The graft consists of two layers of skin with a layer of cartilage in between. 2. Good blood supply is available at recipient site. 3. Very delicate care for the graft is necessary. Do not use forceps. 4. All edges of graft should be less than 1 cm from blood supply of the recipient area. Anesthesia Either general or local anesthesia is used. If local anesthesia is used, no solution is injected into the graft or recipient area. Complications • Partial or complete loss of graft • Deformed donor site with larger grafts when primary closure is attempted without a posterior auricular skin flap
A A liberal incision is made along the alar defect to a point at which there is a good blood supply and adequate thickness. This is most important. A narrow rim of scar tissue may even be excised if necessary. B The donor site is chosen along the edge of the helix of the ear at a site that corresponds to the normal ala. A pattern of the defect is then cut out of a piece of discarded sutUre or knife blade wrapper or sterile chamois. Using 5% alcoholic solution of methylene blue, the pattern is traced on the donor site. C With a 6-0 silk suture through an edge of the graft, a No. 11 blade knife is used to cut the helix. No forceps is placed on the graft; the cut is clean and deliberate. D
The recipient site is clean and the edges are sharp.
E With 6-0 silk sutures, the anterior edges of the skin are first approximated with very delicate care. F The graft is then gently everted using a cottontipped applicator. The posterior skin edges are approximated. G The completed graft is supported internally with cotton soaked with povidone-iodine or antibiotic oint-
ment liquid or impregnated with antibiotic ointment. Externally, a cottonoid also impregnated with povidoneiodine or antibiotic ointment is placed, over which loose cotton is laid. A splint of dental molding compound is then applied over this dressing to protect the graft. If the defect cannot be completely corrected, a subsequent composite graft is "piggy-backed" on the initial graft (Cosman, 1980) 6 months later. H If the defect in the helix is long, a posterior auricular skin flap is elevated, turned, and used to close the defect. I Several weeks later the flap is severed along the dotted line. This flap should be as wide as the hairline permits so that a rolled edge of skin may simulate the removed helix.
J,
K When the alar defect is narrower, a wedge of the helix is removed. If the defect at the donor site is short in length, it may also be converted into a wedge to facilitate primary closure . L The wedge defect is easily closed. The cosmetic result is excellent.
The first dressing may be delayed to the fifth or seventh day and then a similar dressing applied. Alternate sutures are removed at the 10th to 14th day. The remaining sutures are removed in 2 to 3 days. If the defect is large, a two-stage composite graft is used. A first graft is placed that is no wider than 1 cm at anyone point. Three to 4 months later a second composite graft is placed alongside the first graft. Composite grafts may also be used for small defects of the columella.
Type of Flap The surgeon should recognize the fundamental difference relative to the etiology of a defect, for example, trauma or secondary to ablative surgery for a malignant neoplasm. Briefly, avoid the use of flaps for the defects relative to ablative surgery where a prosthetic device will serve the same purpose. Whether the flap be a local transposition of tissue or a microvascular free flap depends on a number of factors: availability of microvascular technique; adequate artery and vein for blood supply; donor site; whether previous radiation therapy has exposed the recipient site or the donor site, which might interfere with the viability of the free flap; and cosmetic, functional, quality of life, and other factors.
THE NOSE AND THE NASOPHARYNX
A
G
J
\
\
\
K
FIGURE 6-26
343
THE NOSE AND THE NASOPHARYNX
Reconstruction of Nose With Arm Flap (Fig. 6-27) Highpoints 1. In young persons, an arm flap is preferred over a forehead flap, since it avoids a forehead scar. 2. Arm flaps should be avoided in the elderly and in those with bursitis. 3. Allow for 30% shrinkage of graft. 4. Allow additional length for folding over to form columella and ala nasi. This may eliminate the necessity of a cartilage graft at the tip. 5. Remove all subcutaneous fat from the graft. See also Figure 8-12. Complications • Bulky result • Color match possibly poor in adults
Note: With any procedure involving reconstruction of the distal end of the nose-nares and/or columellacustom-made silicon or acrylic resin nasal stents may be used to help form the nares and support the bridge of the nose as well as the columella (see the section in
Chapter 3 on maxillofacial prostheses by David Casey).
Full-thickness skin cleared of all subcutaneous adipose tissue is then elevated as a bipedicle flap; a 2-week delay ensues. Some surgeons will prefer a single pedicle flap as the first delaying procedure, with complete elevation of the distal or free end at this stage. If the bipedicle technique is used, after 2 weeks the distal or free end is severed. After another 2 weeks of delaynow we have a single pedicle flap in either case-the entire flap is elevated and returned to its bed and left until most of the edema has regressed. This takes 2 to 4 weeks. D The flap is now ready for transfer. The flap is elevated and split-thickness or dermal graft (free of hair) covers both the donor site and the raw surface of the flap except for edges along the distal end, which will be sutured to the nasal defect. It is well to use catgut sutures on this distal end, because the grafted surface will form the lining of the nose and be inaccessible for suture removal. The edges of the nasal defect are trimmed to expose normal healthy tissue. A generously bared area is important to receive and nurture the flap. By the same token, any portion of the splitthickness skin that lines the flap must be incised and any section must be excised that comes in contact with a bared area of the recipient site.
E The arm and forearm are immobilized in a plaster A The nasal defect consists of the loss of the entire right ala nasi, the nasal tip, and portions of the columella and left ala nasi. 8, C With the nasal defect primarily on the right side, the left arm is used as the donor site. A piece of chamois or other suitable material is used as a form to outline the size of the defect. An allowance is first made for 30% shrinkage, and another allowance is made for the length of the pedicle during transfer. The widest portion of the graft is at its base, because that will be used to form the ala nasi by turning in the edges. As a rule of thumb, this should be 7.5 em wide, whereas the free or distal end should be about 5 em wide. The length is from 12 to 15 em. These measurements may have to be modified depending on the defect, but remember that it is better to err with too large a graft than too small a one. The arm is then placed in position as in D, and the outline form is transferred to the donor site. The angle of the flap is approximately 30 degrees from the horizontal with the base toward the axilla. An area free of hair is desirable in which the texture of the skin simulates that of the remaining nose.
posterior mold splint. Circular plaster then is used to secure the forearm and arm to the head and shoulders and anchor them to the thorax. All pressure points and areas of contact should be previously well padded. F Transection of the pedicle is begun at the end of 2 weeks. This is done in stages during the next week by transecting one third at first, another third in 3 days, and the final third in 3 or 4 more days. Sufficient length is allowed for turn-in flaps to form the edges of the nares and columella. G The nares and columella are shaped after the edema has completely subsided. Final tailoring of these structures depends on defects. The columella will probably require a strut of autogenous cartilage for support. H The extent of the defect along the bridge and whether there is sufficient septal cartilage will govern the need for another cartilage graft to support the bridge. The nares will most likely require a Z-plasty at the apices to shape both a functional airway and natural external contour (see Fig. 6-31 G to I).
THE NOSE AND THE NASOPHARYNX
FIGURE 6-27
THE NOSE AND THE NASOPHARYNX
Nasal Reconstruction With Lateral Forehead Flap (Fig. 6-28) Highpoints 1. Plan forehead flap in such a manner that the returned pedicle and other rotated scalp flaps will cover the forehead donor site. Careful preoperative evaluation of the hairline in men and hairdressing styles in women will aid in this planning. 2. Delay flap three times and before transfer; wait until there is minimal edema. 3. That part of the flap to form the nose should include skin only, whereas the pedicle includes muscle and galea. 4. Line the future new nose flap with split-thickness or dermal skin graft or local turn-in flaps from remaining nose or face (see Fig. 6-30). S. A drawback is a scar on the forehead, which is unfavorable in a young patient. See also Figure 8-12. Complications • Bulky and edematous at nares, causing obstruction • Kinking of flap, causing vascular obstruction
airway
A The flap is outlined using the measurements depicted as a rule of thumb. The extent of the defect will change these measurements. Allow about 15% for shrinkage. At this stage only the upper and lower skin
tiona I length is needed, the upper or lower incision is extended at the base of the pedicie. Possibly only the galea need be incised, thus preserving the precious blood vessels. If desired and if the color of the flap is satisfactory, the lining for the future nose may now be grafted using split-thickness skin only where necessary. At the same time, the opposing donor site is grafted with thick split-thickness skin. The entire flap is then returned and sutured along its bed. The two skin grafts are now face to face. The only drawback may be the collection of some fluid at these graft sites. C After the edema has subsided-this may take up to 2 months-the flap is transferred. The columella is formed by folding over the projecting end of the flap and applying one or two mattress sutures with rubber or plastic booties. Be sure the skin is cleaned of all adipose tissue during this and the next step. The bare forehead donor site is covered with split-thickness skin. A relatively slender, strong strip of bone can act as a bridge support secured at the glabella and as a cantilever attached to the tip (Millard, 1967). Custommade silicone or acrylic resin nasal stents may be used to help form the nares. D The alae nasi are formed by turning in the edges and using mattress sutures with booties. E If a skin graft lining was not used in B, a lining splitthickness skin graft is now applied and held in place with several fine catgut sutures. In any case, the flap
margins are incised, leaving both ends intact. Along
must have bare areas at its point of contact with the
the pedicle portion, the incision is made down through
recipient
the galea while at the distal end, which will form the
be carefully freshened
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.
areas. In turn, these recipient and broadened
areas should if necessary to
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 to undermine the flap completely because there is no significant blood supply from the periosteum.
staged over a period of 1 week. The remaining portion of the flap is then returned to the forehead, removing the unwanted skin graft. The top wing of the V on the returned flap may be rotated downward to meet the lower wing.
Two weeks later the entire flap is elevated, swung into position, and evaluated regarding length. If addi-
B
THE NOSE AND THE NASOPHARYNX
FIGURE 6-28
347
THE NOSE AND THE NASOPHARYNX
Nasal Reconstruction With Combined Scalp and Forehead Flaps (Fig. 6-29) The Sickle Flap The technique of elevation, delay, shaping, and skin grafting is similar to that for the forehead flap, illustrated in detail in Figure 6-28.
Stages A, B
Stages of the technique.
1. Elevate flap between the two ends. 2. Two weeks later the distal or forehead end is transected. 3. Three weeks later the entire flap is elevated and returned to its bed. At this stage a split-thickness graft may be inserted as the lining of the future nose. 4. Six to 9 weeks later-after the edema has subsided-the flap is rotated into position over the nasal defect. 5. Three to 4 weeks later the pedicle is transected in V fashion. This may be staged over a I-week period. 6. Two to 4 weeks later refinement of the grafted nose is begun (see Fig. 6-31). 7. Blood supply is from the superficial temporal and posterior auricular arteries.
tumor, especially when the nasal mucosa is involved, is sound even though frozen section may have been used. Delay also allows skin grafting for the lining of the flap. Turn-in flaps at the site of the defect are not recommended in the surgery for a malignant tumor, because extension of disease at a later date may be masked. During this delay, the raw areas at the site of the nasal defect are covered with split-thickness skin.
C, C1 The flap is outlined and incised as depicted. The details of size and shape are as shown in Figure 6-28A. The distal end does not include the frontalis muscle, which is left in place, as is done in the other forehead and scalp flaps (see Fig. 6-28B). This minimizes the occurrence of a bulbous nose. The remainder of the flap includes all layers down to the periosteum. Hence, the frontalis muscle is split at the medial border of the free distal end so that it can be included in the base of the flap. D The entire flap is elevated and folded on itself, thus covering the major portion of the raw area of the flap. If any raw area remains, especially in the region where the flap crosses the brow and that portion of nose which is intact, split-thickness skin is used for cover. This is most important, because any raw area is susceptible to infection and troublesome drainage. The donor site is likewise skin grafted. E
The flap in position. The distal end forming
nose is shaped
as in Figure
the
6-28C to E. Take care to
The "Scalping" Flap (Converse, 1959)
avoid crossing and touching
The main difference
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 only one delay. If used for reconstruction after subtotal or total nasal resection for carcinoma, the flap is out-
in stages, if necessary. The final shaping follows the technique shown in Figure 6-31. When the flap is returned to the scalp, an attempt is made to adjust it so that a minimal forehead defect results.
in technique
lined and edges incised at the time of the resection. 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 is allowed for permanent histologic sections to be evaluated regarding adequacy of the resection for the carcinoma. This basic principle in the surgery of a malignant
the eyes.
Complications • Problems in shaping • Nasal obstruction
the ala nasi
THE NOSE AND THE NASOPHARYNX
c
FIGURE 6-29
THE NOSE AND THE NASOPHARYNX
Nasal Turn-in Flaps (Fig. 6-30) Indication • In total or subtotal loss of the nose, local turn-in serve as skin lining for the nasal cavity. The covering is obtained from an arm, forehead, or flap. Cartilage grafts are usually necessary for defects. Complications • Absorption of cartilage grafts • Contracture with nasal obstruction
flaps outer scalp large
A Four turn-in flaps are elevated and made as thin as possible. One flap above is brought down from the bridge. One flap below is turned up from the lip for the columella. Two lateral flaps are outlined and reflected from the nasolabial origins. B These flaps are then sutured to one another with 4-0 chromic catgut. If structural support is believed necessary, cartilage grafts are placed on the flaps. One strip is used for the bridge with or without a hinged portion for columella support. Cartilage grafts can also be placed for support of the ala nasi. A portion of the nasolabial defect and lip defect may be closed by advanced flaps. An arm, forehead, or scalp flap is now used for external cover (see Figs. 6-27 to 6-29).
THE NOSE AND THE NASOPHARYNX
FIGURE 6-30
351
THE NOSE AND THE NASOPHARYNX
Nasal Reconstruction
(Fig. 6-31)
Transection of Forehead and Scalp Pedicle A The pedicle of the forehead or scalp flap used for the reconstruction in subtotal or total loss of the nose is transected in 3 to 4 weeks in one or two stages. The method of Penn is ideal, because it acclimates the graft to the remaining portion of the nose. A V type of incision is used as depicted. B The V incision is beveled on the undercut so that a smooth approximation is facilitated along the dorsum (bridge) of the nose. C The completed closure.
approximation
results
Enlargement of Nares With Z-Plasty Proper shaping of the nares at the time of flap reconstruction is not always satisfactory. Revision is done at another stage using a modified Z-plasty. Such a deformity may also be congenital and is corrected in the same fashion.
in a T G A triangular flap of skin is first elevated with its base on the columella. Excess subcutaneous tissue is excised.
Revision of Nasolabial Fold and Ala Nasi D After subtotal or total nasal reconstruction, the lateral borders of the new nose usually require revision. The superior portion of the nasolabial fold may be retracted and too deep. The ala nasi may be too bulky. An incision is made as depicted. E Any excess subcutaneous lateral border of the ala nasi.
F The superior portion of the nasolabial fold is reapproximated with everting mattress sutures while the lateral borders of the ala nasi are reapproximated with simple sutures. If deepening of this lateral border is necessary, these sutures grasp the underlying tissue or even the periosteum. This will tend to invert and deepen the lateral sulcus.
H The lower flap is freed by an incision along the septum and then raised and sutured to the rim of the ala nasi. I The first flap is now swung in against the septum and sutured in place. The same steps are repeated on the opposite side. The nares are then firmly packed with nitrofurazone-soaked cotton.
tissue is excised at the For other Figure 6-20.
nares
and
columella
procedures,
see
THE NOSE AND THE NASOPHARYNX
D
E
F
FIGURE 6-31
THE NOSE AND THE NASOPHARYNX
Resection of Nasal Septum for Carcinoma (Lateral Rhinotomy Approach) (Fig. 6-32) Highpoints 1. Wide resection is performed of septum with adjacent floor of nose. 2. Electrosurgical cutting knife aids in control of hemorrhage when transecting mucous membrane. 3. Adequate visualization is mandatory. This usually requires lateral rhinotomy to evaluate the gross extent of tumor, especially in reference to the floor of the nose. For small lesions centrally located, the septum with both layers of mucoperichondrium can be resected through intact nares. 4. If possible, leave the anterior and dorsal strut of the septal cartilage for nasal support. This must not be done if adequate resection of safe margins around tumor would be jeopardized. Support then is achieved with autogenous cartilage or bone grafts (see Figs. 3-5 and 6-19) or a Silastic strut. Note: With any procedure involving reconstruction of the distal end of the nose-nares and/or columellacustom-made silicone or acrylic resin nasal stents may be used to help form the nares and support the bridge of the nose as well as the columella.
A A lateral rhinotomy incision is made extending along the nasofacial sulcus. When the lower edge of the nasal (frontal) process of the maxilla is reached, the incision is extended into the nasal cavity. The lateral nasal and angular vessels, branches of the external maxillary artery and tributaries of the anterior facial vein, should be identified above and below and be ligated. The lateral attachment of the ala nasi is completely mobilized by swinging the incision into the floor of the nose. B The nasal flap is rotated upward and medially. With the septal lesion located anteriorly or distally on the septum, such a flap suffices for visualization. For more posteriorly located tumors, however, a lateral bone flap is developed. This is performed by transection of the base of the nasal process of the maxilla and transection of its superior attachment along the same plane as the horizontal suture line of the lateral nasal bone. C Additional exposure, if necessary, is gained by transection of the columella at its base. An incision is then made posterior to the columella, the exact location
depending on the anterior extent of the tumor. In the tumor pictured, no septal cartilage remains anterior. The only cartilages in the columella then are the two medial crura of the alar cartilages. With an electrocautery knife, the incision is extended around the septal angle at the tip of the nose and upward along the dorsal aspect of the septum. This incision is through and through, and, if possible, a strut of septal cartilage is preserved along the bridge of the nose for support. Preservation of any nasal supporting cartilage must not be done at the expense of adequate resection of the tumor. In situations in which no anterior or dorsal cartilage strut is preserved, cartilage or bone grafts or Silastic is used either at the time of the primary operation or at a second stage (see Fig. 6-19). D The septal incision has been carried across the posterior aspect down to the floor of the nose. This will entail removal of a portion of the perpendicular plate of the ethmoid and the vomer bones. Care must be exercised in high posterior resections that the cribriform plate of the ethmoid, which is continuous with the perpendicular plate, is not inadvertently fractured, with resultant opening into the anterior cranial fossa. Obviously, extension of disease in this region may require elective removal of a portion of the cribriform plate. The dural leak if small may be handled by the use of a piece of Gelfoam held in place with nitrofurazonesoaked gauze. Massive doses of antibiotics are used to prevent meningitis. Local bacitracin may also be used. Using an osteotome, the inferior portion of the septum is now freed by transecting the crest of the maxillae anteriorly and, if posterior resection is indicated, the crest of the palatine bone. If the tumor has extended farther along the floor of the nose, an entire section of the midportion of the maxillae will require resection (see Fig. 5-9A to F). E The completed resection. An anterior cartilage graft (see Fig. 3-5) with an attached piece of perichondrium is inserted in the columella. The inferior end is placed near the anterior nasal spine. It is important that the mucocutaneous edges be closed behind the cartilage graft so that it becomes completely covered. F All skin edges are approximated after the nasal cavity is packed with antibiotic impregnated one-half inch strip gauze. When the columella and/or caudal end of the septum requires resection, this can be reconstructed with a nasolabial flap based superiorly. The bare contralateral side is covered with a full-thickness or split-thickness skin graft (see Fig. 6-23D and E).
THE NOSE AND THE NASOPHARYNX
A
F FIGURE 6-32
355
TW~Nm~ AND TH~NASOPHARYNX Total Resection of Nose for Carcinoma (Fig. 6-33) Highpoints 1. Unusually wide resection of external framework is required. 2. Careful evaluation of internal extent of disease is mandatory. 3. A wide resection is done of the nasal septum and columella.
A, B The skin incision is outlined. The entire columella is excised, and the incision encompasses the base of the nasal septum to the floor of the nasal cavity. (
The excision is begun from the lateral edge of one
D After both lateral walls of the nose have been sectioned, excision of the columella and nasal septum is begun. Liberal margins are resected. Stay sutures are used on the specimen to avoid use of clamps or forceps, which might fragment the tumor and cause implants. E Whereas the cartilage is easily transected with a knife, the bony septum, nasal bones, and nasal processes of the maxillae, if encompassed in the resection, may require bone-cutting forceps. F The nasal cavity is packed with nitrofurazone-soaked or antibiotic-impregnated gauze strips. G Split-thickness skin is used to cover all bare areas; sutures are used only along the skin margins. A pressure dressing
of nitrofurazone-soaked
naris so that there is adequate visualization to determine
Cosmetic appearance
the extent of the septal invasion by the neoplasm.
forehead flaps (see Figs.
cotton
is applied.
is provided for by a prosthesis or
6-28 and 6-29).
TH~Nm~ AND TH~N~OrHARYNX
B
E
Transected base of columella
F
G
FIGURE 6-33
THE NOSE AND THE NASOPHARYNX
Resection of Nasal GliomaExternal Ethmoid Approach (Fig. 6-34) Highpoints 1. A nasal glioma is a space-occupying expansile lesion, histologically usually benign, arising from congenital central neural elements. It is an encephalocele and not a neoplasm. 2. There may be a connection with the intracranial cavity, and hence removal may cause a dural defect with leakage of cerebrospinal fluid and danger of meningitis unless recognized. 3. In view of the possibility of dural defect, any nasal polypoid mass in the newborn must be considered a glioma until proved otherwise. 4. Intracranial extent of glioma is evaluated by air studies according to signs and symptoms. Computed tomographic scan with enhancement may help in the evaluation of the extent of the lesion. 5. If the intracranial portion is large and especially if a large dural defect is anticipated, the initial surgical approach is transcranial using a craniofacial technique. See Chapter 23 for details. However, dural defects are usually handled easily through an adequate transnasal approach. An important point is to recognize them and treat them accordingly. 6. TWo-stage procedures may be necessary when the initial diagnosis is obscure. In addition to gliomas, meningiomas can extend into the nasal cavity. These require a combined cranio-facial approach. See Chapter 23. Death can occur when an intracranial approach alone is utilized. Entry into the anterior cranial fossa is the serious complication.
A Rhinoscopic view of the polypoid mass that is the intranasal portion of the glioma is shown. The overlying covering is normal-appearing nasal mucosa that arises from the ethmoid region. B The external appearance of a glioma is depicted in this 4-month-old child that was present since birth. It resembles a dermoid cyst. Nasal gliomas may be either external or internal or both. The dotted and solid lines represent the skin incision. The excess skin is left attached to the glioma. The incision is that of an external ethmoid approach.
C Medial and lateral flaps are developed. A O.5-cm diameter (external) pedicle of gliomatous tissue is seen extending through a smooth, well-rounded defect in the nasal bone and nasal (frontal) process of the maxilla. D The inferior margin of the nasal bone and nasal process of the maxilla are exposed, and an incision is made along this margin to elevate the periosteum. E The external portion of the glioma has been removed for simplicity of exposure and working space. Because it is not a neoplasm, this technique is permissible. In a staged procedure, this may conclude the first stage for diagnostic purposes and further evaluation. With a nasal freer, the periosteum is elevated over and under the nasal process of the maxilla. F A lateral osteotomy is performed with a small curved chisel up to the bony defect. From this point, the chisel is directed horizontally across the superior suture 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
Resection of Nasal GliomaExternal Ethmoid Approach (Continued) (Fig. 6-34) G The periosteal bone flap is swung medially along its hinged attachment to the septum. The intranasal portion of the glioma is seen extending from the ethmoid labyrinth covered with nasal mucosa and attached to the septum. With sharp dissection along the mucosal reflection on the septum and careful blunt dissection in the ethmoid region, mobilization is begun. H As the glioma is dissected, another (internal) pedicle becomes exposed, extending through the roof of the ethmoid labyrinth into the anterior cranial fossa. The middle and inferior turbinates are not involved.
I The entire intranasal glioma and as much of its pedicle as possible are removed. There is a small dural defect through which cerebrospinal fluid leaks.A patch of Gelfoam is placed over the dural defect.
J
Antibiotic-impregnated one-fourth-inch strip gauze is inserted through the nares and placed firmly against the Gelfoam to keep the latter in place.
K The periosteal flap is turned back into position and fixed with periosteal sutures of 4-0 chromic catgut. L The skin is approximated with interrupted 5-0 nylon. Massive doses of penicillin and a broad-spectrum antibiotic are used until all evidence of cerebrospinal fluid leak has ceased. Bacitracin is used locally on the packing.
THE NOSE AND THE NASOPHARYNX
Intranasal portion of glioma
K
L FIGURE 6-34 Continued
THE NOSE AND THE NASOPHARYNX
Excision of Rhinophyma
(Fig. 6-35)
Rhinophyma is thought to be the final stage of acne rosacea. It is a benign nodular swelling consisting of dilated blood vessels. Between the nodules are fissures of varying depths containing greatly increased numbers and sizes of sebaceous glands.
A The hyperplastic sebaceous glands, fibrous tissue, and involved skin are planed down to the desired size without injury to the perichondrium. Dermabrasion of not only the grossly involved area but the entire nose has been advocated. B If the area to be grafted is large, split-thickness skin is taken from the clavicular area and sewn tightly in place once the bleeding has been controlled.
Highpoints 1. Do not expose cartilage. 2. Preserve the rim of nares. 3. Grafting usually speeds recovery, although the skin will regenerate if remnants of the epidermis remain.
A
B FIGURE 6-35
THE NOSE AND THE NASOPHARYNX
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AJR Am
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Montgomery WW, Lofgren RH, Chasin WD: Analysis of pterygopalatine space surgery-1970. Presented before the 73d Annual Meeting of the American Laryngological, Rhinological, and Otological Society, Holly Beach, Florida, April 1970. Mullin WR, Millard DR: Management of congenital bilateral cleft nose. Plast Reconstr Surg 75:253-257, 1984. Myers EN, Schramm VLJr, Barnes EL: Management of inverted papilloma of the nose and paranasal sinuses. Laryngoscope 91:2071-2084, 1981: Neel HB, Pearson GR, Weiland LH, et al: Anti-EBV serologic tests for nasopharyngeal carcinoma. Laryngoscope 90: 1981-1990, 1980. Nicolai JPA: Reconstruction of the columella with nasolabial flaps. Head Neck Surg 4:374-379, 1982. Nishimura Y, Ogino Y: Autogenous
septal cartilage graft in the correc-
tion of cleft lip nasal deformity. Br J Surg 31:222-226, 1978. Ommaya AK, Di Chiro G, Baldwin M, Pennybacker JB: Nontraumatic cerebrospinal fluid rhinorrhoea. J Neurol Neurosurg Psychiatry 31:214-225, 1968. Osborn AG, Mclff B: Computed tomography of the nose. Head Neck Surg 4:182-199,1982. Osguthorpe JD, Calcaterra TC: Nasolacrimal obstruction after maxillary sinus and rhinoplastic surgery. Arch OtolaryngoI105:264-266, 1979. Owens H: Observations in treating seven cases of choanal atresia by the transpalatine approach. Trans Am Laryngol Rhinol Olol Soc 295:312, 1951. Parisier SC: Correction of deviated nose. Arch Ololaryngol 92:60-65, 1970. Pastorek NJ: Rhinophyma. In Otolaryngology. New York, Harper & Row, 1979. Pearson BW, MacKenzie RG, Goodman WS: The anatomical basis of transantral ligation of the maxillary artery in severe epistaxis.
Laryngoscope 79:969-984, 1969. Pearson CM, Kline HM, Newcomer VD: Relapsing polychondritis. N Engl J Med 263:51-58,1960. Peck GC: The onlay graft for nasal tip protection. Plast Reconstr Surg 71:27-39, 1983. Penn J: Kiel-bone implants to the chin and nose. Plast Reconstr Surg 42:303-306, 1968. Perez CA, Ackerman LV,Mill WB, et al: Cancer of the nasopharynx: Factors influencing prognosis. Cancer 24:1-17, 1969. Potter GO: The pterygopalatine fossa and canal. AJR Am J Roentgenol 107:520-525, 1969. Pratt FJ, Pratt JA: Intranasal Surgery. Philadelphia, FA Davis, 1924. Pressman JJ: Nasopharyngeal angiofibroma. Arch Ololaryngol 76:167-173,1962. Quain R: The Anatomy of the Arteries of the Human Body and Its Applications to Pathology and Operative Surgery. London, 1844. Reekie RA, Miller CG: Cor pulmonale secondary to chronic nasopharyngeal obstruction in a child. West Indian Med J 20:41-45, 1971. Rees TO: Nasal plastic surgery in the Negro. Plast Reconstr Surg 43:13-18,1969. Regnault P, Alfaro A: The Skoog rhinoplasty: A modified technique. Plast Reconstr Surg 66:578-589, 1980. Riche MC, Chiras J, Melki JP, Merland JJ: The role of embolization in the treatment of severe epistaxis. J. Neuroradiol 6:207-220,1979. Rosen L, Hanafee W, Nahum A: Nasopharyngeal angiofibroma, an angiographic evaluation. Radiology 86: 103-107, 1966. Rulon JT, Brown HA, Logan GB: Nasal polyps and cystic fibrosis of the pancreas. Arch Otolaryngol 78:192-199, 1963. Saad MN, Barron IN: Reconstruction
of the columella with alar margin
flaps. Br J Plast Surg 33:427-429,1980. Sachs ME, Conley J, Rabuzzi 0, et al: Degloving approach for total excision of inverted papilloma. Laryngoscope 94:1595-1598,1984. Safian J: Corrective Rhinoplastic
1935.
Surgery. New York, Paul B. Hoeber,
THE NOSE AND THE NASOPHARYNX
Safian LS: Cosmetic rhinoplasty: Radiological features. Head and Neck Surg 7:139-149,1984. Sanchez-Cas is G, Devine KD, Weiiand LH: Nasal adenocarcinomas that closely simulate colonic carcinomas. Cancer 28:714-720,1971. Sardana DS: Nasopharyngeal fibroma. Arch Otolaryngol 81:584-588, 1965. Saunders WH: Septal dermopiasty for control of nose bleeds caused by hereditary hemorrhagic telangiectoma. Trans Am Acad Ophthalmol Otolaryngol 64:500-506, 1960. Saunders WH: Septal dermoplasty~its several uses. Laryngoscope 80:1342-1346, 1970. Schaeffer JP: Embryology, Development and Anatomy of the Nose, Paranasal Sinuses, Nasolacrimal Passageways and Olfactory Organ in Man. Philadelphia, Blakiston, 1920. Schiff M: Juvenile nasopharyngeal angiofibroma. Laryngoscope 69: 981-1016, 1959. Schuller DE, Lucas JG: Nasopharyngeal paraganglioma. Arch Otolaryngol 108:667-670, 1982. Sheen JH: A new look at supratip deformity. Ann Plast Surg 3:498-504, 1979. Singleton GT,Hardcastie B: Congenitai choanal atresia. Arch Otolaryngol 87:620-625, 1968. Snyder GB: Rhinoplasty in the Negro. Plast Reconstr Surg 47:572-575, 1971. Stark RB, Frileck SP: Conchal cartilage grafts in augmentation rhinoplasty and orbital floor fracture. Plast Reconstr Surg 43:591-596, 1969. Stoksted P, Gutierrez C: Obtaining a gentle contour to the columella by modifying the maxillary spine. Plast Reconstr Surg 68:689-695, 1981. Straith RE: Dropped lateral wall syndrome-the NO.2 complication in rhinoplasty. Ann Plast Surg 6:60-62, 1981. Stucker FJ: Profile contouring including cheiloplasty. Arch Otolaryngol 105:680-683, 1979. Tardy ME, Denneny J, Fritsch MH: The versatiie cartilage autograft in reconstruction of the nose and face. Laryngoscope 95:523-533, 1985. Thibault J, Sevigny B: Use of isografts and homografts in reconstruction of the nasal pyramid. J Otoiaryngol11:9-13, 1982. Thomsen KA: Surgical treatment of juvenile nasopharyngeal angiofibroma. Arch Otolaryngoi 94:191-194,1971. Dnno T, Nelson JR, Ogura JH: The effect of nasal obstruction on pulmonary, airway and tissue resistance. Laryngoscope 78:1119-1139, 1968.
Vecchione TR: Columella reconstruction
using internal nasal vestibu-
lar flaps. Br J Plast Surg 33:399-403,1980. Veltri RW,Raich PC, McClung JE, et al: Lymphomatoid granulomatosis and Epstein-Barr virus. Cancer 50:1513-1517,1982. Vikram 8, et al: Improved survival in carcinoma of the nasopharynx.
Head Neck Surg 7:123-128,1984. Walike JW, MacKay B: Nasopharyngeai angiofibroma: Light and electron microscopic changes after stilbestrol therapy. Laryngoscope 80:1109-1121, 1970. Wang CC: Curative radiation therapy for carcinoma of the nasopharynx. Bull NY Acad Med 50:1001-1008,1974. Weber FT, Donnelly WH, Bejar RL: Hypopituitarism following extirpation of a pharyngeal pituitary. Am J Dis Child 131:525-528, 1977. Webster RC, Smith RC, Barrera A, et al: External splinting of the nose. Laryngoscope 94:1615-1616, 1984. Webster RC, Davidson TM, Smith RC: Nasofrontal angle changes in rhinoplasty. Otolaryngol Head Neck Surg 87:95-108,1979. Weddell G, MacBeth RG, Sharp HS, Caivert CA: The surgical treatment of severe epistaxis in relation to the ethmoidal arteries. Bf J Surg 33:387-392, 1946. Wharam M, et al: Soft tissue sarcoma of the head and neck in childhood: Nonorbital and nonparameningeal sites. Cancer 53:1016-1019, 1984. Wheeler ES, Kawamoto HK, Zarem HA: Bone grafts for nasal reconstruction. Plast Reconstr Surg 69:9-17, 1982. Whitaker SR, Sprinkle PM, Chouh SM: Nasal glioma. Arch Otolaryngol 107:550-554, 1981. Williams HJ: Posterior choanal atresia. AJR Am J Roentgenol 112: 1-11,1971. Wright WK: General principles of lateral osteotomy and hump removal. Trans Am Acad Ophthalmol Otoiaryngol 65:854-816, 1961. Wright WK, Kridel RW: External septorhinoplasty: A tool for teaching and for improved results. Laryngoscope 91:945-951,1981. Wynn SK: Primary nostril reconstruction in complete cleft lips: The round nostril technique. Plast Reconstr Surg 49:56-60, 1972. Young F: The surgical repair of nasal deformities. Plast Reconstr Surg 4:59, 1949. Young L, Weeks PM: Reconstruction of a large uniiateral nasal defect. Ann Plast Surg 1:485-488, 1978.
7
THE FACE
Anatomy of Facial and Scalp Muscles (Fig. 7-1)
to the publication by Walsh (1969) regarding the ligation of the feeder vessels in the treatment of giant strawberry nevi.
A Depicted are the primary muscles of facial expression and the major blood vessels.The reader is referred
Continued
FRONTALIS M. SUPRAORBITAL FRONTAL A. DEPRESSOR
A.
GLABELLAE
M.
ANGULAR A. ORBICULARIS OCULI M. ZYGOMATICUS MINOR M.
SUPERFICIAL TEMPORAL A.
LEVATOR LABII SUPERIORIS ZYGOMATICOORBITALIS
ZYGOMATICUS ORBICULARIS
A. TRANSVERSE A.
MAJOR M. ORIS M.
DEPRESSOR
LABIlINFERIORIS
DEPRESSOR
ANGULI ORIS M.
M.
FACIAL
STERNOCLEIDOMASTOID
A
M.
M.
MODIOLUS RISORIUS M.
367
368
THE FACE
Anatomy of Facial and Scalp Muscles (Continued) (Fig. 7-1) B Frontal section of the head shows the layers of the scalp, skull, and meninges.
C Most of the variations of the facial nerve occur in the face. There are numerous communications with other branches, for example, with the maxillary nerve, which is sensory. If at all possible, when the facial nerve is sacrificed, preserve the most important division, which is the zygomaticotemporal division. This supplies the orbicularis oculi muscle.
SUPERFICIAL FASCIA APONEUROSIS FIBROUS SEPTA OUTER COMPACT BONE
i·~
DIPLOE
-
INNER COMPACT BONE
B
SUBAPONEUROTIC TISSUE PERICRANIUM BONE DURA MATER
SUPERIOR LONGITUDINAL
Trunk and Branches of Facial Nerve
FT - Trunk of Facial Nerve
c
ZT T Z B RM CF C PD SH PA
FIGURE 7-1 Continued
- Zygomaticotemporal - Temporal - Zygomatic - Buccal - Ramus Mandibularis - Cervical Facial - Cervical - Posterior Digastric - Stylohyoid - Post-auricular
SINUS
THE FACE
Basic Technique for Facial Excisions (Fig. 7-2)
B The wedge of skin affords an excellent traction point for the cyst while the capsule is dissected. The cyst is thus easily removed intact, and the more viable skin edges ensure primary healing with a minimum of dimpling. Continued
Sebaceous Cysts
A The incision is outlined to include a wedge of overlying skin with the sebaceous duct involved. Even though the duct may not be apparent, the wedge of skin is always included. Because local anesthesia may obscure the extent of the cyst, its outline can be marked with dye before the use of the anesthetic.
Although malignant change in sebaceous and epidermoid cysts is rare, it does occur in 2.2 % of these cysts as shown by Bauer and Lewis (1980) in a review of 3300 cases reported in the literature.
B FIGURE 7-2
THE FACE
Basic Technique for Facial Excisions (Continued) (Fig. 7-2)
placed so that the knots are buried. These sutures may grasp either the deep edge of the dermis or the superficial fascia, as the case may be.
C The ellipse of skin excised always follows a natural skin crease. D The skin and subcutaneous tissue are cut in a plane at right angles to the skin. Forceps may be used on the specimen but should be avoided on the skin edges. E At least one margin is undermined adequately to prevent tension on the skin closure. This, plus the deep sutures, tends to maintain a fine scar. In this case, in the nasolabial fold only the lateral edge is mobilized to prevent distortion of the corner of the lips and mouth. F The deep or subcutaneous sutures of fine material, either 5-0 white silk or 5-0 absorbable sutures, are
G Sutures of 5-0 or 6-0 nylon are used for the epidermis. Mattress sutures are utilized only when inversion occurs.
If only a one-layer closure is used, it is important to place the skin sutures diagonal to facilitate eversion (see Fig. 7-3C3). For treatment of superficial erythroplasia and Bowen's lesions, boric acid ointment applied daily for several weeks often proves beneficial. However, if there is any possibility of carcinoma the treatment is wide excision with frozen section examination of the depth and margins. Details of Z-plasty, rhombic flap, excision of dogears, and skin incisions are given in Chapter 3.
c
FIGURE 7-2 Continued
THE FACE
Dermabrasion (fig.
7-3)
Dermabrasion is a form of surgical planing of the skin using abrasive devices that removes the epidermis and the superficial layer of the dermis. A new epidermis regenerates from the cutaneous adnexa consisting of the sweat glands and pilosebaceous structures. It is used to smooth irregularities of the skin sutface.
Indications • • • • •
Acne scars Traumatic scars Superficial tattoos Superficial nevi Burn scars when combined with split-thickness skin grafting • Small multiple irregular shallow epidermal lacerations
Anesthesia Local or general infiltration is used. Epinephrine is not injected in any form because of the danger of cardiac arrhythmia.
Highpoints 1. Extensive areas should be treated in a hospital. 2. An Iverson high-speed dermabrader is preferred, using the various-sized emery paper cylinders rather than a wire brush. 3. Proceed slowly, especially over bony prominences. 4. Do not abrade eyelids or the lower anterior neck. 5. Provide preoperative skin care with germicidal soap. Cleaning the skin with ether will remove sebaceous material deep in acne scars. Be careful not to allow the ether to reach the patient's eyes. 6. Saline is used copiously during the procedure and afterward.
371
7. Keep loose gauze clear of revolving parts of equipment. 8. Repeat abrasion usually should be spaced 10 to 12 months apart. 9. Surgical excision of deep scars is combined with dermabrasion. 10. "Feather" the edges of the area to be abraded to avoid sharp depression at the edges. 11. Deep pits are marked with methylene blue. 12. Avoid exposure to sunlight for 6 months postoperatively.
A Iverson dermabrader is shown with guard in position. The inside of the cheek may be supported by packing the buccal space with gauze to add support to the soft tissues. The area to be abraded has been outlined with a suitable dye. The depth is gauged primarily by experience. As the epidermis is removed and dermis is exposed, small bleeding sites will appear, which are the dermal papillae. Next will be seen parallel ridges of collagen. It is wise to terminate the procedure at this level. If one proceeds deeper, adipose tissue will be detected. Ifdeep scars remain, they are best excised at the conclusion of the abrasion. This is the purpose of first marking with methylene blue. This is especially necessary if local infiltrative anesthesia is used, because the pockets of the scars may be partially obliterated. At the margins the planing must be feathered so that there is a gradual sloping area to normal skin; otherwise, a sharp depressed edge will result. Immediate use of dermabrasion for small multiple irregular shallow epidermal lacerations may be advantageous. Continued
A
FIGURE 7-3
3'2
THE FACE
Dermabrasion
• Erythema. This reddish hue always occurs immediately
(Continued) (Fig. 7-3)
B Close-up view of Iverson dermabrader shows small cylinder covered with emery paper sleeve.
•
Postoperative dressing consists of antibiotic ointment covered with Telfa or Adaptex and an outer fluffed gauze pad held in place with a Kling bandage. This outer pressure dressing may be removed in 24 to 48 hours, whereas the inner dressing is left in place for 7 to 10 days. It is important that this inner dressing not be forcibly removed earlier because this would injure the regenerating epithelium. Approximate regeneration periods include: • 1 week-Complete epithelialization. • 1 month-Pigment begins to reappear. • 6 months-Epidermis approaches normal thickness (dermis does not reach preoperative thickness). Complications
Patients should be told to avoid excessive sunlight and use sunscreens, ascorbic acid, and cortisone. Oral contraceptives can also induce this complication. Patients should discontinue this medication several months before dermabrasion. • Milia. These are small white cysts that arise from the epidermal appendages as the epidermis regenerates (i.e., pilosebaceous structure and sweat glands). If these small cysts do not disappear spontaneously as they usually do, they may require uncapping and pressure to remove their contents.
• Hyperpigmentation.
• • •
after dermabrasion and usually gradually disappears. Again, overexposure to sunlight is to be avoided. Hypertrophic scars. These result with too deep dermabrasion or with dermabrasion in which there is a paucity of cutaneous adnexa, as in the lower anterior neck. Hypopigmentation. This is usually due to deep abrasion into the dermis. Pain. This is rare. Infection. Although rare, it is usually due to Staphylococcus aureus and should be treated vigorously to prevent scarring. Use bacitracin ointment plus systemic antibiotics, depending on results of culture and sensitivity studies. ( Depicted are the steps associated with the dermabrasion and then the excision of a deep scar. 1. The epidermis alongside the depressed scar is feathered by dermabrasion down to the dotted lines. 2. The remaining deep scar is excised along the dotted lines. 3. The edges of the resected scar are approximated. The skin sutures are placed diagonally as depicted to evert the skin edges slightly. In selected patients a dermal graft can be placed over a deep dermabraded area.
2
FIGURE 7-3 Continued
THE FACE
373
,
Excision of Tumors of Skin of Forehead (Fig. 7-4) Highpoints 1. All layers of scalp are excised for malignant lesions. 2. Margins depend on the type of tumor: basal cell carcinoma requires 0.8 to 1 cm; squamous cell carcinoma requires 1.5 to 2.0 cm beyond gross disease. Use frozen section on margins and depth of resected specimen. 3. Use full-thickness skin mobilization without muscle for advanced flaps to cover defect. 4. Both basal cell and squamous cell carcinomas can invade periosteum and bone, the latter metastasizing to regional lymph nodes (basal cell carcinoma very rarely metastasizes). 5. Basosquamous cell carcinoma, although rare, can occur as two types: (1) pure basal cell and pure squamous cell in the same tumor as separate entities lying side by side and (2) an admixture of both basal and squamous cell with the basal cells as a rim and the squamous cells in the center of the neoplasm. Type 2 can be highly malignant. 6. Basal cell carcinoma can spread deep to the skin without any evidence on the skin surface-the
"RODENT" spread or morphea type of spread in which strands of tumor infiltrate the subdermis, sometimes for a distance of several centimeters. Multiple frozen sections are done with resection of the entire thickness of the skin and muscle if positive. Basal cell carcinoma can be invasive at times, involving periosteum and bone, resulting in the necessity to do an orbital enucleation or a transcranial approach to metastatic disease intercranially (see Chapter 23).
A Smaller lesions off the midline are excised as outlined, including skin, superficial fascia, galea, and muscle. The galea is the tendinous aponeurosis that connects the occipitalis and frontalis muscles. The galea and muscles together form the epicranial layer. The line of cleavage is the subepicranial connective tissue space. B A single, lateral, full-thickness skin flap is mobilized. The underlying frontalis muscle and nerve are left intact except in the area excised when the tumor is malignant. C The lateral flap is advanced and sutured in place using several subcuticular sutures of 4-0 chromic or 5-0 white silk and 5-0 nylon sutures for the skin.
Continued
A FIGURE 7-4
THE FACE
Excision of Tumors of Skin of
E Bilateral full-thickness flaps are elevated, preserving the frontalis muscle and nerve.
Forehead (Continued) (Fig. 7-4) D When the lesion is larger or in the midline, a shield-shaped excision is used with bilateral advanced flaps. Again the tissue is excised through the subepicranial space.
F
Closure is in similar fashion as in C.
D FIGURE 7-4 Continued
THE FACE
Excisions for Carcinoma of Skin of Temple (Fig. 7-5)
excised tissue is carried down to the temporal fascia. Branches of the superficial temporal artery are ligated. Undermining is mainly carried out on the lower skin flap. This plane (E) is through the subcutaneous tissue, superficial to the fascia overlying the parotid gland. The branches of the facial nerve cross the zygomatic arch. The more medial is the zygomatic branch, which
Basal Cell Carcinoma
Highpoints 1. Wide excision is done down to deep fascia. 2. Liberal mobilization of skin flaps is required. Refer to Highpoints on page 373. Keep in mind that the zygomaticotemporal branches of the facial nerve are superficial to the temporal fascia, being in the same anatomic plane as the superficial temporal artery and vein. The auricular temporal nerve, although close to the ear lobe, is also in this same plane.
A, Al The skin incision is made as outlined. The upper edge is slightly concave, and the lower edge is convex. B If compatible with adequate excision, a branch of the temporal division of the facial nerve is preserved at the inner angle of the operative site. At other areas, the
can be further medial and cross the zygoma. The temporal branch is lateral; the auricular temporal nerve is still more lateral. The auriculotemporal nerve is a branch of the mandibular division of the fifth cranial nerve and is closely related to the superficial temporal artery. The mandibular division is primarily sensory with two other branches, namely, the lingual and the inferior alveolar nerve. Parasympathetic nerve fibers leave the otic ganglion and join the auriculotemporal nerve to reach the parotid salivary gland. It is these parasympathetic nerve fibers that are involved in Frey's syndrome (see p. 876). C A minimum of undermining is done on the upper flap. Here, the plane (E) is superficial to the temporal fascia. Care is taken not to injure branches of the facial nerve as they cross the zygomatic arch. Continued
FIGURE 7-5
THE FACE
Excisions for Carcinoma of Skin of Temple (Continued) (Fig. 7-5)
Closure is then achieved by raising a more extensive face flap with a postauricular incision. As the flap is
rotated upward, the postauricular dog-ear is excised. D
Two-layer
closure
is used with 5-0 white
silk
With squamous
lymphadenopathy
buried and 5-0 nylon for the skin.
cell carcinoma,
careful evaluation
of
within the parotid salivary gland or
in the preauricular lymph nodes is important. E
Depicted is the cross-sectional
Parotidectomy is then necessary and, possibly, radical neck dissection.
anatomy.
Squamous Cell Carcinoma
If the lesion is malignant melanoma, then elective
F When the tumor is bulkier or is a squamous cell carcinoma, the area excised must be wider and deeper.
parotidectomy with node dissection is indicated, depending on the Clark level or the Breslow depth of the tumor.
Temporalis m. Auricularis m. Temporal fascia Zygomatic arch
Ant. parotid fascia Parotid gland
E
FIGURE 7-5 Continued
THE FACE
Rotation Flaps (Fig. 7-6)
Complications
Temporal Scalp Flap (After Mustarde,
• Facial nerve injury • Edema of the lower lid
1969) The design of the flap must take into account the shifting of the hairline and traction on the eyebrow. Injury to the facial nerve must be avoided by any flaps that are used to cover the operative defect. The zygomatic branch to the orbicularis oculi muscle is the important one, and usually this will not be injured if the lines of incision are above a horizontal line drawn from the lateral canthus of the eye. Above this level is the temporal branch to the forehead. Highpoints
Correct Method
A Depicted is a lesion with the area of resection and large scalp flap. When this flap is rotated, there will be minimal upward pull on the eyebrow. The amount of hairline advanced onto the forehead at the temple will be quite acceptable. Note the back cut, which adds to the length of the flap. Incorrect Method
I. Adequate deep and wide resection of lesion is necessary if it is malignant -show no regard to facial nerve if it is clearly involved by tumor, except to identify
B This poorly devised flap is short and almost vertical.
and tag proximal and distal ends, if feasible, for a sural nerve graft (see pp. Il2 and Il3). 2. However, do not injure the zygomatic branch with a flap incision. 3. Avoid traction superiorly on the eyebrow-flap must
C The result is an objectionable upward distortion of the eyebrow and noticeable drop in hairline on a conspicuous area of the forehead.
be well mobilized and long.
A
B
;I ... 1I:.z; ....~:.~ ... .
:0-.,
fl.'
,
.'
I
-.-
....
'.
FIGURE 7-6
Continued
THE FACE
Rotation Flaps (Continued) (Fig. 7-6) Cheek Flap (After Mustarde, 1969) D, E A lesion inferior to the lower lid on the cheek has been excised, including a small triangle of skinstippled area below the resected area to facilitate a
closure without the formation of a dog-ear. Also prevented is downward tension of the lower lid, averting ectropion. A cutback incision (dotted line) may be necessary to afford greater length to the flap and to avoid tension. The cheek flap involves only skin and subcutaneous tissue, thus avoiding the branches of the facial nerve.
FIGURE 7-6 Continued
THE FACE
379
Excision of Tumors of Cheek by Cheek Flap Rotation (Fig. 7-7) Highpoints 1. Adequately mobilize and extend the cheek flap to prevent ectropion. 2. When elevating the flap, preserve the branches of the facial nerve to the orbicularis oculi muscle. Complications • Injury to facial nerve • Edema and/or ectropion
of lower lid
A Tumor is located below the lower lid close to the nasolabial fold. An area of excision is outlined, with the cheek flap elevation shown in the stippled area. The horizontal portion of the flap incision is just above the level of the lateral canthus. A back cut is shown if necessary (dotted line).
B. The completed procedure. If directly in the nasolabial fold, this lesion can be managed with a local flap or split-thickness epidermal graft (see Figs. 6-21 A to D and 6-25E to G) or a midline forehead flap (see Fig. 8-12D). C, D Tumor is smaller and located more laterally. The area of excision is outlined, with the stippled area indicating a lateral cheek flap. If there is undue tension, the cheek flap is extended as in A and B.
When the involved and with a free Chapter 24). Fig. 8-llA to
c
D FIGURE 7-7
entire or major portion of the cheek is resected, reconstruction can be performed microvascular abdominal wall flap (see Another option is a forehead flap (see G).
THE FACE
Facial Paralysis Shirley A. Anain and John M. Lore, Jr.
The problem of rehabilitation of the paralyzed face still remains an enigma. Bell's palsy is one problem; the other is facial paralysis due to trauma, surgery, or congenital anomalies. The functional and psychological consequences are often profound, and, to be treated as effectively as possible, the etiology of the paralysis must be determined. Idiopathic facial nerve paralysis (Bell's palsy) is the most frequently diagnosed unilateral facial paralysis, with up to 85 % of patients with spontaneous recovery requiring no further treatment of their paralysis. Up to 15% of patients will have some residual deficit. Surgical resection of tumors of the facial nerve or near the nerve with identified transection is best treated with immediate end-to-end anastomosis of the facial nerve under microscopic control. Large gaps are repaired with interposition nerve grafts. If more than 7 cm of graft is needed, the sural nerve has been recommended. Hypoglossal-facial anastomosis has been recommended, although it can create mass movement and dyskinesis. Delayed identification of facial nerve injury, post-traumatic paralysis, and post-acoustic neuroma resection problems are more complicated to treat. Because recovery is common, by the time facial paralysis is deemed permanent, muscular loss is irreversible. As with congenital anomalies, definitive treatment of the nerve and muscle may be needed. Immediate exploration and decompression or repair are advocated by many in trauma. Facial lacerations can often be repaired with primary neurorrhaphy (see Fig. 7-8C) (microscopic end-to-end interfascicular group repair) with 8-0, 9-0, or 10-0 nylon suture if the edges are well approximated. Primary nerve grafting is needed if the edges need to be debrided or if there is significant soft tissue loss. Repair of individual branches distal to the lateral canthus or nasolabial fold is not only technically difficult but also probably unnecessary, because there appears to be neurotization (regeneration) of the denervated fibers from the intact surrounding area. There is certainly more controversy in blunt injury, skull fracture, and facial nerve decompression. Patients with acute paralysis after closed injury may benefit from electromyography, as has been recommended in patients with Bell's palsy. Angeli and Chiossone recom-
mend decompression and repair of the facial nerve within the temporal bone if there is 90% degeneration in electro neurography within 21 days of injury and no voluntary facial motion is noted on electromyography. High-resolution computed tomographic (CT) scanning is recommended preoperatively. Brodsky and colleagues (1983) and McCabe (1970) have reported recovery with delayed surgery (Brodsky and colleagues at 2.5, 3, and 14 months and McCabe at 21 days). Even though many recommend early surgical intervention, it may be worth considering late surgical intervention. In discussing management possibilities in patients with facial paralysis, one must consider their deficits as well as their goals. Many "cosmetic" procedures will improve symmetry, especially in patients with some preexisting issues on the contralateral side. These include brow ptosis correction (bilaterally, if needed, with asymmetrical pull) and rhytidectomy. All patients are counseled in eye care: copious use of normal saline wetting solution, eye protection (sunglasses when outdoors), night-time protection, and close evaluation by an ophthalmologist. Gold implants have been utilized with some success in paralysis of the orbicularis oculi to aid in closure of the eye, often in combination with lower lid procedures (see Fig. 7-9A and B). The goal in many patients is to achieve symmetry. Conley stated: "It is never possible to restore natural, spontaneous expression, full motor power, and perfect synchronous movement by any operation." In recent years great strides have been made in re-creating spontaneous motion in the mid face area. It is beyond the scope of this atlas to delve into all the possible techniques to treat this problem or to describe even a major number of the various surgical techniques involved. The technique of nerve graft is depicted in Figure 17-4, and that of facial reanimation with cross-face nerve grafting and free muscle transfer in Figure 7-8. Fascial slings are described in Figure 7-12. Some say that the sling procedures are obsolete, although there are indications: 1. As a temporary method to "relieve a sagging cheek protruding into the mouth" (Rubin, 1980) 2. When dynamic procedures have failed 3. As a primary procedure in patients unwilling or unable to undergo more complex procedures
THE FACE
Management
Possibilities (Baker et aI.,
381
Facial Reanimation
1980; Tolhurst and Bas, 1982)
Cross-Face Nerve Grafts with Microvascular Muscle Transfer (Fig. 7-8)
Nerve
1. Immediate end-to-end anastomosis, if feasible 2. Interposed graft (e.g., greater auricular nerve or sural nerve) (see Fig. 3-8) 3. Hypoglossal-facial nerve anastomosis (see Fig. 7-10) 4. Crossover facial nerve graft from the contralateral facial nerve with sural nerve grafts (see Fig. 7-8A and B)
Spontaneous facial animation with the most naturalappearing motion of the restorative procedures has been championed by several authors (Harii et al., 1982). This two-step procedure requires patient cooperation for the most complete rehabilitation.
Muscle
• Paralysis of the upper lip and commissure
1. Masseter transposition (see Fig. 7-11) 2. Temporalis transposition 3. Free muscle transfer (gracilis, pectoralis minor, serratus anterior) (see Fig. 7-8A to C)
Advantages
Nerve and Muscle Combinations
Disadvantages
1. Reanimation with cross-face nerve graft (see Fig. 7-8A) followed by free neurovascular muscle transfer (see Fig. 7-8B and C) 2. Nerve crossover a. To facial muscles b. To masticatory muscles
• Complicated two-step procedure • Asymmetrical smile • Additional scars on calf and thigh
Slings
1. Fascial 2. Superficial musculoaponeurotic
system (SMAS)
Another important consideration is that reported by Martin and Helsper in 1960, in which they documented spontaneous recovery of verified sectioning of the facial nerve without any reconstruction. This phenomenon has been described many times. They suggested the possibility of cross re-innervation via the trigeminal nerve. Conley (1974) had reported data relative to another route of cross-innervation. Parnes and colleagues (1982) have reported data that further suggest, in addition to the facial nerve, the facial muscles that have an additional nerve supply, hence the difficulty in evaluation of the various surgical procedures used in the management of facial nerve paralysis.
Indications
• Spontaneous muscle function • Can be combined with other reanimation techniques
Highpoints
I. Identify several buccal nerve branches before sacrificing one or two to anastomose to the sural nerve. 2. Mark the end of the sural graft on the zygoma of the paralyzed side. 3. Follow Tinel's sign to follow nerve growth. 4. Frozen section identification of nerve tissue in the nerve graft is helpful at the time of the second procedure. 5. Carefully mark the relaxed gracilis muscle in situ before dividing with silk sutures placed approximately 2 cm apart. 6. Identify and dissect the facial artery and vein and the nerve graft. 7. Place nonabsorbable sutures in the zygoma and in the desired locations in the upper lip and commissure before muscle transfer. Pull to check proper angle of contraction.
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Cross-Face Nerve Grafts with Microvascular Muscle Transfer (Continued) (Fig. 7-8) 8. Transfer the muscle and suture into place keeping the silk sutures at 2 em distances to allow for maximal contraction force. 9. Proceed with microscopic anastomosis of the vessels followed by the nerve.
A The contralateral buccal branches are identified surgically through a preauricular or nasolabial fold incision as they exit from the anterior portion of the parotid fascia. A nerve stimulator (set at its minimum) is used to identify three to five buccal branches. A sural nerve graft is tunneled to the involved side with the end marked and left high on the zygoma. Microscopic anastomoses are undertaken with one or two of the branches (to prevent weakness on the contralateral side). The rate of regeneration is followed by Tinel's sign (distal tingling on percussion) and takes 9 to 12 months to reach the zygoma. B Once the nerve growth is complete, the patient is taken to surgery for muscle transplantation. The choice muscle is determined by the best re-creation of the angle and pull of the normal side on animation, as
well as surgeon preference. The author prefers segmental gracilis muscle with tailoring. A preauricular incision is made on the affected side. The end of the nerve is identified, as are the facial artery and vein. The origin and insertion are prepared, and nonabsorbable sutures are placed. C An end-to-end neurorrhaphy of the nerve of the gracilis to the prior sural nerve graft is completed microscopically utilizing interrupted 8-0, 9-0, or 10-0 nylon sutures (six to eight sutures per fascicle). No sutures are necessary in the epineurium.
Upper Lid Gold Weights (Fig. 7-9) A Upper lid function in facial paralysis can be improved by the use of gravity with a gold weight. To assess the amount of weight required preoperatively, a series of weights are taped to the eyelids until normal closure is obtained but still with the ability to open the lids. B Under local anesthesia, an incision is made in the upper lid crease. The appropriate weight is inserted above the tarsus and sutured to the tarsus.
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B
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
383
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Hypoglossal-Facial Nerve Anastomosis (Fig. 7-10) (After Conley and Baker, 1983) Although the author has no specific experience with the anastomosis of the 12th to the 7th nerve for facial nerve paralysis, this procedure nevertheless has been accepted as one of the methods of treatment of facial nerve paralysis when the proximal main trunk of the facial nerve is not accessible and, thus, interposition graft is not feasible. The 12th cranial nerve is identified just anterior to the internal carotid and external carotid arteries medial to the vagus nerve and the internal jugular vein. It is identified as it passes beneath the posterior belly of the digastric muscle. The nerve is then followed upward beneath the stylohyoid muscle and beneath the tendon of the digastric muscle and is traced superiorly toward
the tongue. It is transected just deep to the mylohyoid muscle. The proximal end of the hypoglossal nerve is tunneled beneath the posterior belly of the digastric muscle and anastomosed with the distal end of the main trunk of the facial nerve. Problems may occur in that the distal end of the main trunk of the facial nerve may be lacking and there may be only the cervicofacial and the zygomaticotemporal divisions available for anastomosis. Whether the 12th nerve is then split and independently anastomosed is a moot question. At any rate, the anastomosis is performed using the operative microscope or a four-power loupe utilizing several epineural sutures of 10-0 nylon. The problems associated with this type of anastomosis are basically twofold. One is the hemiparalysis of the tongue, and the other is the mass movement of the facial muscles basically related to the act of chewing and swallowing and speaking. The reader is referred to Conley and Baker's article (1979).
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/
/
FIGURE 7-10
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Masseter Muscle TranspositionIntraoral (Fig. 7-11) Indications • Paralysis of the upper lip and commissure
Advantages • Does not interfere with the seventh nerve-possible return of function • Can be combined with other types of restoration of seventh nerve function
Disadvantages • Infection • Bleeding • Difficulty of exposure
2. Use antibiotics for prophylaxis. 3. Intraoral approach-this may be the source of considerable bleeding from the facial artery. Thus, it might be well to ligate the inferior edge of the muscle before transection. 4. Split the masseter muscle only half the distance superiorly, with the medial mobilized portion further split-one fourth to the upper lip, one fourth to the lower lip. S. Exercise extreme care when splitting the muscle to avoid injury to the delicate branches of the motor nerve to the muscle.
A Diagram of the masseter muscle shows its split nerve supply and the mobilized medial half of the muscle one fourth to the upper lip and one fourth to the lower lip. This mobilization is performed through the intraoral approach.
of the muscle intra orally
• Masseter muscle can never be a substitute expressIOn
for natural
Highpoints
The nerve supply is from the
branch of the trigeminal nerve and reaches the undersurface of the masseter muscle superiorly between the condylar process and the coronoid process of the mandible.
Continued 1. Plot the exact location line and compare
of melolabial
(cheek-to-lip)
with normal side.
FIGURE 7-11
THE FACE
Masseter Muscle TranspositionIntraoral (Continued) (Fig. 7-11) B The intraoral incision passesalong the anterolateral surface of the mandible posteriorly from the region of the ascending ramus anteriorly to just posterior to the mental foramen. Exposure is important, and this is achieved by the use of a single-side mouth gag with the endotracheal tube secured to the contralateral side of the operative field. The exact technique is taken from the article by Sachs and Conley (1982): "The masseter muscle is first freed medially by raising the muscle off the mandible with the large broad-tipped periosteal elevator, sweeping the dissection to the level of the coronoid process superiorly and to the edge of the mandible inferiorly. The anterior and medial portion of the masseter muscle is thus exposed and is then stabilized with a forceps, while a lateral tunnel is sharply and bluntly raised with a scissorsin a plane just above the masseteric fascia and medial to the soft tissues of the face. Having freed the muscle medially and laterally, it now must be detached from its insertion at the inferolateral edge of the mandible. A curved right-angled scissors is invaluable for this maneuver in which first the muscle is cut inferiorly and
that the muscle is split only approximately halfway superiorly to avoid injury to its motor supply. To help avoid excess bleeding, the muscle is clamped along its inferior edge before mobilization. C This depicts the two skin incisions. The superior one is located halfway between the melolabialline and the lateral edge of the vermilion border of the upper lip. The lower incision is placed along its vermilion edge. These slips of muscle are brought through a common tunnel, which is lateral to the buccinator and inferior to the Stenson duct. The orbicularis oris muscle is preserved. These slips of muscle have been grasped by inserting clamps through the external incision into the intraoral incisions. The ends of the muscle are secured with 4-0 white silk through the strong fascial segment of the inferior masseter muscle and then to the deep dermal layers of the skin. The tension on the muscle slips is toward overcorrection. It is important that these sutures be placed in the dermal layers of the skin rather than in the subcutaneous tissues. If there is significant atrophy of the orbicularis oris muscle,the massetermuscle slips can be tunneled over the atrophic orbicularis oris, thus achieving augmentation of the atrophied muscle.
then an appropriate amount of the anterior portion (usually half) is split from the remaining posterior segment. This anterior half is then split again, fashioning two slips of muscle that ultimately will be tunneled to
The dressing is likewise important in that the upward traction of the lips is reinforced with tape to further stabilize the reconstruction. Feeding is with a naso-
the external incisions." Again, it must be emphasized
esophageal tube, and the patient is kept NPO for 5 days.
B FIGURE 7-11 Continued
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Fascial Slings for Facial Paralysis
Highpoints
(Fig. 7-12) 1. Two basic features of the problem include:
Facial nerve paralysis should be initially managed at the source, whether it be Bell's palsy or traumatic or surgical section of the nerve. The etiology and pathologic anatomy of Bell's palsy are disputed. However, edema with compression of the facial nerve in its bony canal appears quite evident. A discussion of whether an intratemporal bone decompression of the facial canal should be performed and, if so, when is beyond the scope of this atlas. However, conservative management, consisting of corticosteroids, antibiotics, and proteolytic enzymes, is begun immediately. Frequent evaluation of the progress of the impaired physiology is followed with electric stimulation. Apparently, weak sinusoidal stimulation has been found to be of some help in maintaining muscle tone. The same can be said for a light massage of the facial muscles. Both these forms of therapy should be delayed until any local edema or tenderness, both of which are rare, disappears. This same regimen is followed after parotid surgery when temporary paresis occurs. After a nerve graft, only the electrical stimulator is used. When wound healing is complete, light massage and electrical stimulation are employed. A Hilger stimulator may be used. Galvanic stimulation of the muscles themselves has also been utilized by the patient himself. Anyone utilizing a muscle or nerve stimulator should be aware of the controversial reports relative to DC stimulators (Hughes et al. [1981], including reviewer's comments by May). A suggested nerve stimulator is the Xomed-Treace Nerve Integrity Monitor 2 (Xomed Surgical Products). Occasionally, drooping of the side of the face occurs after a radical maxillectomy when the major portion of the malar (zygoma) bone is removed. The fascial sling operation described is of distinct help. Stage I is not necessary, the fascial sling being attached to the muscle and the dermis (using a fine white nonabsorbable suture) at the lowest point of the droop through a small skin incision. The other end of the fascia is fixed in the temporal region as in stage II. It is performed in one stage. The drooping or sagging of the cheek under the eye is also aided. When the facial paralysis is ascertained to be permanent-a waiting period of up to 9 to 12 months is justified-a fascial sling procedure can be performed to provide static support for the drooping face, especially for the corner of the mouth. The problem relative to closing the eye, especially during sleep, to protect the cornea is believed better helped by performing a tarsorrhaphy (see Fig. 11-15) rather than by extension of the sling procedure to include the orbicularis oculi muscle.
2.
3. 4. 5. 6.
a. Static suspension (In the operation described, static suspension is involved.) b. Dynamic action Two stages: a. Fascia implanted at orbital region b. Sling from first stage to temporal region An essentially similar procedure can be done in one stage, which may be preferable. Fascial support at oral cavity only on paralyzed side, slightly crossing midline Autogenous fascia Slight overcorrection No procedure is 100% perfect and may not be lasting. Inform the patient of this.
Stage I (From Ragnell, 1968; After May, 1980)
A Depicted is one method of obtaining autogenous fascia from fascia lata. A fascia stripper is used to obtain a piece of fascia 0.6 em wide and 18 em long. Superiorly, the fascia lata is in two layers; inferiorly,the two layers fuse to form the iliotibial band. B Three small incisions are made: (1) just lateral to the philtrum column on the normal side; (2) opposite No.1 on the lower lip; and (3) lateral to the commissure on the paralyzed side in or close to the nasolabial fold. Another approach is through a longer incision along the nasolabial fold superiorly beyond the alae nasi. This facilitates placement of another sling near the alae nasi to correct any distortion of the nose, which in turn can cause some nasal obstruction. With the use of a fascia carrier, one end of the fascial strip is passed from the lateral incision (3 in B) in a plane between the oral mucous membrane (do not perforate it) and the paralyzed orbicularisoris muscle of the upper lip out through the muscle of the normal side at incision 1 in B. The fascia strip, locking the normal muscle, is then passed back laterally between the paralyzed muscle and the subcutaneous tissue to the point of beginning (incision 3). The position of this doubled-back fascia is depicted in sagittal section in B2, including the same maneuver on the lower lip. The four ends of the fascial strip are then tightened, with care being taken not to make them too tight for fear of stenosis. If the patient wears dentures, these must be in place at this moment. These ends are then tied together or sutured with 4-0 Tevdek. The wounds are closed and sealed with collodion. Continued 81, 82
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82 FIGURE 7-12
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Fascial Slings for Facial Paralysis (Continued) (Fig. 7-12) Complications • Disruption of sutures holding sling • Wound infection. Because facial paralysis may be associated with mastoid disease, be sure the ears are "dry." • Some sag may be expected over the years. Ragnell (1968) performs a vastly different second stage in that he affixes one end of a fascial sling to the transected upper end of the coronoid process and the other end to the zygomatic arch. If warranted, as time goes by, excision of additional skin along the nasolabial fold is performed. Stage /I (Several Months
Later)
C By direct exposure a wider (1 to 1.5 em) and longer (15 em) piece of fascia lata is removed and used as the sling. The previous lateral incision 3 in B is opened, and the ends of the previously placed fascia are localized. Another incision is made in the temporal region with a preauricular extension if a rhytidectomy (face-lift) is also planned. The temporal fascia is exposed. A subcutaneous tunnel is then made connecting the two incisions. A long slender clamp or fascia carrier can be used for this purpose.
D The lower end of the fascia is then passed around the loop formed by the fascia placed in stage I and sutured with 4-0 nonabsorbable material. Redundant skin may be excised, and then the dermis on the lateral skin wound (rolled edge) is approximated to the fascia with fine white non absorbable sutures. This wound is left open until the operation is completed so as to view the resulting effect with tension on the sling. E The fascial sling is then drawn upward through the temporal incision so that the deformity is slightly overcorrected. The fascial end is then passed through
two incisions in the temporal fascia as depicted and sutured securely in place with 4-0 Tevdek. The skin incisions are closed with 5-0 nylon. A collodion dressing is used as extensively as possible. A supportive Kling dressing is used for as long as possible (1 month). The patient should avoid chewing and excessive talking for at least 1 to 2 weeks. F The completed operation schematically depicting the location of the fascial strips. Also shown are modifications of fascial strips placed around the eye. These latter strips can be secured around the medial canthal ligament. An alternate approach to achieving narrowing of the palpebral fissure is the performance of a lateral canthoplasty (see Fig. 11-15).
Treatment of Paralysis of the Depressors of the Lower Lip This deformity, usually due to injury of the mandibular branch of the facial nerve, as well as transection of the platysma muscle, which at times extends over the mandible and blends with other muscles (e.g., the risorius muscle), often follows operations in the submandibular region and in the parotid salivary gland and neck dissection (see Fig. 7-1). Often, it resolves with time, especially when it is due solely to section of the platysma muscle and when this muscle is carefully approximated at the time of the wound closure. However,
if the deformity persists, several procedures are available for at least partial correction. These include the following: 1. Z-plasty (see Fig. 9-2G and H). 2. Plication of the orbicularis oris muscle (see Fig. 9-6). 3. Transposition of the tendon of the subdigastric muscle into the lower lip. This procedure, of course, would have to be performed at the time of the definitive surgery, and although the author (JML) has had no personal experience with this technique, the fact that the lip is fixed in a depressed position may be a cause of additional deformity.
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c
E
F FIGURE 7-12 Continued
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Trigeminal Neuralgia (Tic Douloureux) (Fig. 7-13) Since the 1980s, the treatment of trigeminal neuralgia has developed to the point where most patients can be reasonably relieved of their symptoms either permanently or semipermanently (Dalessio, 1981). Medical and surgical management are a cooperative endeavor, with most authorities agreeing that medical treatment is the initial treatment of choice. Response to diethylcarbamazine (carbamazepine) usually occurs within 24 to 48 hours; if not, the diagnosis is in doubt. Regardless of the response, evaluation of disease in the paranasal sinuses and nasopharynx, as well as glaucoma, IS mandatory. Pain from trigeminal neuralgia should not be confused with pain from other sources, because the pain of trigeminal neuralgia is usually extremely severe and excruciating, at times causing the patient to throw himself or herself on the floor and roll around in utter agony. The pain may well be cyclic. In these severe episodes, patients simply cannot wait 24 to 48 hours for medical relief. It is then that blockage of the peripheral nerves involved is indicated with a suitable local anesthetic. At the same time, a long-acting anesthetic agent can supplement the immediate action of a short-acting agent. In addition, injection of 1 to 2 mL of 90% alcohol can also be performed. At times, patients will have relief for weeks and months after this management. This response has prompted the author to utilize peripheral neurolysis in selected patients before the habitual use of carbamazepine, which can result, although rarely, in severe blood dyscrasias (e.g., anaplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia). Carbamazepine can also cause ataxia and may act as a sedative. Nevertheless, the relatively simple blockage of the peripheral nerve is rarely used today. Other drugs can be used (e.g., phenytoin sodium, baciofen, and chlorphenesin carbamate). However, between 25% and 50% of patients will eventually require some type of surgical management. Surgical management can be divided into the following categories: 1. Treatment of the peripheral nerves by either anesthetic blockage or neurolysis. This is seldom used at the present time. 2. Radiofrequency electrode insertion, producing a thermal lesion in the sensory roots of the trigeminal nerve. The recurrence rate is 10% to 25%.
3. Decompression of the trigeminal nerve root. This compression may be due to an arterial loop; however, it is not certain that this arterial loop exists until the actual exploration, which requires a craniotomy (Voorhies and Patterson, 1981). Complications • Recurrence of symptoms • Anesthesia over nerve distribution A Location and distribution of supraorbital (1), frontalis (2), supratrochlear (3), infratrochlear (4), and infraorbital (5) nerves. These are the sites for the injection of the local anesthetic and possibly the 90% alcohol. Injection is directed into the bony orifice of the nerves, if possible. This may require probing with a needle until the excruciating pain is elicited, if not present at that time-an indication of exactly the correct site-followed by injection of a short-acting then a long-acting anesthetic and then, ifdesirable, the alcohol. There should be a good response within 15 minutes. However, the patient may have a short breakthrough of pain for 5 to 10 minutes during the next 24 hours. It is at this time that the patient can be placed on the carbamazepine. B The surgical approach to those nerves is demonstrated through three incisions. One or all nerves are exposed and sectioned depending on the clinicalpicture. The eyebrow is never shaved. The approach to the infraorbital nerve is depicted in detail in Figure 5-2A to
C. ( Details of the technique of section and avulsion of the supraorbital and frontalis nerves are shown. The same technique applies to all the other nerves. The orbicularis oculi muscle fibers are split. D
The nerves are mobilized with nerve hooks.
E Clamps are placed proximally and distally, and the nerve is transected. F By twisting the clamps, both proximal and distal ends are avulsed. For pain distribution along the lateral side of the tongue or lower lip, an intraoral block and injection of
THE FACE
A
B
FIGURE 7-13
the lingual nerve or inferior dental nerve is performed. Various techniques to block the maxillary division of the trigeminal nerve in the pterygopalatine (sphenomaxillary] fossa as it leaves the skull through the foramen rotunda have been used. The reader is referred to Hollinshead (1954] for an anatomic description of the problem.
Resection of portions of the lingual and inferior dental nerves has been performed intraorally. The lingual nerve is exposed at the posterior floor of the mouth, while the inferior alveolar nerve is exposed on the lateral aspect of the oropharynx, overlying the mandibular foramen on the inner surface of the mandible and offering some temporary relief.
THE FACE
Incision and Drainage of Abscesses (Fig. 7-14) Highpoints
1. All intraoral and intranasal abscesses are simply drained with no anesthesia or topical or local anesthesia. General anesthesia is contraindicated unless an endotracheal tube is used. 2. Abscesses at or near cartilage should be drained early. 3. Massive amounts of systemic antibiotics are administered. Complications
• Cavernous sinus thrombosis • Chondritis if cartilage is involved, with possible slough of cartilage Deep abscesses of either face or neck, especially the latter, may be very difficult to locate. The use of a needle often will aid in localizing the abscess. The needle is left in the abscess and used as a guide while the incision and drainage is performed.
A Septal abscess. A vertical incision is made to the most dependent point. Postoperatively, vasoconstrictor nose drops with or without sulfathiazole are used. A drain is optional. Abscess of upper lip. A horizontal incision is made in the presenting mass on the inner aspect of the lip.
B, C
D
A rubber tissue drain is sewn in place with nylon.
E Abscess of lower lip. An incision is made along the vermilion border. If there are multiple abscesses, a separate incision is made on the opposite side and connected under the lip. F A through-and-through incisions.
drain is used with the two
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E
F
FIGURE 7-14
396
THE ~ACE
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THE FACE
Farrior RT: Reconstructive surgery for the middle one-third of the face. Eye Ear Nose Throat Mon 44:83-87, 102-105, 111-116,1965; 45:108-112,1966. Farrior RT: Implant materials in restoration of facial contour. Laryngoscope 76:934-954, 1966. Fisch U, Rouleau M: Facial nerve reconstruction. J Otolaryngol 9: 487-492,1980. Freeman BS: Review of long-term results in supportive treatment of
facial paralysis. Plast Reconstr Surg 63:214-218,1979. Fujino T: Microsurgery in the field of plastic surgery. Asian Med J 25(11), 1982. Fujino T, Yamamoto K, Kuboto J, et al: Microsurgical technique in resection of hemangioma in infants. Ann Plast Surg 14:190-204, 1985. Gaisford JC, Hanna DC: Facial pedicle flap reconstruction: Immediate repair after surgical excision. Am J Surg 108:514-516, 1964. Ge XX, Spector GJ, Carr C: The pathophysiology of compression injuries of the peripheral facial nerve. Laryngoscope 92:1-15,1982. Georgiade NG, Matton GE, Kessel F: Facial burns. Plast Reconstr Surg 29:648-657, 1962. Gilchrest BA, Goldwyn RM: Topical chemotherapy of pigment abnormalities in surgical patients. Plast Reconstr Surg 67:435-439, ] 981. Glasscock ME, Pensak ML, Gulya AJ, Baker DC: Lyme disease: A cause of bilateral facial paralysis. Arch Otolaryngollll :47-49, 1985. Gorlin RJ, Cohen MM Jr: Frontometaphyseal dysplasia: A new syndrome. Am J Dis Child 118:487, 1969. Grabb WC, Dingman RO,Oneal RM, Dempsey PD: Facial hamartomas in children: Neurofibroma, lymphangioma, and hemangioma. Plast Reconstr Surg 66:509-527,1980. Griffith BH, Monroe CW, McKinney P: A follow-up study on the treatment of keloids with triamcinolone acetonide. Plast Reconstr Surg 46:]45-150,1970. Gross CW, Montgomery WW: Fibrous dysplasia and malignant degeneration. Arch Otolaryngol 85:97-101,1967. Guerrero-Santos J, Ramiez M, Espaillat L: lteatment of facial paralysis by static suspension with dermal flaps. Plast Reconstr Surg 48:325-328, ] 971. Guguere P: Bony chin reconstruction. J Otolaryngol11:1-8, 1982. Guilford FR: Surgical consideration in disorders of the horizontal and vertical portions of the facial nerve. Ann Otol 79:241, 1970. Habal MB, Maniscalco JE: Categorization of craniofacial deformities based on our experience
with surgical manipulation.
Ann Plast
Surg 6:6-10, 1981. Hagstrom WJ, Faibisoff B, Soltani K, Robson M: Dysplastic nevus syndrome (B-K mole syndrome). Plast Reconstr Surg 71:219-224, 1983. Harii K, Ono I, Ebihara S: Closure of total cheek defects with two combined myocutaneous free flaps. Arch OtolaryngoI108:303-307, 1982. Harris WH, Dudley H Jr, Barry RJ: The natural history of fibrous dysplasia. J Bone Joint Surg 44A:207-233, 1962. Hausamen JE: Principles and clinical application of micro-nerve surgery and nerve transplantation in the maxillofacial area. Ann
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Plast Reconstr
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7]:481-485,1983. Hollinshead WH: Anatomy for Surgeons. New York, Hoeber-Harper, 1954, vol ], pp 62-67.
Hughes G, et al: Clinical electro neurography, statistical analysis of controlled measurements in twenty-two normal subjects. Laryngoscope 9]:1834-1846,1981. Iwasaki
H, Mitsui T, Kikuchi M, et al: Neuroendocrine
carcinoma
(trabecular carcinoma) of the skin with ectopic ACTH production. Cancer 48:753-756, 1981. Jackson EG, Glasscock ME, Hughes G, Sismanis A: Facial paralysis of neoplastic origin: Diagnosis and management. Laryngoscope 90:1581-1595, ]980. Jannetta Pl: Neurovascular compression in cranial nerve and systemic disease. Ann Surg ]92:518-525, 1980. Jobe RP, Briggs RM: Marking the surgical specimen in skin neoplasm excision. Surg Gynecol Obstet 126:]325-1326, ]968. Jongkees LBW:The timing of surgery in intratemporal facial paralysis. Laryngoscope 79:1557-1561, 1969. Kamerer D: Intratemporal facial nerve injuries. Otolaryngol Head Neck Surg 90:612-6]5,1982. Karlan MS: Contour analysis
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surgery.
Arch OtolaryngolI05:670-679, 1979. Kettel K: Danish Otolaryngological Society Symposium: Management of peripheral facial palsies. Arch Otolaryngol 81:441-546, ]965. King GD, Salzman FA: Keloid scars: Analysis of 89 patients. Surg Clin North Am 50:595-598, 1970. Krane S: Hyperostosis, neoplasms, and other disorders of bone and cartilage. In Wintrobe MM (ed): Harrison's Principles of Internal Medicine. New York, McGraw-Hili, 1974. Kucan 10, Robson MC, Parsons RW: Amniotic membranes as dressings following facial dermabrasion. Ann Plast Surg 8:523-527, 1982. Lampe I, LaTourette HB: Management of hemangiomas in infants. Pediatr Clin North Am 6:5]]-528, 1959. Langer K: On the anatomy and physiology of the skin: Skin tension by Professor K. Langer, presented at the meeting of 27th November 1861. Br J Plast Surg 31:93-106, 1978. Levine HL, Bailin PL: Basal cell carcinoma of the head and neck: Identification of the high risk patient. Laryngoscope 90:955-961, 1980. Levine H, Bailin P: Carbon dioxide laser treatment of cutaneous hemangiomas and tattoos. Arch Otolaryngol 108:236-238, ]982. Lunsford LD: lteatment of tic douloureux by percutaneous retrogasserian glycerol injection. JAMA 248:449-453,1982. Mahler D, Ben-Yahar Y, Barruchin A: Plication of the orbicularis oris muscle to repair partial paralysis of the lower lip. Ann Plast Surg 8:224-226, 1982. Martin H, Helsper JT: Spontaneous return of function following surgical section
or excision
of the seventh
cranial nerve in the
surgery of parotid tumors. Ann Surg 151:538, 1960. Masson JK, Soule EH: Desmoid tumors of the head and neck. Am J Surg 112:615-622, 1966. Masters FW, Robinson DW, Simons IN: Temporalis transfer for lagophthalmos due to seventh nerve palsy. Am J Surg ]]0:607-6]], 1965. May M: Facial paralysis, peripheral type: A proposed method of reporting. Laryngoscope 80:33] -390, ] 970. May M: Management of cranial nerves I through VII following skull base surgery. Otolaryngol Head Neck Surg 88:560-575, 1980. May M: Trauma to the facial nerve. Otolaryngol Clin North Am 16:66]-670, 1983. May M: The Facial Nerve. New York, Thieme-Stratton, 1986. McCabe BF: Management of hyperfunction of the facial nerve. Ann Otol 79:252, 1970. McCandless GA, Schumacher MH: Auditory dysfunction with facial paralysis. Arch OtolaryngolI05:271-274, ]979. McCoy EG, Boyle WF: Reinnervation of the facial muscles following extratemporal facial nerve resection. Laryngoscope 81:1-7, 1971. McGovern FH: Chorda tympani neurectomy for Bell's palsy. Arch Otolaryngol 92: 189-190, 1970.
THE FACE
Meyerhoff J: Lyme disease. Am J Med 75:663-670, 1983. Miglets AW:Lip transposition in patients with facial paralysis. Presented at the meeting of the middle section of the American Laryngological, Rhinological and Otological Society, Inc., Indianapolis, January 20, 1979. Mohs FE: Chemosurgery for the microscopically controlled excision of skin cancer. J Surg Oneal 3:257-267, 1971. Mohs FE: Chemosurgery for facial neoplasms. Arch Otolaryngol 95:62-67, 1972. Munro lR, Chen YR: Radical treatment for fronto-orbital fibrous dysplasia: The chain-link fence. Plast Reconstr Surg 67:719-729, 1981. Mustarde JC: Repair and Reconstruction in the Orbital Region. Edinburgh, E & S Livingstone, 1969. Nicolai JPA: Free muscle grafting in facial paralysis. Br J Plast Surg 34:91-94, 1981. Nicolai JP, Vlngerhoets HM, Notermans SL: Our experience with Freilinger's method for dynamic correction of facial paralysis. Br J Plast Surg 35:483-488, 1982. Ohmori K: Major osteotomies of the cranium, facial bones, and mandible. Ann Plast Surg 4:481-494,1980. Ohtsuka H, Shioya N: The fate of free omental transfers. Br J Plast Surg 38:478-482, 1985. Ousterhout DK, Penoff JH: Surgical treatment of facial deformity secondary to acromegaly. Ann Plast Surg 7:68-74, 1981. Panje WR, Ceiiley RI: The Influence of embryology of the mid-face on the spread of epithelial malignancies. Laryngoscope 89:1914-1920, 1979. Parker G, et al: Surgical repair of extratemporal facial nerve: A comparison of Suture repair and microfibrillary collagen repair. Laryngoscope 94:950-953, 1984. Parnes SM, Strominger N, Silver S, Goldstein JC: Alternate innervations of facial musculature. Arch OtolaryngolI08:418-421, 1982. Phelan JT, Milgrom H: The use of Mohs' chemosurgery technique in the treatment of skin cancers. Surg Gynecol Obstet 125:549-560, 1967. Piersol GA: Human Anatomy, 3rd ed. Philadelphia, JB Lippincott, 1911. Pilney FT, Broadbent TR, Woolf RM: Giant pigmented nevi of the face: Surgical management. Plast Reconstr Surg 40:469-474, 1967. Poppen JL: An Atlas of Neurosurgical Techniques. Philadelphia, WB Saunders, 1960. Pressman JJ, Berman W, Simon MB: Primary repair of defects following a surgical removal of tumors of the face. Arch Surg 79:921-938, 1959. Pulec JL: Facial nerve grafting. Laryngoscope 79:1562-1583, 1969. Ragnell A: Experience
with dynamic
and static reconstruction
in
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(carcinoma)
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1981.
Rubin LR: Discussion: Superficial musculoaponeurotic system suspension and buccinator plication for facial nerve paralysis. Plast
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Sachs ME, Conley J: A composite hair-bearing and non-hair-bearing sideburn flap. Ann Plast Surg 7:295-297, 1981. Sachs ME, Conley J: Intraoral masseter muscle transposition: Use with reconstruction of regional paralysis. Arch OtolaryngolI08:397-400, 1982. Schaefer SD, Byrd HS, Holmes RE: Forehead and scalp reconstruction after wide-field resection of skin carcinoma. Arch Otolaryngol 106:680-684, 1980. Schrudde J, Petrovlci V: Surgical treatment of giant hemangioma of the facial region after arterial embolization. Plast Reconstr Surg 68:878-889, 1981. Schultz RC: Reconstruction of facial deformities with alloplastic material. Ann Plast Surg 7:434-446, 1981. Shikhanl AH, Shehadi SI: Surgical treatment of giant hemangiomas of the head and neck. Otolaryngol Head Neck Surg 94:113-122, 1986. Silverstein, H.: Surgery of the facial nerve. J OtolaryngollO:449-458, 1981. Smith TE, Canady JW, Jons CD: Cervicofacial high-pressure hydraulic Injection Injury. Arch Otolaryngol 108:452-453, 1982. Spira M, Gerow FJ, Hardy SB, Beall AC Jr: Windshield injuries of the face. J Trauma 8:513-526, 1968. Strahan RW, Calcaterra TC: Otolaryngologlc aspects of mycosis fungoldes. Laryngoscope 81:1912-1916,1971. Stratoudakis AC, Savitsky LB: Microsurgical reimplantation of avulsed scalp. Ann Plast Surg 7:312-316, 1981. Symposium on Facial Pain. Headache 9,1969. Thomas ML, Andress MR: Angiography in angiomas of the face. Am J Roentgenol Radium Ther Nucl Med 112:332-338, 1971. Thomas ML, Mitchell DP: Facial paralysis with absence of Internal and external carotid arteries. J Otolaryngol 9:353-356, 1980. Tolhurst DE, Bas JE: Free revascularlzed muscle grafts in facial palsy. Plast Reconstr Surg 69:760-769, 1982. 1\Jerk M: The Ivy loop. Ann Plast Surg 6:14-19, 1981. 1\Jlenko JF, Conway H: An analysis of sweat gland tumors. Surg Gynecol Obstet 121:343-348, 1965. Upton J, Mulliken JB, Hicks PD, Murray JE: Restoration of facial contour using free vascularized omental transfer. Plast Reconstr Surg 66:560-567, 1980. Van der Meulen JC, Moscona AR, Vandrachen M, Hirshowitz B: The management of orbitofacial neurofibromatosis. Ann Plast Surg 8:213-220, 1982. Van der Meulen JCH, Hauben DJ, Vaandrager JM, BlrgenhagerFrenkel DH: The use of a temporal osteoperiosteal flap for the reconstruction of malar hypoplasia in Treacher-Collins syndrome. Plast Reconstr Surg 74:687-693, 1984. Vandervord JG, Teasdale GM: Forehead reconstruction using a bipedicled bone flap. Br J Plast Surg 35:75-79, 1982. Voorhies R, Patterson RH: Management
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8
Microvascular free flaps are depicted in Chapter 24. Some of the areas require reconstruction, outlined in this and other chapters. For example, large defects of the buccal wall, face, and lips may be better reconstructed with a microvascular free flap.
Introduction: Flap Selection and Design (Tables 8-1 and 8-2) Highpoints
1. Etiology of the primary defect: should a flap be utilized or is a prosthetic device preferred? 2. Donor site consideration is a factor. 3. The simpler the flap, the better. 4. Is a local or distant flap necessary? Should it be cutaneous or myocutaneous? 5. Age and general medical condition of the patient are factors. 6. There should be a minimal number of stages. 7. There should be minimal disability. 8. Inform the patient that the flap may be hair bearing! Three Basic Principles Etiology of the Primary Defect
Should a flap be utilized or is a prosthetic device preferred? Is the defect due to (1) surgical ablation for neoplasia, (2) trauma, or (3) congenital deformity? Although many
TABLE8-1
flaps are interchangeable, the cause of the defect is important in the decision regarding the use and selection of flaps. The use of a flap developed from the potential areas of spread of a malignant tumor is contraindicated (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 when such a tumor has a high rate of local recurrence is likewise contraindicated (e.g., an orbital defect after a maxillary resection and orbital enucleation). In this case a split-thickness skin graft with prosthetic device is preferred. Another example is a defect due to a recurrent adenoid cystic carcinoma of the palate or nose. A prosthetic device is also preferred in this situation. Regardless of the type of flap utilized, the adage of avoiding coverage of areas of highly probable recurrent carcinoma still applies. Most of the time this problem cannot be avoided except for coverage as mentioned earlier of an orbital defect or a defect after resection of the ear. In these two latter areas, a full-thickness flapeither free microvascular or full-thickness local rotated flap-thwarts the use of a prosthetic eye or ear in addition to masking recurrent disease. As a basic principle, knowledge of the natural history of a malignant neoplasm is paramount when deciding whether a flap is preferred over a free skin graft and/or a prosthetic device. Aside from the natural history of the malignant neoplasm, the surgeon must determine whether the defect site is such that a prosthetic device is the simpler method of rehabilitation. Circumstances that usually are more amenable to devices are (1) total
Examples of Defects and Choices of Flaps
DefectExample
Choices
Totalor subtotal nasal loss Portion of cheek Floor of mouth, large portion of tongue Major portion of buccal wall Hypopharynxand oropharynx
Prosthesis-scalpingflap (see Fig. 6-29) Advanced lateral cheek flap/free groin flap (see Fig. 7-6) Pectoralis major flap (see Fig. 8-2A)/apron flap (see Fig. 8-6) Forehead flap (see Figs. 8-10and 8-U)/free groin flap Pectoralis major flap with dermal graft (see Fig. 8-2A),deltopectoralis flap (see Fig. 8-4Aand B), and posterior tongue flap and dermal graft (see Fig. 21-7)
399
G~N~RALPURPOS~FlAPS
Simplified Classification of Flaps Blood Supply
Random Axial Free
Dermal and subdermal plexus Predominant artery and vein in flap Microvascularanastomosis
ear replacement, (2) large palatal defects, and (3) large nasal defects. This does not mean that flaps are not to be utilized in the last two instances. In certain large nasal defects, the patient's attitude, desires, and personality may be the deciding factors. For example, an elderly patient once flatly refused a necessary total resection of the nose for squamous cell carcinoma unless he was rehabilitated with living tissue. He refused a prosthetic device (see Fig. 6-29). Donor Site Consideration Another consideration is the nature of the defect at the donor site. For example, use of a forehead flap in a young individual for reconstruction of a significant facial defect secondary to trauma is usually contraindicated because of scarring of the forehead, whereas in elderly patients, scarring of the forehead is usually much less noticeable. To minimize the apparent defect, the incisions are best placed along the hairline above and just above the eyebrows below. Gillies has described various rotation flaps to minimize the defect of the donor forehead site. Others have suggested not to apply skin grafts to the donor site immediately but rather to wait for granulation tissue to fill in the depression along the edges and then to apply a skin graft. Others have utilized full-thickness grafts from the clavicular area after drilling the cortex of the frontal bone. The dorsalis pedis free microsurgical flap is contraindicated because of the disability at the donor site. If a free flap is preferred, the groin flap, with or without iliac bone, by and large would be the one of choice. The problem with this flap may be its color rendition when it is utilized to replace large defects in the cheek. Dermabrasion may aid in improved color rendition. The groin flap may be ideal for a large buccal wall replacement, or a forehead flap externally and a pectoralis major flap for interior cover. Another donor site problem could arise with use of the deltopectoral flap in certain females in whom a defect of the anterior chest wall is undesirable. The Simpler the Flap, the Better The use of local advanced skin or mucosa flaps, if feasible, is often preferred. At times no flap is necessary at
all-using a skin graft or leaving a wound to granulate may suffice. With the introduction, or re-introduction, of "new flaps," there often is an eagerness to try them out. This is understandable in our attempt to further evaluate something new and may be justified under certain circumstances. Yet, constraint must be employed based on experience and the final results to be achieved. It must be emphasized that because a procedure is possible and feasible does not mean it is an indication for the procedure. All in all, most flaps are nonfunctional in that they do not have muscular activity in relation to the part that they are replacing. There are few exceptions. Flaps brought into the floor of the mouth and to the tongue are simple space-occupying boluses of tissue. They may reduce scar contracture and aid in the preservation of the mandible-a very important objective-but they do not have motor function. The pectoralis myocutaneous flap supplies bulk and probably has the potential for the best survival rate of any distant flap. It can be combined with a deltopectoral flap on the ipsilateral side and can be brought deep to or superficial to the cervical skin. Its length can be increased by sectioning the muscle at the base of the pedicle or resecting the medial third of the clavicle. Classification of Large Transposed Myocutaneous Flaps 1. Pectoralis major myocutaneous flap. This is able to handle up to 90 % of virtually all defects that require a significant amount of soft tissue. 2. 1l'apezius flap. This flap has a very questionable blood supply that is often interrupted during a radical neck dissection; however, some authors have indicated that this flap can be utilized despite the interruption of the transverse cervical artery. Nevertheless, because of its questionable blood supply, it is seldom necessary and is rather awkward to use because the patient has to be rotated or has to be specially positioned with an inflatable thyroid pillow. It is seldom utilized. 3. Latissimus dorsi flap. Usually, this flap has a good blood supply and an adequate amount of tissue; however, its drawback is that the surgeon must change the position of the patient, which also becomes awkward. A potential advantage is additional length. The blood is from the thoracodorsal artery. 4. Sternocleidomastoid myocutaneous flap. There is usually no application for this flap in major head and neck oncologic surgery, because it violates the neck. One exception is its use in the modified neck dissection for thyroid cancer. If the lesion on the face is of such a size that it requires a myocutaneous flap, the possibility of nodal metastasis, present either at
GENERAL PURPOSE FLAPS
the time of the initial surgery or later on, is so high that the flap will obscure the clinical early detection of metastatic cervical disease. This results in the socalled violated neck. A pectoralis myocutaneous or free vascularized flap is recommended. S. Forehead flap. This is an excellent flap as far as blood supply is concerned. The problem is in the defect in the donor site, which can be minimized by placing the incision along the hairline. Nevertheless, in a younger individual the defect is not warranted if some other flap can be utilized. A free vascularized flap would be preferred. Limitations and Pitfalls with Major Standard Regional Flaps 1. Usual lack of function of a flap (e.g., a flap brought into the floor of the mouth and/or tongue will not in itself move with deglutition); dysphagia and pooling of food may result. 2. Compromise of viability of the flap by ablative surgery and/or radiotherapy relative to the donor site 3. Generalized arteriosclerosis 4. Severe diabetes mellitus S. Severe malnutrition 6. Kinking or compromise of a flap by dressings, drains, tubes, or tracheostomy tube tape 7. Flap must be in contact with the underlying structure that is to be protected. This must be accomplished without pressure on an underlying firm object, whether it be a clavicle, a zygomatic arch, Kirschner wire, Steinmann pin, or a mandibular bar or plate. Limitations and Pitfalls According to Specific Flaps Deltopectoral
Flap
1. A failure rate of 9% to 18% may occur, especially with an extended deltopectoral flap. Although this failure is usually not a disaster, if the flap is used to cover the carotid vessels in the presence of a fistula and/or previous radiotherapy, carotid artery blowout is a possibility and has been reported. 2. When used to reconstruct defects of the hypopharynx, oropharynx, cervical esophagus, or oral cavity, a planned fistula is usually necessary. This then requires at least one more operative stage and prolongs the "wait to swallow period" up to 11/, to 3 months. At times, de-epithelialization of a portion of a flap may obviate the fistula. A simpler one-stage reconstruction utilizing a tongue flap and dermal graft is possible for hypopharyngeal defects up to 8 em in length. A free jejunal or tubed radical forearm free flap is ideal for this type of defect.
3. Previous radiotherapy to the neck may result in scatter radiation over the anterior chest wall. This could be avoided by shielding during the radiotherapy; otherwise, the upper incision of the flap should be moved inferiorly 2 to 4 em below the level of the clavicle, and delay may entail several stages, starting with only skin incisions. 4. 1fthe deltopectoral flap is used to cover, for example, a vascular anastomosis just above or deep to the clavicle after a radical neck dissection, a dead space can result with carotid artery blowout unless the clavicle is resected. S. Dependent traction of a deltopectoral flap by its mere weight can cause deformity (e.g., reconstruction of a large portion of the skin of the soft tissue of the chin will pull the lower lip inferiorly). Suturing of the upper and lower lips with a small opening in the middle may minimize this problem. On the other hand, bilateral advanced lateral cheek flaps (e.g., Bernard [with Burow triangles] method) would prevent this problem (see p. 482). Forehead Flap
1. Donor site defects especially in the younger patient are detrimental. 2. Compromise of blood supply is possible via the superficial temporal artery if a simultaneous radical neck dissection has sacrificed the external carotid artery. Although McGregor and Reed (1970) minimize this possibility, loss of a portion of the forehead flap can occur. 11is most important to include the posterior auricular artery with a portion of the scalp above and behind the ear. Delay is advised. 3. In the reconstruction of the floor of the mouth and portion of the tongue, do not drape the flap over a bare Kirschner wire that is being utilized to stabilize the mandibular ends when a section of the mandible has been resected. Another problem that can occur is pinching of the flap if it crosses opposing teeth to reach the floor of the mouth or tongue. 4. There is danger of compromise of blood supply if the flap is tunneled deep to the zygomatic arch. 1f this is the approach to reach the oral cavity, it is best to fracture the arch outward with two osteotomies. The other approach is over the zygomatic arch. S. Injury to the facial nerve may occur when performing an access to the oral cavity. Nape of the Neck Flap
1. This flap must be delayed. 2. Possible injury may occur to the spinal accessory nerve. 3. This flap has limitations in regard to its length.
GENERAl PURPOSE FlAPS
Apron Flap
1. Do not extend below the level of the clavicle, otherwise the tip may necrose. 2. Unless an epithelial shave is utilized, a planned, yet temporary, orocutaneous fistula will result when this flap is utilized to reconstruct the floor of the mouth. Converse Scalping Flap for Total or Subtotal
Nasal Reconstrucuon 1. Take care to avoid pressure on the eye on the side of the base of the flap. 2. There is a problem in shaping the ala nasi. 3. Nasal obstruction may occur. Pectoralis Major
Myocutaneous
Flap
1. This flap appears to be one of the best myocutaneous flaps utilized in head and neck surgery. 2. Muscle bulk can be a problem in this flap. When utilized for the reconstruction of the cervical esophagus and/or hypopharynx, use a dermal graft for the posterior wall of reconstructed gullet rather than a flap (see Fig. 8-2G and G'). 3. If muscle bulk is desirable, be certain that the nerve supply is preserved. 4. There is some limitation as to the length and mobility because of the vascular supply. Resection of medial third of clavicle is of help (see p. 1041) but is rarely used. Trapezius Myocutaneous
Flap
1. There will be a defect at the donor site with a shoulder droop. 2. At times there are problems with blood supply, usually from the transverse cervical artery. When the blood supply is solely or primarily from the transverse cervical artery, this flap can be mobilized on its long vascular pedicle and utilized as an island flap. Reports state that this can be combined with bone from the spine of the scapula. Bulk may be a problem if it is used to reconstruct cervical esophagus. Free Flaps with Microvascular
Anastomosis
1. These flaps require additional time. 2. They are not for the surgeon who performs the isolated reconstruction; the operation is relegated to larger services with two teams. 3. Skin and adipose tissue should be 10% to 15% larger than is needed.
4. Bulk is good and bad-good for buccal wall defect, bad for cheek defects. 5. Details are presented in Chapter 24.
Blood Supply to Skin Flaps (Fig. 8-1) (After McGregor and Reed, 1970; Ariyan, 1979; Baek et aI., 1981) The blood supply to skin flaps has been described by McGregor and Reed (1970) as being axial or random. Actually, a combination of both types may exist in a number of skin flaps, for example, the pectoralis major myocutaneous flap (Ariyan, 1979), which is the most versatile of all flaps for head and neck reconstruction. The axial pattern has a distinct arteriovenous circulation that follows the long axis of the flap, giving off branches to the dermal-subdermal plexus of vessels. The viability of the flap depends on the length of these axial vessels (artery and veins) and not on the ratio of length to width. The random flap, on the other hand, has no axial vessels and derives its blood supply from the communication vessels in the dermal-subdermal plexus (the deltopectoral flap [Bakamjian, 1968]). Hence, the length of the random flap has a significant relation to the width of the flap. It should be stressed that the axial-patterned flap can and does have random portions, depending on the location of the flap, either at its distal end or along its sides. For example, the distal end of a pectoralis major myocutaneous flap can have a random portion beyond the pectoral branch of the thoracoacromial artery when the skin and underlying rectus fascia are included. In addition, a random portion of the pectoralis major myocutaneous flap can have a medial random portion extending over the sternum (Baek et a!., 1982). Any of these random portions, however, can be tenuous and not as reliable as the pure axial component. The myocutaneous axial flap is based on a dominant axial arteriovenous circulation from segmental vessels that lie beneath the transposed muscle. This axial circulation in turn has branches (perforators) that supply the muscle. Either directly from the axial vessel (myocutaneous) or from the perforators (direct cutaneous) are cutaneous vessels that supply the skin. Depicted (after Ariyan, 1979; Harii, 1983) are variations of the myocutaneous flap that involve flat muscles (e.g., the pectoralis major, trapezius, and latissimus dorsi muscles). The pectoralis major muscle without skin can be used for reconstruction of the pharynx. The fascia of the flap is sutured to the esophagus and the pharynx. This is ideal for reconstruction after partial resections 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 pectoralis major flap, the axial vessels (the pectoral branch and at times the lateral thoracic) are seen arising from the thoracoacromial artery giving off the perforating muscular branches, and these in turn give off the two types of cutaneous vessels, the myocutaneous and direct cutaneous. The axial portion of the flap is with the pectoralis major muscle and axial vessel. The portion of the skin beyond the extent of the muscle and the axial vessel is the random portion of the flap. This random portion without the axial vessel depends on its viability from small vessels in the dermalsubdermal plexus. Not shown are the accompanying veins, which are as important as the arteries. This type of flap is utilized when the entire portion of the overlying skin is required to cover the defect as well as forming a tube flap pedicle (see Fig. 8-2 0).
B This is the so-called paddle myocutaneous flap in which the arteriovenous circulation along with the overlying muscle is transposed. The intervening skin between the base of the flap and the paddle is not utilized. The advantage of this flap is that the axial vessels and the muscle can then be buried under skin. Numerous examples are shown in the following figures. C This modification, in which the muscle is transected, is primarily used to achieve additional length and can be more easily rotated. The danger is in the interruption of the vascular pedicle, especially the veins. Additional length can be achieved with a pectoralis major myocutaneous flap by resection of the clavicle (see Fig. 8-2H). Another application is the use of these flaps as free flaps with microvascular anastomosis. This variation has many drawbacks and is usually not utilized with the pectoralis major myocutaneous flap.
GENERALPUR~SEFLAPS
Pectoralis Major Myocutaneous Flap (Fig. 8-2) (After Ariyan, 1979) 6. Highpoints
1. Outline the course of the pectoral branch of the thoracoacromial artery to the pectoralis major muscle (see Fig. 8-2B). Sometimes the pectoral branch of the thoracoacromial artery is not significantly developed at all and the major blood supply to the pectoralis major is from the lateral thoracic artery. This could be a disaster and points out the importance of inspecting the underportion of the pectoralis major flap with an incision along its lateral border, thereby verifying the usual position of the pectoral branch of the thoracoacromial artery. A sterile Doppler device may be of help in delineating this at the time of surgery. 2. Outline the size and the configuration of skin and muscle that are required to cover the defect. These dimensions obviously will vary depending on the size and the location of the defect. This flap can reach the orbit and at times the forehead. 3. If there is any possibility of the need of a deltopectoral flap, this flap should first be elevated from its distal portion, at least to the medial aspect of the thoracoacromial artery. Both a pectoralis major myocutaneous flap and a deltopectoral flap can be utilized on the same side. Preserve the lateral thoracic artery if possible, especially if double sideby-side paddles are to be utilized (see Fig. 8-30) (Freeman et al., 1981). This artery can be preserved by dividing the humeral head of the pectoralis major muscle and the lateral border of the pectoralis minor muscle (Krespi et aJ., 1983). 4. The initial incision for the flap is then along the lateral border of the outlined skin for the pectoralis major flap. The incision is carried down to the pectoralis major muscle. 5. If this incision is close to the lateral margin of the pectoralis major muscle, then this lateral margin is elevated deep to a plane along the anterior surface of the pectoralis minor muscle. Otherwise, the pectoralis major muscle is split along its fibers, with the certainty that the pectoral branch of the thoracoacromial artery is medial to this line of separation. If there is any question regarding location of the vascular pedicle, it is safer to visualize first the pedicle via the lateral border of the pectoralis major muscle. As this incision is made, the edges of the skin are sutured to the underlying
7.
8.
9. 10.
n. 12.
13.
14.
15.
16. 17.
muscle to prevent separation and retraction of these two structures. Be certain to establish by blunt dissection the plane and the adventitia deep to the pectoralis major muscle, which is along the pectoralis minor muscle, and the ribs, being certain that the pectoral artery and vein and the lateral pectoral nerve are attached to the undersurface of the pectoralis major muscle. Preserve the fascia surrounding the neurovascular bundle. Keep the vascular bundle in view during the entire dissection to avoid injury to this bundle. The nerve is necessary if muscle bulk is permanently desired. On the other hand, the nerve is sacrificed if muscle atrophy is desired. Do not dissect the vascular bundle from its surrounding fascia. This is very important if the muscle is freed from its clavicular attachment to gain more length. The vascular bundle with its surrounding fascia is then freed of the muscle. The flap is placed anterior to the clavicle, or the medial one half of the clavicle is resected. Resect the medial half of the clavicle if additional length is necessary. This maneuver also serves other purposes: It allows filling in of the dead space just above the level of the clavicle resulting from a radical neck dissection, protects the vascular pedicle from any compression over the clavicle, and eliminates any bulk over the clavicle. It also protects the subclavian vein. Use a separate Hemovac suction drain for the donor site on the chest. The donor site can almost always be closed by advancing the medial and lateral skin flaps. When a very large portion of skin is utilized, a skin graft may be necessary. No circular dressing or tapes around the neck are utilized that might compress the vascular pedicle; especially vulnerable are the veins. This would lead to a "wet gangrene." A tracheostomy should be performed when the flap is utilized to reconstruct the hypopharynx, oropharynx, or oral cavity. Avoid twisting or rotating the vessels on themselves, because this might primarily obstruct the veins as well as the arteries. Separate Hemovac drains are used in the cervical area. Postoperative clindamycin coverage is preferred rather than use of a cephalosporin because clindamycin binds to leukocytes and may reach the actual area of demarcation of a flap.
GENERAL PURPOSE FLAPS
PECTORALIS MAJOR M.
SERRATUS ANTERIOR
MJ RECTUS FASCIA
LATISSIMUS DORSI M. EXTERNAL OBLIQUE M.
A FIGURE 8-2
A Depicted is the muscular anatomy related to the anterior and lateral chest wall. Of particular importance are the various directions of the fibers of the pectoralis major muscle. The superior fibers are horizontal, whereas the inferior fibers are oblique. Hence, these inferior fibers can usually be split, whereas the superior fibers, particularly those attached to the humerus, require transection. Continued
The thick fan-shaped pectoralis major muscle has three origins: (1) clavicular from the medial half of the clavicle, (2) sternocostal from the manubrium and body of the sternum and the first or second to the sixth costal cartilages, and (3) abdominal from the rectus fascia. The muscle inserts into the crest of the greater tuberosity of the humerus. The direction of the muscle fibers ranges from horizontal to oblique. This must be kept in mind when dissecting, transecting, and splitting the muscle fibers during the development of the flap. It is thus obvious that the horizontal fibers at the axilla must be transected to mobilize the pectoralis major muscle fully. It is in this location that the lateral thoracic artery is identified and preserved, if feasible. This is advisable if a longitudinal double paddle is to be utilized (see Fig. 8-3D). The nerve supply to the pectoralis major muscle is
from the lateral pectoral nerve (also known as the anterior lateral thoracic nerve) and the medial pectoral nerve (also known as the anterior medial thoracic nerve). The lateral pectoral nerve arises from the lateral cord of the brachial plexus, whereas the medial pectoral nerve arises from the medial cord of the brachial plexus. It is interesting, however, that in their distribution to the pectoralis major muscle, the medial pectoral nerve actually is located laterally, whereas the lateral pectoral nerve is located medially. These nerves enter the muscle near the axilla under the horizontal fibers of the muscle and can be visualized between the pectoralis minor and the pectoralis major muscles. The lateral pectoral nerve is closely related to the pectoral branch of the thoracoacromial artery and is contained in the neurovascular bundle. The medial pectoral nerve is somewhat more lateral and often pierces the pectoralis minor muscle to reach the pectoralis major. The medial pectoral nerve almost always has to be sacrificed in the mobilization of the pectoralis major myocutaneous flap. Their exact identification can be easily confirmed with a nerve stimulator. There seems to be some evidence that the preservation of these nerves will aid in maintaining the muscle bulk, if this is advantageous. The converse is also true; that is, when using the flap with a dermal graft to reconstruct the hypopharynx and cervical esophagus, the muscle then tends to atrophy if these nerves are sacrificed.
GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous Flap (Continued) (Fig. 8-2) (After Ariyan, 1979) B Depicted are the dotted lines that indicate graphically the general course of the pectoral branch of the thoracoacromial artery, which is the main axial artery of the pectoralis major myocutaneous flap. This pectoral branch may be displaced laterally on females with large pendulous breasts. The initial dotted line runs from the shoulder tip to the xiphoid process. The second line runs from the midportion of the clavicle at a right angle to the first line. Continued
The thoracoacromial artery is a short trunk arising from either the first or second part of the axillary artery several centimeters below the clavicle. The thoracoacromial artery pierces the coracoclavicular fascia, which runs from the subclavius muscle to the pectoralis minor muscle. The axillary artery (Anson and McVay, 1971), which is a continuation of the subclavian artery, extends from the outer margin of the first rib to the lower border of the teres major muscle, where it becomes the brachial artery. The subclavian artery is divided into three divisions or sections. The first division lies behind the clavicular pectoral fascia and the clavicular head of the pectoralis major muscle, the second division lies behind the pectoralis minor muscle, and the third division lies partially behind the pectoralis major muscle extending to the lower border of the teres major muscle. Another more simplified description is that the first division is above the upper border of the pectoralis minor muscle, the second behind the pectoralis minor muscle, and the third from the lower border of that muscle to the teres minor muscle. The thoracoacromial artery thus usually arises from the first division of the axillary artery, although some authors state that it arises from the second division beneath the medial edge of the pectoralis minor muscle. Regardless, numerous variations of the branches of the axillary artery occur. The pectoral branch of the thoracoacromial artery lies between the pectoralis major and the pectoralis minor muscles, is enveloped in fascia that is contiguous
with the deep fascia of the pectoralis major muscle, and runs inferiorly along the oblique fibers of that muscle to about the fifth or sixth rib. This axial artery is thus medial to the nipple. However, in two overweight female patients with pendulous breasts, this vessel could not be identified in this location. In one patient in whom the distal one third to one half of the flap failed, there was a major vessel more lateral. On venous digital subtraction angiography performed postoperatively on the contralateral side, no pectoral branch as such could be identified. The more lateral vessel appeared to be the lateral thoracic artery. In any event, in overweight females with pendulous breasts, it appears worthwhile to identify the blood supply to the pectoralis major muscle with preoperative digital subtraction angiography. 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 perforator of the pectoral artery, as described by Kaplan and Harwick (1983). The thoracoacromial artery usually has four branches (pectoral-the largest, acromial, clavicular, and deltoid), although there may be a fifth branch, the lateral thoracic. DeGares, in Gray's Anatomy, states that the lateral thoracic artery arises directly from the axillary artery (as depicted) in 30% of patients, whereas in 60% of patients it arises from the thoracoacromial artery or the subscapular artery. In any event, the lateral thoracic artery contributes to the blood supply of the pectoralis major muscle as well as the pectoralis minor muscle, and this author attempts to preserve this vessel whenever possible. It often lies behind the pectoralis minor muscle and may run to the lateral border of the pectoralis minor for 4 or 5 em and then reach the pectoralis major muscle. In summary, the pectoralis major muscle derives its blood supply in order of importance from (1) the pectoral branch of the thoracoacromial artery, (2) the lateral thoracic artery from the axillary artery or from the thoracoacromial artery, and (3) from the superior thoracic artery to a lesser extent. The blood supply is also obtained from the pectoral branches and perforators of the internal mammary artery. These vessels are of course always sacrificed in the mobilization of this flap. The reader is referred to the excellent anatomic injection studies of Freeman and colleagues (1981). These authors also review the historical background of this flap.
GENERAL PURPOSE FLAPS
l ACROMIAL A. DELTOID A. THORACOACROMIAL
A. , SUPERIOR THORAC1IC A.
AXILLARY A. PECTORAL BRANCH (THORACOACROMIAL A.)
'1
I'
t
f41.1
I
!
1
LATERAL THORACIC A.
I I
}
/ (
,
B FIGURE 8-2 Continued
407
408
GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous Flap (Continued) (Fig. 8-2) (After Ariyan, 1979) C The course of the pectoral artery has been scribed with a 'marking pen, and the appropriate paddle of skin has been outlined. The length and width of the paddle should be carefully measured relative to the defect to be reconstructed. In general, for large defects it is somewhat better to make the paddle larger, both in width and length, than initially calculated. The lateral incision is first made superiorly. The skin edges are tacked to the immediate underlying muscle to prevent separation and retraction of the skin from the muscle. These sutures must not be placed deep into the muscle, thus avoiding injury to the pectoral artery or any of its branches. The safest method of avoiding injury to the pectoral
artery is to identify the lateral
major muscle with the muscle. The pectoral artery lies within this fascia. Another advantage to this approach is the probability and possibility of the preservation of the lateral thoracic artery. D An alternate method is to split the pectoralis major muscle 2 em medial to its lateral border and then enter the plane between the pectoralis major and the pectoralis minor muscle. In overweight females this is not advised. Regardless, the surgeon must be certain that the artery is medial to this muscle split. Using this technique, it is more difficult to preserve the lateral thoracic artery, if not impossible.
Continued
The superior extension of the skin incision toward the clavicle is optional. If there is enough elasticity to
border of the pectoralis major muscle, which is retracted
the skin beneath
the clavicle,
the flap can then
be
medially, A plane is then developed between the pec-
tunneled under the skin. The main point is not to have
toralis major and the pectoralis minor muscles, taking
too much
care to keep the fascia on the deep side of the pectoralis
through the tunnel.
pressure
on the
pedicle
as it is passed
GENERAL PURPOSE FLAPS
LATERAL THORACIC A. ;;A,
PECTORALIS
PECTORALIS
MAJOR M.
MINOR M.
D FIGURE 8-2 Continued
GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous Flap (Continued) (Fig. 8-2) (After
Ariyan,
1979)
E Further mobilization of the flap is shown. Its attachments to the rectus fascia and the costochondral cartilages have been transected. Perforating vessels as well as the pectoral vessels from the internal mammary artery are ligated. Smaller vessels are cauterized. The reflected flap demonstrates the pectoral artery and vein. Somewhat laterally are the lateral and medial pectoral nerves. The medial nerve is lateral, and the lateral nerve is medial. The superior portion of the lateral skin incision is optional. This incision can be turned medially and reach the clavicle or the muscle flap brought under the skin through a wide open tunnel. An alternate method is to elevate the distal end of the deltopectoral flap, if such a flap is to be used concomitantly
or later on.
this incision and courses along the lateral border of the pectoralis minor muscle, supplying both the pectoralis major muscle and the pectoralis minor muscle. It anastomoses with the pectoral branch of the thoracoacromial artery. If the lateral thoracic artery is not to be preserved, the muscle is transected somewhat more medially closer to the pectoral artery. Another deciding factor is the amount of muscle bulk that is desired, for example, if the tissue mass resulting from a radical neck dissection is to be matched, the width of the pectoralis major muscle should be somewhat wider than the sternocleidomastoid muscle that has been resected. If a double paddle-side by side-is to be used, preservation of the lateral thoracic artery is virtually necessary, with the lateral paddle supplied by the lateral thoracic artery and the medial paddle by the pectoral artery (see Fig. 8-3D).
F The flap is mobilized farther and brought under a skin tunnel to pass over the clavicle.
The horizontal fibers of the pectoralis major muscle,
An alternate
method
is to transect the skin along the dotted line or to
those that are attached to the humerus and that form the anterior fold of the axilla, are transected somewhat
develop a deltopectoral
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 the axilla. The lateral thoracic artery is thus medial to
has been preserved
flap. The lateral thoracic artery
in this stem, showing transection
Continued
GENERAL PURPOSE FLAPS
NEUROVASCULAR
BUNDLE A.V.& N.
( ,
\
CLAVICLE
\
PECTORALIS MAJG{R
HORIZONTAL FIBERS OF THE PECTORALIS MAJOR TO THE HUMERUS
E
PECTORAL SR.
LATERAL THORACIC A.
F FIGURE 8-2 Continued
GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous Flap (Continued) (Fig. 8-2) (After Ariyan, 1979) Reconstruction of the Entire Hypopharynx and Portion of Cervical Esophagus, Oropharynx, and Nasopharynx (see p. 1188)
The pectoralis major myocutaneous flap can be used for reconstruction of the pharynx following totallaryngopharyngectomy in some patients, particularly thin males, in whom other methods of reconstruction are precluded or whose general medical condition calls for an expeditious reconstruction. The difficulty of tubing this flap 360 degrees can be overcome by combining it with a dermal graft. G Also depicted is an excellent method of reconstruction of the entire hypopharynx after total laryngectomy and total hypopharyngectomy as well as a portion of the cervical esophagus when the defect is too large for a tongue flap and dermal graft (see Fig. 21-7). The pectoralis major flap is tubed 270 degrees (reducing the bulk of the flap if it were tubed 360 degrees), forming the anterior and lateral walls of the reconstructed gullet, just as a tongue flap is used (see Fig. 21-7). The dermal graft forms the posterior wall of the hypopharynx and esophagus. It can be extended superiorly to reconstruct the posterior wall of the oropharynx and nasopharynx to just above the level of the eustachian tube. It is important that the
flap and dermal graft be sutured to the prevertebral fascia to prevent tension on the mucosal closure suture lines. This method reduces the bulk of an entirely tubed pectoralis major flap, which is detrimental to adequate deglutition. (See p. 1188 for tongue flaps and dermal graft.) Cross Section of Reconstructed Hypopharynx Gl When the dissection includes the lateral wall of the nasopharynx, the internal carotid artery can be jeopardized because it may only be several millimeters deep to the mucosa. Hence, take extreme care in this dissection. When the vessel is exposed, it should be protected with either a transposed muscle flap or a turned-in flap of prevertebral fascia. The fascia is then covered with a dermal graft, which likewise covers the posterior wall of the nasopharynx. Preoperative evaluation of intracranial blood flow may be indicated. Angiography is also advisable as well as computed tomographic scans with enhancement to localize the internal carotid artery. MR angiography and improved resolution MR images can also be helpful regarding evaluation of the vascular structures. The advantage of the improved resolution MR imaging is that it also demonstrates soft tissue as well. Balloon occlusion of the internal carotid artery can be utilized. However there is a reported incidence of stroke of 1%. At the time of operation, trial occlusion can be done with evaluation of back flow from the distal internal carotid artery.
Continued
GENERAL PURPOSE FLAPS
ESOPHAGUS
DERMAL GRAFT
G
FIGURE 8-2 Continued
413
GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous Flap (Continued) (Fig. 8-2) (After Ariyan, 1979)
and medial to the neurovascular bundle are transected. At times the pectoral nerves require transection to obtain additional length and mobilization.
A word of caution is needed regarding covering of the resected lateral wall of the nasopharynx especially when disease has extended superiorly from the oropharynx. Recurrent or persistent neoplastic disease can be so located. Skin grafts and flaps can mask this disease. Once out of control, spread can extend superiorly to the skull base as well as laterally into the paraph aryngeal space (see Chapter 23).
I A pectoralis major myocutaneous flap is shown in the reconstruction after a hemiglossectomy with preservation of the mandible. The mandible has been transected in the midline, and the so-called mandibular swing operation (see Fig. 15-14) approach has been performed. The major drawback in tongue reconstruction is the fact that this flap, like all other transposed flaps, is adynamic. It is a space-filling method and somewhat minimizes the tethering effect that otherwise would occur if the remaining tongue was sutured to the mucosa on the inner side of the mandible. Conley has attempted to achieve some motion to the flap by anastomosing the 12th nerve to the medial and/or lateral pectoral nerves supplying the muscle. He reports only very slight motor function of very questionable value. This flap is also utilized to cover a bent Kirschner wire and tie wires (see Fig. 14-5) when a portion of the mandible has been resected. It is important not to drape the neurovascular bundle of the flap over the Kirschner wire to prevent kinking and obstruction of the vessels. The flap bulk will usually reduce in size as time goes by, depending on the transection of the medial and/or lateral pectoral nerves. Continued
H Further development of the flap with the clavicle removed is shown. This figure depicts the underlying
anatomy, which is usually not visualized this well because of the overlying soft tissue and fascia. Awareness of these structures, however, is important. The lateral thoracic artery has not been preserved in this step. The white dotted horizontal line indicates the line of transection of the pectoralis major muscle from its attachment to the clavicle to gain additional length. This, of course, is optional. The flap is then attached only by its neurovascular bundle and enveloping fascia. If this is done, extreme care must be taken to avoid injury to this neurovascular bundle. A modification can be performed in which the muscle fibers only lateral
GENERAL PURPOSE FLAPS
\
\
THYROCERVICAL TRUNK VERTEBRAL
A.
COMMON CAROTID A. SUBCLAVIAN
A.
INTERNAL THORACIC A. THORACOACROMIAL
A.
FIRST RIB
H
FIGURE 8-2 Continued
GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous Flap (Continued) (Fig. 8-2) (After Ariyan, 1979)
J
An example is shown of a distal skin paddle of a pectoralis major flap used to reconstruct skin and parotid loss after resection of these structures involved in previous surgical and radiation failure. An advanced or rotated medial cheek flap would usually suffice. However, because of the scatter radiation, such a flap might not survive. The very distal end of one of these flaps was randomized, and 1.5 cm of the skin was lost. The irradiated recipient site or the fact that this patient had leukemia may well have contributed to this failure. The defect healed, yet it may be well to avoid random extensions when there is an irradiated recipient area, the patient has leukemia, or there is severe arteriosclerosis or diabetes. K Virtually the entire mammary portion of the flap has been utilized to cover a massive resection of cervical skin that was devitalized after radiotherapy. This is another
reason we no longer use preoperative
or
routine postoperative radiotherapy. The nipple is located posterolaterally. This procedure is reasonably adopted in the male; in a female with pendulous breasts it might well be quite a cosmetic oddity. The donor site in this particularly massive flap usually requires a skin graft (see Fig.
A modification in the female is the utilization of the pectoralis major muscle without the overlying skin and breast. The bare area of the external portion of the muscle can then be covered with a free-skin graft. This same technique can be used in any pectoralis major flap (i.e., when lining an intraoral defect). The inner portion of the muscle is then covered with a free-skin graft. L A pectoralis major myocutaneous flap is ideally suited to reconstruct and to serve as the placement of the tracheostoma after a Sisson procedure for resection of stoma recurrence (see Fig. 19-11 A). A temporary problem that may be encountered is too much bulk on the proximal side of the new tracheal stoma. Care must be taken to trim bulk off the muscle so that the axial artery is not injured. A temporary 6-cm piece of endotracheal tube secured on two tongue depressors taped to the tube serves as a temporary stent to prevent rollover of the bulky flap, which might partially occlude the stoma. The tongue depressors are applied to the skin and help position the endotracheal tube. M
A paddle with a pectoralis major flap has been
utilized to reconstruct skin, soft tissue, and a portion of the trachea associated with resection of carcinoma of the cervical esophagus.
8-3G).
FIGURE 8-2 Continued
Continued
GENERAL PURPOSE FLAPS
FIGURE 8-2 Continued
417
GENERAL PURPOSE FLAPS
Pectoralis Major Myocutaneous Flap (Continued) (Fig. 8-2) (After Ariyan, 1979) Complications
• Loss of flap-usually only the distal portion. This has been encountered in only two situations: in the overweight female with pendulous breasts and when 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 granulation tissue to develop. This has sufficiently protected the carotid vessels to avoid blowout. If there is a suspicion of flap loss at the time of surgery, a possible precautionary measure would be to cover the carotid vessels initially with a levator scapulae muscle flap (see Fig. 22-36) and place this under the pectoralis major flap. Total loss of the flap occurred in one patient because the lateral thoracic artery was not preserved. Fluorescein injected into the deep vasculature and visualized under ultraviolet light might have prevented this complication. • Infection-to avoid a serious calamity when a fistula develops, adequate cervical and chest wounds must be appropriately drained (Hodgkinson, 1982). • Large flaps-any type tends to obscure early recurrent disease. • Possible limited use of ipsilateral upper extremity,
• Hematomas and seromas at the donor site (Biller et al., 1981).
• Hair-bearing portion may be a nuisance; it is best to inform the patient regarding this possibility before the surgery . • Necrosis of flap (especially tubed)-it is best to immediately excise the necrotic portion and reapproximate if at all possible, because necrosis tends to spread. N Depicted is a recurrence of oral carcinoma previously treated by surgery and radiotherapy. Afistula is present. The patient was then treated with chemotherapy followed by wide surgical excision and resection of the mandible.
o
The resected area was reconstructed with a tubed pectoralis major myocutaneous flap. Ifthe tube cannot be completely encircled with chest wall skin from the flap, a temporary split-thickness skin graft is used to cover the bare area as a temporary dressing. This also avoids any compression of the axial vessels. Because the patient had had a previous radical neck dissection, the flap was necessarily external to the skin of the neck. A portion of the internal and common carotid arteries was exposed, and these arteries were adequately covered. by the muscular portion of the pectoralis 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 sacrifice (Schuller, 1980) • Bulk of flap possibly not desirable in some instances • Fistula formation-if this is anticipated because of difficulty and/or tension on suture lines, a suction catheter is inserted into the reconstructed gullet for decompression purposes. This catheter is brought out via the cervical incision.
inner mucosal lining and the proximal paddle for the skin coverage. Because the recipient area was heavily irradiated, the tubed pedicle was transected in stages: the first stage in 10 weeks, the second stage in another month. Ariyan has reported transection of these pedicles in 2 weeks.
GENERAL PURPOSE FLAPS
FIGURE8-2 Continued
GENERAL PURPOSE FLAPS
Applications of the Pectoralis Major Flap (Fig. 8-3) Depicted in Figure 8-3A to G are the outlines of the various applications of the pectoralis major myocutaneous flap. It is obvious that of all the flaps utilized in head and neck reconstruction this flap is the most versatile. The shapes and areas of the skin are numerous; the muscle bulk can be minimal to maximal. The deformity of the donor site is minimal and usually can be closed by advanced localized chest flaps. The patient does not require changes in position during the operation, and, if desirable, two teams can work simultaneously to reduce the operating time. From the author's point of view, it is the first choice of all the major flaps in head and neck reconstruction.
A A large paddle is useful to replace major skin losses of the neck. This can be enlarged to include the entire
B A double paddle is used when two separate areas require coverage. This is ideal for replacement of an intraoral or intraoropharyngeal defect and skin. The distal paddle is used for the mucosal reconstruction, and the proximal paddle is used for the skin. A fold is then made between the two paddles, taking care not to obstruct the vascular pedicle. An example of this double paddle used to close a persistent fistula is depicted in Figure 8-2N and O. C A long skin paddle is used, for example, as a tubed pedicle external to the skin of the neck. The distal end may be random. When a random portion is utilized, the ratio of length to width is important in the randomized portion. This type is depicted in Figure 82N and 0, in which types 2 and 3 are combined. Continued
mammary region, as depicted in G.
PECTORALIS MAJOR M.
RECTUS FASCIA
LATISSIMUS DORSI M. EXTERNAL OBLIQUE M.
A FIGURE 8-3
GENERAL PURPOSE FLAPS
PECTORALIS MAJOR M.
LATISSIMUS DORSI M.
,j
RECTUS FASCIA
EXTERNAL OBLIQUE M.
B
PECTORALIS MAJOR M.
j
LATISSIMUS DORSI M.
1
EXTERNAL OBLIQUE M.
c FIGURE 8-3 Continued
RECTUS FASCIA
GENERAL PURPOSE FLAPS
Applications of the Pectoralis Major Flap (Continued) (Fig. 8-3) D A side-by-side double paddle is useful for closing two separate areas (Morain and Geurkink, 1980). Preservation of both the pectoral branches and the lateral thoracic arteries is usually necessary (Lore and Zingapan, 1971). The pectoral branch is the axial artery for the medial paddle, and the lateral thoracic artery is the artery for the lateral paddle. This flap can be utilized to reconstruct the base of the tongue or a portion of the mouth with the medial paddle and the lateral oropharyngeal wall with the lateral paddle. Care must be taken to preserve the lateral thoracic artery, which usually arises directly from the axillary
artery (see Fig. 8-2B). The lateral thoracic artery is mobilized by transecting some of the lateral horizontal fibers of the pectoralis minor muscle (lore and Zingapan, 1971; Krespi et aI., 1983). E The pectoralis major flap is combined with a deltopectoral flap. This can be performed simultaneously or at different stages, if required. F Use of an inframammary paddle is an excellent cosmetic procedure in the younger female (Ariyan and Cuono, 1980). A tunnel is developed under the breast for delivery of the flap.
Continued
(
PECTORALIS MAJOR M.
,
~
RECTUS LATISSIMUS DORSI M.
I FASCIA i
EXTERNAL OBLIQUE M.
D FIGURE 8-3 Continued
GENERAL PURPOSE FLAPS
PECTORALIS MAJOR M.
RECTUS FASCIA
LATISSIMUS DORSI M. EXTERNAL OBLIQUE M.
I
4
E
PECTORALIS MAJOR M.
/
LATISSIMUS DORSI M. EXTERNAL OBLIQUE M.
F FIGURE 8-3 Continued
RECTUS FASCIA
GENERAL PURPOSE FLAPS
Applications of the Pectoralis Major Flap (Continued) (Fig. 8-3) G Virtually the entire pectoralis major muscle, overlying skin with the breast, has been utilized in a male to cover a total defect on one side of the neck. In the male there is little problem, but in a female with a pendulous breast this could offer quite a cosmetic problem at the recipient site. The donor site in this type of flap is virtually the only place that a skin graft has been necessary to close the defect.
Another variation of the pectoralis major myocutaneous flap is the incorporation of a portion of the fifth rib, which has been reported to be used for reconstruction of the mandible. The author has no experience with this variation and would not use it. Kirschner wires bent and secured with tie wires are preferred for stabilization and reconstruction of the transected mandible at the time of the ablative surgery. The Kirschner wire is then covered with the pectoralis major flap. This flap, or any other flap for that matter, must be placed so that the flap and its axial vessels are not draped over the Kirschner wire. Otherwise, the Kirschner wire may act as a guillotine and devitalize the flap. The muscle portion of the pectoralis major flap has been used for protection of the carotid artery after radiotherapy to the neck, by burying it in the cervical flaps (Lee, 1980).
PECTORALIS MAJOR M.
RECTUS FASCIA
LATISSIMUS DORSI M. EXTERNAL OBLIQUE M.
G FIGURE8-3 Continued
GENERAL PURPOSE FLAPS
Deltopectoral
Flap (Fig. 8-4)
(After Bakamjian, 1965) Although there are now a large number of various flaps for reconstruction after major tissue loss in head and neck surgery, the deltopectoral flap (Bakamjian, 1965) still has a useful place in our armamentarium. It is a full-thickness (including the fascia of the pectoral muscles) anterior chest wall skin flap medially based, with its blood supply from the first through the fourth perforator vessels and branches of the internal mammary artery. Characteristics
1. 2. 3. 4.
5. 6.
7. 8. 9. 10.
and Advantages
It is usually not delayed. It can be unilateral or bilateral. The bilateral procedure can be simultaneous. Usual length of the flap reaches the tip of shoulder but it can be extended behind the shoulder or inferior to the deltoid prominence or superior to the spine of the scapula. The deltoid portion is usually not hair bearing. The flap is usually outside radiotherapy fields; however, it may be in the field of scatter radiation unless the donor site is lowered below the clavicles. Blood supply is excellent with dependent venous drainage. The donor site is hidden, thus cosmetically acceptable. Flap can be rotated deep or superficial to cervical flaps, depending on purpose. Flap can be split longitudinally and distally and deepithelialized proximally (Krizek and Robson, 1973).
Disadvantages
This flap requires a second stage to close an orocutaneous fistula unless an epithelial shave is performed. An epithelial shave is the removal of the epithelium of the flap where it comes in contact with the overlying cervical flap. The failure rate is 9 % to 18 %. If the flap is used to cover the carotid vessels, blowout of the carotid artery is a hazard if the flap fails.
Types of Delay
1. Complete skin incision without elevation (preserves thoracoacromial vessels). 2. Complete skin incision with elevation and return (transects thoracoacromial vessels). 3. Partial skin incision: a. Leave small area along the axillary area for dependent venous drainage. b. Leave small area along superior margin near thoracoacromial vessels. Reconstruction of Oropharynx, Hypopharynx, and Portion of Cervical Esophagus For a discussion of carcinoma of the hypopharynx and cervical esophagus, see Chapter 21.
Highpoints
1. Ratio of base of flap to length of flap concern.
2. Exercise caution when elevating flap at base to avoid injuring the perforator vessels. The flap includes the fascia of the pectoral muscles, excluding the thin musculature investing fascia. 3. Meticulous care should be taken in the handling of the flap. 4. Provide postoperative care to avoid kinking or compression of the flap by dressing, drains, tubes, or tape of the tracheostomy tube. S. If the flap is to be passed beneath cervical flaps, the lower cervical incision must be horizontal and is usually the same incision as the superior incision of the flap. 6. Delay flap, if: a. Tissue turgor is poor. b. Systemic disease is present (e.g., severe arteriosclerosis, diabetes, or severe malnutrition). c. Excessive length-however, Bakamjian does not necessarily use this as a reason for delay. d. Scatter radiation over donor site. 7. Usually incise distal esophagus in vertical plane for 1 to 2 em to enlarge the esophageal opening when the flap is used to reconstruct the esophagus. 8. Do not drape flap over the hardware that is used to stabilize the ends of resected mandible. 9. If there is a significant and objectionable dead space above the clavicle, resect the medial one third of clavicle to coapt flap to underlying soft tissue and vessels.
IS
of little
GENERAL PURPOSE FLAPS
Deltopectoral Flap (Continued) (Fig. 8-4) (After Bakamjian, 1965) A, A 1 Skin incision is outlined for a total laryngopharyngectomy, partial cervical esophagectomy, and left radical neck dissection with immediate reconstruction using a deltopectoral flap. The dotted line at the distal end of the flap depicts an extension of the flap below and behind the deltoid prominence. A' depicts a more horizontal and posterior extension, which is preferred. The distal end of the flap can be extended superior to the spine of the scapula (dotted
line). This has the advantage of combining the cervical incision with the superior flap incision throughout its entire length. This eliminates the small posterior triangular skin flap X in step A. The lower horizontal cervical incision (McFee) is the same as the superior incision for the flap at its medial end. B The ablative surgery has been performed. The deltopectoral flap is elevated without delay and gently passed beneath the bipedicle cervical flap.
Continued
GENERAL PURPOSE FLAPS
A INT. MAMMARY AND PERFORATOR ARTERIES /
B
FIGURE 8-4
GENERAL PURPOSE FlAPS
Deltopectoral
Flap (Continued)
(Fig. 8-4) (After Bakamjian, 1965) C The distal end of the flap is approximated to the transected end of the pharynx with interrupted or continuous nylon, chromic catgut, or Dexon sutures. Although nylon causesthe least tissue reaction, it can
be troublesome, because it does not absorb. If the distal end of the flap is curved superiorly, the posterior cervical triangular skin flap X is eliminated. This modification is more desirable. The knots should be buried if nylon is utilized. A feeding tube is passed along the inside of the flap.
BASE OF TONGUE EDGE OF PHARYNX
FIGURE8--4 Continued
GENERAL PURPOSE FlAPS
\
\
FIGURE 8-4 Continued
For defects of the hypopharynx, reconstruction can be achieved by a one-stage operation utilizing a tongue flap and a dermal graft (see Fig. 21-7).
D The anastomosis of the distal end of the flap to the pharynx is completed, and the flap is tubed. Depicted
is the vertical line of closure of the flap, thus forming the tube with the skin surface as the lining of the new gullet. The feeding tube has been passed into the esophagus. The esophageal lumen is incised (along the dotted line) for 1 or 2 cm to enlarge the opening. Continued
GENERAL PURPOSE FLAPS
Complications
Deltopectoral Flap (Continued) (Fig. 8-4) (After Bakamjian, 1965) E, F Anastomosis of the side of the tube flap to the end of the esophagus is performed using interrupted sutures. If nylon is used, the knots are buried. G Completion of the anastomosis except for a most inferior portion, which forms the fistula (arrow). Conley has performed an epithelial shave-removal of the epidermis-at this site and then has closed the fistula at this initial stage. Usually,closure of the fistula is performed some 4 to 6 weeks later. Continued
• Nine percent of the deltopectoral flaps in the author's hands have lost viability. • A carotid artery blowout occurs if flap loses viability when used to cover the vessel. • Serious aspiration may occur when flap is used in combined reconstruction. A laryngectomy could have been performed; however, the problem was simply solved by performing a permanent tracheostomy and total stripping and suture approximation of both vocal cords. • Dysphagia and pooling of food may occur. • Most flaps do not have any muscular function; hence, there may be difficulty in swallowing and propelling food. • There may be infection and fistula formation. • Stenosis of reconstructed gullet may occur.
GENERAL PURPOSE FlAPS
ESOPHAGU
FIGURE8-4 Continued
431
GENERAl PURPOSE FlAPS
Deltopectoral Flap (Continued) (Fig. 8-4) (After Bakamjian, 1965) H The first-stage reconstruction and the ablative surgery are complete. The fistula (arrow) is lateral to the tracheostoma. The tube flap esophageal anastomosis with the feeding tube and the vertical closure of the flap to form the new gullet are "ghosted in" for clarification. A split-thickness skin graft covers the donor site. Care must be taken that there is no compression of the "neck" of the flap by a circular dressing or the tracheostomy tube tape.
Four to 6 weeks later the second stage is performed to revise the lower anastomosis and thus close the fistula as well as transect the flap and return the proximal unused portion of the flap to the chest wall. The previous anastomosis is exposed and the flap transected along the dotted line. The skin graft is partially elevated off the flap and chest wall.
J
Transection of the flap is completed along the dotted line and returned to the chest wall.
K The original side-to-end anastomosis is now converted to an end-to-end anastomosis. The skin is then closed without wound drainage. A feeding tube is inserted and kept in place for about 1 week.
GENERAL PURPOSE FLAPS
TUBED FLAP
FIGURE 8--4 Continued
GENERAL PURPOSE FLAPS
Applications of Deltopectoral
Flap
(Figs. 8-5 and 8-6) The deltopectoral flap can be used to reconstruct the cervical esophagus (see Fig. 8-4), intraoral defects, floor of mouth, tongue, skin of the neck, chin and face, wall of hypopharynx, and oropharynx and can be used as a covering for carotid artery and vascular grafts. It can also be combined with other flaps (e.g., apron flap) (Haar, 1970). Bilateral deltopectoral flaps can also be utilized, with one flap forming the inner lining and the other flap used as the outer skin covering. Several examples are depicted. Reconstruction of the lower lip can be done with Bernard flaps (see p. 482) or the modified Dieffenbach technique (see p. 484).
B A long deltopectoral flap extending around the tip of the shoulder was delayed and then used to reconstruct a portion of the soft palate, lateral oropharyngeal wall, and a portion of the base of the tongue. The flap is to be rotated on its long axis. This flap lies beneath the cervical flap of a radical neck dissection. After assurance of the viability of the deltopectoral flap, the overlying cervical bipedicle flap is resected and discarded. The fistula associated with this flap is then closed by using local turn-in flaps. C A long deltopectoral flap is utilized to cover a large defect in the region of the parotid gland, neck, and face. The base of this flap is exterior to the cervical skin and is either tubed or bare under the area dressed with split-thickness skin. After viability is ensured, the unused portion of the pedicle of the flap is returned to the chest wall if the pedicle has been tubed.
A A deltopectoral flap is used to cover a large skin defect in the region of the chin after resection of a portion of the mandible and anterior floor of the mouth. The inner lining can be covered with the forehead flap brought intraorally under the detached zygomatic arch (see Figs. 14-10 and 15-10). The lips are sutured together to temporarily prevent the lower lip from drooping. The portion of the flap lying beneath the cervical flap can be de-epithelialized-an epithelial
Another application of the modification of the deltopectoral flap is the splitting of the flap at its distal end in such a fashion that a portion of the flap can then be used for outside covering while the other portion of the flap is used for inside covering. This is particularly
shave (Krizek and Robson, 1973)-thus eliminating a second procedure to return that portion of the
applicable for uses in the oral cavity with an external defect.
deltopectoral
flap to the donor site.
GENERAL PURPOSE FLAPS
o
FIGURE 8-5
GENERAL PURPOSE FLAPS
Applications of Deltopectoral Flap (Continued) (See Fig. 8-6) Apron Flap A Depicted is an apron flap (Edgerton, 1960; Edgerton and Snyder, 1965; Farr et aI., 1969) elevated with a concomitant resection of the floor of the mouth, partial glossectomy, and radical neck dissection. The mandible has been preserved according to the criteria in some reports. Farr and colleagues (1969) extend the inferior dip of the apron flap below the clavicles. Tip necrosis can occur with such a long flap. The X represents a superior extended deltopectoral flap, which is usually preferred.
B The apron flap has been brought into the floor of the mouth and sutured to the remaining tongue and
gingiva, thus allowing reconstruction of the intraoral defect after a resection of the floor of the mouth and partial glossectomy, with preservation of the mandible. The apron flap donor site is now covered with a deltopectoral flap (Haar, 1970). This may be readily combined with a radical neck dissection. The arrow depicts the planned fistula, which is closed at a second stage. An epithelial shave can prevent this fistula during the first stage.
Although a deltopectoral flap can be used directly to reconstruct the anterior portion of the floor of the mouth, this combination with the apron flap has proved to be very adaptable. The forehead flap is somewhat more adaptable for reconstruction of the anterior floor of the
mouth, whereas the deltopectoral flap is more adaptable for reconstruction of the posterior regions.
GENERAL PURPOSE FLAPS
FIGURE 8-6
GENERAL PURPOSE FLAPS
Laterally Based Chest Flap (Fig. 8-7) (After Conley, 1960) Highpoints 1. It is usually not delayed. 2. The donor site is cosmetically acceptable in males and not as adaptable in females because of the breast. 3. The donor site is able to be covered with local advancement flaps or skin graft.
A Pictured is a patient with two separate recurrences after a right jaw and radical neck resection for carcinoma of the floor of the mouth. One recurrence is in the submandibular region; the other involves soft tissue over the sternoclavicular area. Treatment consisted of planned preoperative super-voltage radiation therapy followed by surgical resection and immediate reconstruction using a bipedicle cervical flap combined with a laterally based chest flap. The areas of resection are outlined in solid lines, which correspond to horizontal cervical skin incisions. Between the two areas of resection is a bipedicle horizontal cervical flap. The laterally based chest flap is outlined with the broken line. A vertical incision below the nipple is made to facilitate closure of the donor site. Both flaps are full thickness. The chest flap includes all soft tissue down to the level of the pectoral muscles. The blood supply of this laterally based chest flap is the following: (1) cutaneous branch, coracoid branch,
and transverse scapular artery; (2) cutaneous branch, coracoid branch, thoracoacromial branch, and axillary artery; (3 and 4) cutaneous branch, deltoid branch, thoracoacromial branch, and axillary artery. The lateral thoracic artery may likewise contribute to the flap. In faint outline are the inverted Y- and H-type neck dissection incisions from the original surgery. These are well healed and offer no problem for new flaps as planned.
B The areas of local recurrence have been resected. The medial third of the clavicle can be removed if necessary (see Fig. 8-2G). The upper bipedicle cervical flap is elevated and advanced upward. This advancement enlarges the lower defect, which, however, will be easily closed by the laterally based chest flap. C The laterally based flap is elevated, including all soft tissue, to the level of the pectoral muscles. Its blood supply, laterally based, is preserved. The perforating vesselsof the branches of the internal mammary artery medially are necessarily sacrificed. The flap is then rotated upward to close the lower cervical defect. The donor site is closed by advancing the inferior skin margins upward. A vertical incision is of some help in this maneuver. Hemovac tubes are inserted as depicted. If the donor site is too large, it is covered with a splitthickness skin graft. D
The completed procedure.
GENERAL PURPOSE FLAPS
( /
FIGURE 8-7
439
GENERAL PURPOSE FLAPS
Mutter (1842) Nape of Neck Flap (Fig. 8-8) (After Corso et al., 1963) This is a cutaneous flap, not to be confused with the trapezium myocutaneous flap. Highpoints
1. Delay is recommended. 2. The flap may be lined with split-thickness skin graft or not lined, depending on the defect to be covered. 3. If a concomitant radical neck dissection is performed, it is best to preserve posterior auricular and occipital arteries. 4. This flap may be preferable to a deltopectoral flap in females, because the latter type flap deforms the breast. S. It is useful in closing orocutaneous fistulas and defects of the side of the face and neck as well as of the palate and lateral oropharynx wall. 6. It preserves the 11th cranial nerve.
A The arterial supply is superior via the posterior auricular and occipital arteries on the homolateral side. If there has been an interruption of these vessels during a radical neck dissection, the superior base of the flap can be widened to include the same group of vessels on the contralateral side. This, however, will limit the mobility of the flap to some extent. One of two types of delay is performed, depending on the type of defect to be covered.
Two-Stage Delay B If an extensively lined flap is necessary (e.g., with an orocutaneous fistula), and time is of little concern, a two-stage delay is performed by first making the two lateral parallel incisions and then lining the flap and the donor site with split-thickness skin. C In 10 to 14 days, the inferior margin is transected. The excess split thickness on the flap lining is removed, leaving an island of skin corresponding to the size of the orocutaneous fistula, as depicted. A portion of split-thickness graft is left proximal to the dotted line of the flap if not tubed. If the flap is tubed, all splitthickness skin is removed from the proximal portion of the flap. The edges of the fistula are cleared of granula-
tion tissue and possibly some skin to afford a good base for the transposed flap. Occasionally, sufficient skin can be mobilized around the edge of the fistula to form a trap door-type turn-in flap to line the transposed flap. Usually, this has not been successful and is not recommended because of a poor blood supply to the trap door flap. The flap is transected when blood supply and healing around the fistula are secured. This occurs 2 to 3 months later. The remaining portion of the flap is returned to the donor site. A rubber-shod intestinal clamp or Huffman-Iowa clamp can be placed across the pedicle for 15 minutes to evaluate the adequacy of blood supply. One-Stage Delay
D A single-step delay is achieved by simply incising around the entire flap, as depicted. The flap is elevated to include the fascia of the underlying muscles and is returned to the donor site. The area to be covered is a large skin defect overlying the side of the cheek. E In 10 to 14 days, the flap is swung into position and sutured in place. The original defect may have occurred along with a neck dissection. In such cases, the delay is done before the neck dissection so that the definitive surgery and the reconstruction are performed concomitantly. F After suitable healing has occurred, the flap is transected and the remaining portion is returned to the donor site. The time interval may be from 6 to 12 weeks, depending on the estimated blood supply. Cross clamping the pedicle with a lightweight rubbercovered clamp can be performed to evaluate this blood supply as described under C. The histamine wheal test can also be used to evaluate the competency of the blood supply. This is performed by first occluding the blood supply at the base of the pedicle with clamps, as described previously (see C). Several areas just distal to the clamp and a comparable area on the opposite side of the body are scarified with a needle. A drop of 1:1000 histamine acid phosphate is then applied to each scarified area. Ifthere is an adequate blood supply, a wheal will occur in both areas at about the same time, usually within 8 minutes (after Conway et aI., 1951).
GENERAL PURPOSE FLAPS
B
D
\
\
F
FIGURE 8-8
I
441
GENERAL PURPOSE FLAPS
Posterior Scapula Flap (Fig. 8-9) Highpoints
The blood supply of this flap is from the ascending branch of the occipital artery. The other solid lines are the incisions for the scapula flap and the cervical flap.
1. This flap is indicated primarily in large basal cell or smaller squamous cell carcinoma of the skin located in a posterior lateral cervical region. 2. It may be combined with radical neck dissection by utilizing a large cervical flap based anteriorly. 3. Wide and deep resection of lesion is possible. 4. It is a non-delayed flap. 5. It is a wide base to scapula flap.
B Appearance after the lesion has been excised. It is advisable to obtain frozen sections to check the adequacy of the depth of resection if there is any question regarding deep extension. If so, underlying muscle is removed. The larger scapular flap and smaller cervical flap are undermined and advanced.
A A triangular area with a lesion to be excised is shown. The blood supply of the scapula flap is from the superficial cervical and transverse cervical arteries arising from the subclavian artery. The dotted line depicts a superior extension that may be necessary to mobilize a superior occipital flap to aid in the closure.
C The completed closure should be made with minimal tension. One drawback to this type of closure is the three lines of closure at the apex. If the occipital portion is elevated and advanced, there will be four suture lines at the apex; this is a further drawback. A pectoralis major myocutaneous flap may be preferred (see Fig. 8-2A).
GENERAL PURPOSE FLAPS
A
\
WabnTIt
B
\
c
\ FIGURE 8-9
GENERAL PURPOSE FLAPS
Forehead Flap (Temporal Flap) (Fig. 8-10) (After McGregor, 1963) 5. General Data
The forehead flap, a myocutaneous flap, and its modifications can be used for a large number of reconstruction procedures: cheek (inside and outside), floor of the mouth, nose, upper eyelid, chin covering for reconstructed mandible, portion of tongue, and alveolar region. More often than not it can be nondelayed if both the superficial and temporal and posterior auricular arteries are included in its base and not extended beyond the midline. It is best to delay the flap if it extends 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 has been performed in which the feeding vessels of the external carotid artery have been sacrificed, although some surgeons report no difference at all (McGregor, 1963). Another problem is the cosmetic deformity. In younger patients, it is much less desirable, especially in reconstruction procedures for tissue loss after trauma. Other flaps from the neck or pectoral region are much preferred. When using the forehead flap, less deformity is usually noted if the entire forehead is utilized. Follow the hairline. There may be a problem in males with subsequent receding hairlines. A split-thickness skin graft taken from the anterior chest wall if practical is best for covering the donor site of the forehead. Numerous variations of forehead flaps are depicted in the following figures. Other varieties are in Figures 6-28, 6-29, 8-llA to G, 8-12, 14-10, and 15-10. Remember not to cause more deformity than what is being reconstructed. For example, use of a forehead flap to reconstruct a palate is hardly justified when a prosthesis will serve the purpose.
6. 7.
8.
or just below the arch. The superficial temporal artery must not be injured. The tunnel may be superficial or deep to the zygomatic arch. If deep, fracture the arch outward to avoid pinching of the base of the flap between the arch and the temporalis muscle or resect the coronoid process of the mandible. When teeth are present, the flap can be pinched as it crosses the occlusion line. Another serious point of jeopardy is the crossing of the flap over a Kirschner wire if there is undue tension or angulation. The base or pedicle can be returned in 3 to 4 weeks but should be limited to only hair-bearing areas.
The forehead flap is outlined. Note that the contour follows the eyebrows and the forehead hairline. This is more pleasing cosmetically. The lower incision of the flap must not extend beyond the level of the lateral canthus to avoid injury to the facial nerve. The incisions are beveled to minimize the cosmetic deformity along the remaining edges of the forehead and scalp. The dotted horizontal line depicts the incision through which the flap enters the oral cavity. A lower point of entrance can also be utilized. If so, do not injure the facial nerve or the parotid duct system. A, A 1
Highpoints
B A tunnel is formed through an incision just below the zygomatic arch. This can be performed with Metzenbaum scissors or a large Kelly clamp. Effort must be made to avoid injury to the facial nerve and parotid salivarygland. The donor site and bare exposed area of flap are covered with split-thickness skin. Skin from the anterior chest wall, if not hairy, is a good cosmetic cover. The dotted line indicates the intraoral position of the flap. Tailor the intraoral portion to avoid excess length and bulk.
1. The flap is usually not delayed if the posterior auricular artery and the superficial temporal artery are included in the base and the flap does not extend beyond the midline of the forehead; otherwise, delay the flap, especially with radical neck dissection. 2. A full-thickness flap is taken down to periosteum of skull (pericranium) including the frontalis muscle. 3. Use only a non-hair-bearing portion of the forehead for intraoral reconstruction. The base does include hair at the temporal region, but this is later returned. 4. Some surgeons bring the flap through the cheek, via a separate incision well below the zygomatic arch. Care must be taken not to injure the facial nerve or the ducts of the parotid salivary gland. Others prefer to tunnel the flap through an incision either just above
C The distal end of the flap is brought into the intraoral defect and sutured in place with 3-0 or 4-0 nylon. It can be used to cover cheek, alveolar region, floor of mouth, tongue, and a somewhat posterior to tonsil region if it is wide enough. The flap is not sutured to the tongue if only the buccal wall is reconstructed. Suturing it to the tongue would tether the tongue and create a problem in mastication and swallowing. On the other hand, it may be necessary to approximate the tongue to the flap if the tongue is the only soft tissue available medially. The arrow delineates the tunnel and a temporary fistula. The pedicle is sectioned along to the dotted line in 3 to 4 weeks, and the base of the flap is withdrawn from the tunnel and returned to the forehead or discarded.
GENERAL PURPOSE FLAPS
SUPERIOR TEMPORAL A.
\
,
\
/
B
c FIGURE 8-10
The free vascularized flap would be the first choice for buccal wall reconstruction if the defect involves the skin. Jejunum (free graft vascularized) is a method to replace the mucosa and underlying soft tissue because it provides moist mucosa and may prevent scar contracture. An alternate is dermal graft for inner lining. D An alternate tunnel is deep to the zygomatic arch, which is fractured along the dotted line. (The coronoid process of the mandible may be likewise fractured if
there is pressure on the flap.) This method of introduction is preferred by the author. The section of zygomatic arch is left attached to the overlying fascia and realigned after the base of the flap is returned. Complications • Hemorrhage • Necrosis, especially • Facial nerve injury
at pressure
points
GENERAL PURPOSE FLAPS
Reconstruction of Cheek with Forehead Flap (Fig. 8-11) This type of forehead flap with a lined skin graft surface is available for deep soft tissue and bony defects of the maxillary region. However, most of these areas are for the most part better reconstructed with a microvascular free flap, especially large facial defects. Intraoral defects can be reconstructed either with a pectoralis major myocutaneous flap (see pp. 404 and 420) or microvascular free flap (see Chapter 24). On the buccal wall if there is need for a skin graft, a dermal graft is preferred. The flap must bridge the defect. A cavity simulating the antrum is thus reconstructed with dependent drainage, because otherwise a closed cavity could result with fistula formation or repeated infections. The problem in reconstruction is the ultimate viability of the flap, because the only source of blood supply is at the edges of the defect and the pedicle itself. The edges of the defect may be further compromised has received
any radiation
therapy.
is preserved
and not transected.
The flap is full thickness, encompassing all soft tissue with muscle down to but not including the pericranium (periosteum of the skull). The flap is rotated nearly 180 degrees and swung over the defect. The distal end of the flap should easily overlap the farthest edge of the defect by 1 cm. The incisions mobilizing the flap are thus extended as necessary, with care taken not to injure the main trunks of the superficial temporal vessels and posterior auricular vessels. At times only the galea aponeurosis need be released. The posterior and medial walls of the defect have previously been covered with split-thickness skin graft. B
C After satisfactory mobilization, the flap is returned and sutured with continuous 5-0 nylon. The flap is delayed in this case because of the poor vascularity of the defect, which was previously irradiated.
if the patient
Hence, the pedicle
Highpoints 1. Preserve superficial temporal and posterior auricular vessels. 2. A forehead flap can be used with or without delay. Delay in this case is preferred. 3. Allow permanent drainage from antrum into oral cavity. 4. The base of the defect is previously skin grafted. 5. Delay all forehead flaps if external carotid artery has been ligated. 6. A full-thickness defect of the buccal wall and cheek can be reconstructed by using a forehead flap for the outer cover and a pectoralis major flap for inner cover. Another alternative is a microvascular free flap.
A The skin incision as outlined includes the superficial temporal vessels. The dotted line indicates the inclusion of the posterior auricular artery, which facilitates nondelay. In a male, hair-bearing scalp may be included, but in a female it should be excluded. The defect consists of a loss of the entire anterior and lateral bony wall of the maxilla along with the overlying skin and muscles.
D In 2 to 3 weeks the flap is again elevated, rotated 180 degrees, and swung over the defect. If any shrinkage has occurred, release incisions are again made with the same precautions. Now, the inner side of the flap and the donor site are grafted with split-thickness skin, using slightly thicker skin for the forehead donor site. Be sure the donor sites for the split-thickness skin are hairless, because hair in the new antrum is a nuisance because occasionally some hair will grow. E, F The edges of both defect and flap are trimmed and freshened and very carefully approximated with fine interrupted sutures. If the soft tissue is scant at any edge on the defect, a wire suture through bone is used and secured on the flap with a button or silicone disk so the flap is not injured. Because the entire undersurface of the flap has been previously covered with grafted skin, the base of the pedicle need not be tubed. F1 After 2 to 3 months, the dependent edge may be revised if it becomes rolled and edematous. This is done by undercutting and overlapping the edges or by using the fat flip flap of Millard (see Fig. 8-13). G The drainage tunnel from the new antrum is depicted in the gingivobuccal sulcus. The patient cares for this with daily irrigations.
Continued
GENERAL PURPOSE FLAPS
FIGURE 8-11
GENERAL PURPOSE FLAPS
Reconstruction of Cheek with Forehead Flap (Continued) (Fig. 8-11) H After 4 to 6 months, the pedicle of the flap is denuded of skin and buried. In this fashion the superficial temporal vesselsare preserved, and viability of the flap is ensured. This is safer than transecting the 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.
I The inner layer of skin of the pedicle is dissected and discarded.
J
The skin on the side of the face under which the vascular pedicle will be buried is now elevated with upper and lower skin flaps. Continued
GENERAL PURPOSE FLAPS
"'-l" , j
I
j,'
FIGURE 8-11 Continued
~9
GENERAl PURPOSE FLAPS
Reconstruction of Cheek with Forehead Flap (Continued) (Fig. 8-11) K The full-thickness lower skin flap is elevated. The same technique is used on the upper flap.
L The pedicle is covered with the upper and lower flaps, using interrupted sutures of 5-0 nylon.
M The remaining defects are covered with portions of skin from the pedicle, which are trimmed accordingly. N Subcutaneous adipose tissue is removed from the distal portion as required to achieve a smooth surface.
This is a type of island flap with the vascularpedicle buried.
GENERAL PURPOSE FLAPS
FIGURE 8-11 Continued
GENERAL PURPOSE FLAPS
Midline Forehead Flap (Fig. 8-12) (After Kazanjian, 1946) Highpoints 1. This flap is useful for full-thickness defects of the nose, including the ala and portions of the columella and cheek, especially below the eye. 2. It may be lined with split-thickness skin if necessary. 3. No delay is required. 4. Blood supply is via both supratrochlear arteries with contribution from the dorsal nasal branches. 5. Extreme care must be exercised with incisions: The upper portions of the incisions are carried down to the periosteum, whereas below the level of the nasofrontal angle the incisions are through skin only, and dissection at this area is blunt to avoid injury to the supratrochlear vessels. 6. Be sure there is adequate length, keeping in mind the fact that the flap must be rotated in loose fashion so as not to compromise the vascular supply. Depicted is a nasal defect resulting a tumor; this type of reconstruction suited to a defect due to trauma.
from resection of is equally well
A 1 The flap is turned down to the nasofrontal angle with sharp dissection. From here down, meticulous blunt dissection is used to preserve the blood supply via the supratrochlear and dorsal nasal vessels. Tardy states that mobilization of the base of the flap can be below the level of the eyebrows by careful dissection so as not to injure the supratrochlear arteries. Interestingly enough, there are redundant skin and soft tissue in this area that facilitate rotation of the flap without tension. A patch of split-thickness skin is sutured with 5-0 chromic catgut to the raw surface of the flap corresponding with the deep through-and-through defect in the nose. B
Through-and-through
defect of the nose.
C The major portion of the donor site is closed by mobilization of the lateral skin margins. This may require rather extensive undermining of the skin. Inferiorly, the donor defect is covered with a triangular section of split-thickness skin; otherwise, mobilization of skin at this point will bring the eyebrows too far medially. When the flap is severed in about 3 weeks, the unused portion is returned to that portion of the donor site that had been covered with the splitthickness skin graft.
A
Outline of the flap with associated
and tumor extent
blood supply
of the nose to be resected.
of the midline incisions reaches
The upper the hairline.
D
Here this flap is utilized to close a defect of the
cheek just below the lower lid. The advantage
This portion of the flap is carried by sharp dissection
type
down to the periosteum.
prevention
From the nasofrontal
the incisions are carried only through
angle,
of reconstruction of ectropion
is ease
of coverage,
of this with
of the lower lid.
the skin, as out-
lined by the dotted lines. There is minimal interference with motor function any significant
of the forehead,
portion
involved in the flap.
because
of the frontalis
little if
muscles
is
A modification of this flap is the island flap (Esser, 1917), in which the flap with its blood supply is
tunneled under an intact bridge of skin at the glabella.
GENERAL PURPOSE FLAPS
FIGURE 8-12
GENERAL PURPOSE FLAPS
Fat Flip Flap (Fig. 8-13) (After Millard
et aI., 1969)
A The skin scar is excised along one border of the flap.
Indication • To reduce bulging edema of transposed
B The skin and some subcutaneous tissue elevated from the adjacent area are slightly thinner than their counterparts from the flap. The fat flap is outlined with the dotted line. This includes the bulging edematous adipose tissue from the original flap.
flaps
Highpoints 1. Stage the procedure with l-month interval (Le., operate one border of flap at a time). 2. Excise skin scar along one edge. 3. Elevate skin and subcutaneous tissue of half of flap. 4. Dissect edematous and bulging fat in retrograde fashion as a second flap. 5. Elevate at a slightly more superficial plane surrounding adjacent skin juxtaposed to the flap. 6. Turn the fat flap back as far as possible and suture. 7. Perform skin closure in a straight line if the closure follows a natural skin line; closure should be in multiple Z-plasties if it crosses a natural skin line. 8. Repeat the same technique on the other side of the flap about 1 month later.
TRANSPOSED
C The fat flap is flipped over 180 degrees and sutured as far as possible across and under the elevated skin of the adjacent area. In this manner the bulging adipose tissue is transferred to the adjacent area, which is depressed and wanting of adipose tissue. D The final closure is shown in cross section. The skin closure is in a straight line approximating a natural crease. Where the skin closure crosses the natural lines, multiple Z-plasties are performed (see Fig. 3-2Q to V).
FLAP
A
c
B
D FIGURE 8-13
GENERAL PURPOSE FLAPS
BIBLIOGRAPHY Acharya G, Johnson ML: Use of pectoralis major myocutaneous flap in Grillo procedure. Ann Plast Surg 6:11-13,1981. Adams WM: The use of neighboring tissues in the correction of an extensive facial deformity. Piast Reconstr Surg 2:105-109,1946. Andrews EB: Island naps in faciai reconstruction. Piast Reconstr Surg 44:49-51, 1969. Anson BJ, McVay CB: Surgical Anatomy, 5th ed, voi 2. Philadelphia, WB Saunders, 1971. Ariyan S: The pectoralis major myocutaneous nap. Plast Recoostr Surg 63:73-81, 1979. Ariyan S: Further experiences with the pectoralis major myocutaneous flap for the immediate repair of defects from excision of head and neck cancers. Plast Reconstr Surg 64:605-612, 1979. Ariyan S, Cuono CB: Myocutaneous flaps for head and neck reconstruction. Head Neck Surg 2:321-345,1980. Ariyan S, Cuono CB: Use of the pectoralis major myocutaneous flap for the reconstruction of large cervical, facial or cranial defects.
Am J Surg 140:J03-JOG, 1960,
Coleman CC Jr: Local flaps for reconstructions after head and neck tumor surgery. Plast Reconstr Surg 42:225-231, 1968. Conley JJ: The historical development of regional flaps. Pack Medical Foundation. Conley JJ: A one stage operation for the immediate reconstruction of the pharynx and cervical esophagus following radical resection. West J Surg 63:344, 1955. Conley JJ: The use of regional flaps in head and neck surgery. Ann Otol 69:1223, 1960. Conley JJ: One stage radical resection of cervical esophagus, larynx, pharynx, and neck with immediate reconstruction. Arch Otolaryngol 58:546, 1963. Conley JJ: Pendulosity in regional flaps about the head and neck. Ann Plast Surg 16:75-81, 1986. Conley JJ, Parke RB: Pectoralis myocutaneous flap for chin augmentation. Otolaryngol Head Neck Surg 89:1045-1050,1981. Conway H, Stark RB, Joslin D: Cutaneous histamine reaction as a test of circulatory efficiency of tubed pedicles and flaps. Surg Gynecol
Obslet 93:l85 1951. J
Arufe HN, Cabrera VA, Sica IE: Use of the epaulette flap to relieve burn contractures of the neck. Plast Reconstr Surg 61:707-714, 1978. Badran HA, et al: The laterai intercostal neurovascular free flap. Plast Reconstr Surg 73:t7-25, 1984. Baek S, Bitler HF, Krespi YP, Lawson W: The lower trapezius island myocutaneous flap. Ann Plast Surg 5:108-114,1980. Baek S, Lawson W, Biller HF: Reconstruction of hypopharynx and cervical esophagus with pectoralis major island myocutaneous nap. Ann Plast Surg 7:18-24, 1981. Baek S, Lawson W, Bilier HF: An analysis of 133 pectoraiis maior myocutaneous naps. Plast Reconstr Surg 69:460-467,1982. Bakamjian VY: A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg 36:173-184,1965. Bakamjian VY: Totai reconstruction of pharynx with medially based deltopectoral skin flap. NY J Med 68:2771-2778,1968.
Corso PF, Gerold FP, Frazell EL: The rapid closure of large salivary fistulas by an accelerated shoulder nap technic. Am J Surg 106: 691,1963. Cramer LM, Culf NK: Symposium on Cancer of Head and Neck. St. Louis, CV Mosby, 1969. Davis GN, Hoopes JE: A new technique of delivery of the total forehead flap for intraoral reconstruction. Presented at the Society of Head and Neck Surgeons meeting, Aprtl1970. Dennis D, Kashima H: Introduction of the Janus flap. Arch Otolaryngol 107:431-435, 1981. Dingman RO, Grabb WC, O'Neal RM, Ponitz RJ: Sternocleidomastoid muscle transplant to masseter area. Plast Reconstr Surg 43:5-12, 1969. Dufourmentel C: La fermeture des pertes de substance cutanee limitees. Ann Chir Plast (Paris) 7:60-66, 1962. Dufourmentel C: Traitement chirurgical des naevi pigmentaires benins. 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. Excerpta Medica International Congress, Series No. 174, Transactions of the Fourth International Congress of Plastic and Reconstructive Surgery, Rome, October 1967. Baker DC, Shaw WW, Conley 1: Microvascular free dermis-fat flaps for reconstruction after ablative head and neck surgery. Arch Otolaryngol 106:449-453, 1980. Bartlett SP, May JW, Yaremchuk MJ: The latissimus dorsi muscle: A fresh cadaver study of the primary neurovascular pedicle. Plast Reconstr Surg 67:631-635, 1981. Barton FE, Spicer T, Byrd S: Head and neck reconstruction with the latissimus dorsi myocutaneous flap: Anatomic observations and report of 60 cases. Plast Reconstr Surg 71:199-204,1983. Bell MS, Barron PT: The rib-pectoralis maior osteomyocutaneous nap. Ann Plast Surg 6:347-355, 1981. Bertotti JA: Trapezius-musculocutaneous
island flap in the repair of
major head and neck cancer. Plast Reconstr Surg 65:16-21, 1980. Biller HF, Baek S, Lawson W, et a1: Pectoralis major myocutaneous
island nap in head and neck surgery. Arch Otolaryngol 107:23-26, 1981. Bowers DC: Double cross lip flaps for lower lip reconstruction.
Plast
Reconstr Surg 47:209, 1971. Bray DA: Clinical applications of the rhomboid flap. Arch Otolaryngol 109:37-42, 1983. Briant TOR, Gilbert RW: Refinement of the pectoralis major myocutaneous flap. J Otolaryngol13:387-390, 1984. Chretien PB, Ketcham AS, Hoye RC, Gertner HR: Extended shoulder flap and its use in reconstruction
of the defects of the head and
neck. Am J Surg 118:752-755, 1969.
of Plastic
and Reconstructive
Surgery, 5th ed. Melbourne,
Butterworth, 1971, pp 1223-1226. Edgerton MT Jr: Reconstruction of hypopharynx and the cervical esophagus after removal of cancer. In Proceedings of the Fourth National Cancer Conference, 1960, p 685. Edgerton MT Jr, Snyder GB: Combined intracranial-extracranial approach and use of the two-stage split flap technic for reconstruction with craniofacial malignancies. Am J Surg 110:595-602, 1965. Esser JFS: Studies in plastic surgery of the face. Ann Surg 65:297, 1917. Esser JFS: Cheek rotation. Rev Chir Plast 3:298-300, 1934. Farr HW, Jean-Gilles B, Die A: Cervical island skin nap repair of oral and pharyngeal defects in the composite operation for cancer. Am J Surg 118:759-763, 1969. Farrior RT: Cancer of the head and neck: Primary and reconstructive
surgery. Arch Otolaryngol 71:891-905, 1960. Farrior RT: Rehabilitation by skin grafting. Arch Otolaryngol 83:120134,1966. Finseth F: Commentary on the differing effects of isoxsuprine on muscle flap and skin nap survival in the pig. Plas! Reconstr Surg 64:819, 1979. Freeman JL, Walker EP, Wilson JSP, Shaw HJ: The vascular anatomy of the pectoralis major myocutaneous nap. Br J Plast Surg 34:3-10, 1981. Furnas OW, Conway H: Correction of major facial defects by pedicle naps. Plast Reconstr Surg 31:407, 1963. Furnas DW, Furnas H: Absence of the lower part of the latissimus dorsi muscle: An important anatomical variation. Ann Plast Surg
10:70-71, 1983.
GENERAL PURPOSE FLAPS
Gaisford JC: Reconstruction of head and neck deformities. Surg Clin North Am 47:295-322,1967. Goodwin WJ, Rosenberg GJ: Venous drainage of the lateral trapezium musculocutaneous island flap. Arch Otolaryngol 108:411-413, 1982. Guillamondegui OM, Larson DL: The lateral trapezius musculocutaneous flap: Its use in head and neck reconstruction. Plast Reconstr Surg 67: 143-150, 1981. Guillane PJ: Muscle flaps in the head and neck. J Otolaryngol 8: 132-137,1979. Haar J: Personal communication, 1970. Hancock OM: The repair of facial defects resulting from surgery for locally advanced buccal carcinoma. Plast Reconstr Surg 20: 117, 1957. Harii K: Myocutaneous flaps: Clinical application and refinements.
Plast Recomtr Surg 63:49-57,1979,
Ann Plag( Surg 4:440,4~6, 1981 Harii K, Iwaya T, Kawaguchi N: Combination myocutaneous flap and microvascular free flap. Plast Reconstr Surg 68:700-711, 1981. Hirshowitz B, Mahler 0: T-plasty technique for excisions in the face. Plast Reconstr Surg 37:453, 1966. Hodgkinson OJ: The pectoralis maior myocutaneous flap for intraoral reconstruction: A word of warning. Br J Plast Surg 35:80-81, 1982. Hoopes JE, Edgerton ML: Immediate forehead flap repair in resection for oropharyngeal cancer. Am J Surg 112:527, 1966. Irons GB, Witzke OJ, Arnold PG, Wood MB: Use of the omental free flap for soft tissue reconstruction. Ann Plast Surg 2:501-507,1983. Johns ME, Winn HR, McLean WC, Cantrell RW: Pericranial flap for the closure of defects of craniofacial resections. Laryngoscope 91:1-7, 1981. Jurkiewicz MJ, Nahai F: The omentum, its use as a free vascularized graft for reconstruction of the head and neck. Ann Surg 195: 756-765, 1982. Kaplan lB, Harwick RD: Pectoralis major myocutaneous island flap revisited: A sentinel vessel simplifying dissection. Head Neck Surg
McGraw lB, Myers B, Shanklin KD: The value of fluorescein in predicting the viability of arterialized flaps. Plast Reconstr Surg 60(5), November 1977. McGregor IA: The temporal flap in facial cancer: A method of repair. Presented before the Third International Congress of Plastic Surgery, 1963. McGregor lA, Reed WH: Simultaneous temporal and deltopectoral flaps for full-thickness defects of the cheek. Plast Reconstr Surg 45:326, 1970. Mehrhof AI, et al: The pectoralis major myocutaneous flap in head and neck reconstruction. Am 1 Surg 146:478-482, 1983. Mendelson BC: The pectoralis major island flap: An important new flap for head and neck reconstruction. Br J Plast Surg 33:318-323, 1980. Millard DR, Stokley PH, Campbell RC: The fat flip flap. Plast Reconstr Surg 44:202-204, 1969. Milton SH: Experimental studies on island flaps: 1. The surviving length. Plast Reconstr Surg 48:574-578, 1971. Moloy Pl, Gonzales
5:452-456,1983. Katoh H, Nakajima T, Yoshimura Y: The double-Z rhomboid plasty: An improvement in design. Plast Reconstr Surg 74:817-822,1984. Kazanjian VH: The repair of nasal defects with the median forehead flap: Primary closure of the forehead wound. Surg Gynecol Obstet 83:37,1946. Kazanjian VH: The use of skin flaps in the repair of facial deformities. Plast Reconstr Surg 5:337-352, 1949. Khoo CT, Bailey BN: The behavior of free muscle and musculocutaneous flaps after early loss of axial blood supply. Br J Plast Surg 35:43-46, 1982. Krespi YP, Wurster CF, Sisson GA: A longer muscle pedicle for pectoralis major myocutaneous flap. Laryngoscope 93:1360-1361,1983. Krizek TJ, Robson MC: The split flap technique in head and neck reconstruction.
Magee WP, McCraw JB, Horton CE, Mcinnis WO: Pectoralis "paddle" myocutaneous flaps. Am J Surg 140:507-513, 1980. Maisel RH. Liston SL: Combined pectoralis major myocutaneous flap with medially based deltopectoral flap for closure of large pharyngocutaneous fistulas. Ann Otol Rhinol Laryngol 91:98-100, 1982. Mathes SJ, Nahai F: Classification of the vascular anatomy of muscles: Experimental and clinical correlation. Plast Reconstr Surg 67: 177-187,1981. Maves M, Phillippen LP: Surgical anatomy of the scapular spine in the trapezius-osteomuscular flap. Arch Otolaryngol 112:173-175, 1986. McGraw lB, Furlow LT:The dorsalis pedis arterialized flap: A clinical study. Plast Reconstr Surg 55:177-185,1975. McGraw lB, Magee WP, Kalwaic H: Uses of the trapezius and sternomastoid myocutaneous flaps in head and neck reconstruction.
Presented
before the Society
of Head and Neck
Surgeons and American Society for Head and Neck Surgery, Hot Springs, VA, May 1973. Lee KY,Lore JM Jr: lWo modifications of pectoralis maior myocutaneous flap (PMMF). Laryngoscope 96:363-367, 1986. Lee YT:Carotid artery protection by pectoralis major muscle flap. Am J Surg 140:464, 1980. Leeb DC, et al: Reconstruction of the mouth with a free dorsalis pedis flap. Plast Reconstr Surg 59:379-381, 1977. Lore JM Jr: Total reconstruction of the hypopharynx with tongue flap and dermal graft. Ann Otol Rhinol Laryngol 83:476-480, 1974. Lore JM Jr. Klotch OW. Lee KY: One stage reconsrruction of the hypopharynx using myomucosal tongue flap and dermal graft. Am J Surg 144:473-476, 1982. Lore JM Jr, Zingapan EG: Oeltopectoral flap. Arch Otolaryngol 94: 13-18, 1971. Macomber WB, Wang MH: Tubed neck flaps in facial reconstruction. Plast Reconstr Surg 45:346, 1970.
FE:
Vascular anatomy of the pectoralis major
myocutaneous flap. Arch Otolaryngol Head Neck Surg 112:66-69, 1986. Morain WD, Geurkink NA: Split pectoralis major myocutaneous flap. Ann Surg 5:358, 1980. Mouly R: Le lambeau en "u" jugal pour la reparation des pertes de substance mentonnieres. Ann Chir Plastique (Paris) 8:209-213, 1963. Mustarde lC: The use of flaps in the orbital region. Plast Reconstr Surg 45:146,1970. Myers MB, Cherry G: Differences in the delay phenomenon in the rabbit, rat, and pig. Plast Reconstr Surg 47:73-78, 1971. Narayanan M: Immediate reconstruction with bipolar scalp flap after excisions of huge cheek cancers. Plast Reconstr Surg 46:548-553, 1970.
Nichter LS, Morgan RF, Harman OM, et al: The trapezius musculocutaneous
flap in head and neck reconstruction:
Potential pitfalls.
Head Neck Surg 7:129-134,1984. Nieto IS: Local flaps. Ann Plast Surg 8:99- 106, 1982. Ossoff RH, Wurster CF, Berktold RE, et al: Complications after pectoralis major myocutaneous
flap reconstruction
of head and neck
defects. Arch Otolaryngol 109:812-814, 1983. Owens N: A compound neck pedicle designed for the repair of massive facial defects. Plast Reconstr Surg 15:367, 1955. Paletta FX: Early and late repair of facial defecls following treatment of malignancy. Plast Reconstr Surg 13:95, 1953. Quillen CG: Latissimus
dorsi myocutaneous
flaps in head and neck
reconstruction. Plast Reconstr Surg 63:664-670, 1979. Rayner CRW: Oral mucosal flaps in midfacial reconstruction. Br J Plast Surg 37:43-47, 1984. Reinisch JF: The pathophysiology of skin Oap circulation. Plast Reconstr Surg 54:585-598, 1974.
GENERAL PURPOSE FlAPS
Richardson CS, Hanna DC, Caisford JC: Midline forehead flap nasal reconstructions
in patients
with low browlines.
Plast Reconstr
Surg 49:130-133,1972. Schechter GL, Biller HF, Ogura JH: Revascularized skin flaps: A new concept in transfer of skin flaps. Laryngoscope 79:1647-1665, 1969. Schrudde J, Petrovici V: The use of slide-swing plasty in closing skin defects: A clinical study based on 1,308 cases. Plast Reconstr Surg 67:467-481, 1981. Schuller DE: Limitations of the pectoralis major myocutaneous flap in head and neck cancer reconstruction. Arch Otolaryngol 106:709-714, 1980. Schuller DE: Latissimus dorsi myocutaneous flap for massive facial defects. Arch OtolaryngolI08:414-417, 1982. Shapiro MJ: Use of trapezius myocutaneous flaps in the reconstruction of head and neck defects. Arch Otolaryngol 107:333-336, 1981. Sharzer LA, et al: The parasternal paddle: A modification of the pectoralis major myocutaneous flap. Plast Reconstr Surg 67:7S3-762, 1981. Sherlock EC, Maddox WA: The versatile deltopectoral skin flap in reconstruction about the head and neck. Am J Surg 118:744-751, 1969. Silverman DG, LaRossa DD, Barlow CH, et al: Quantification of tissue fluorescein delivery and prediction of flap viability with the fiberoptic dermofluorometer. Plast Reconstr Surg 66:545-553, 1980. Sisson GA, Goldstein JC: Flaps and grafts in head and neck surgery. Arch Otolaryngol 92:599-610, 1970. Smith CJ: The deltoscapular flap. Arch OtolaryngolI04:390-392, 1978. Smith F: Flaps utilized
in facial and cervical reconstruction.
Reconstr Surg 7:415-455,1951.
Plast
Terz JJ, Lawrence W Jr: Primary reconstruction of oropharyngeal surgical defects with a forehead flap. Surg Gynecol Obstet 129:533-537, 1969. Thomas CV: Thin flaps. Plast Reconstr Surg 65:747-752, 1980. Tiwari RM, Gorter J, Snow GB: Experiences with the deltopectoral flap in reconstructive surgery of the head and neck. Head Neck Surg 3:379-383, 1981. Tobin GR, Moberg AW, DuBou RH, et al: The split latissimus dorsi myocutaneous flap. Ann Plast Surg 7:272-280, 1981. Tobin GR, Schusterman M, Peterson GH, et al: The intramuscular neurovascular anatomy of the latissimus dorsi muscle: The basis for splitting the flap. Plast Reconstr Surg 67:637-641, 1981. Tolhurst DE, Haesecker B, Zeeman RJ: The development of the fasciocutaneous flap and its clinical applications. Plast Reconstr Surg 71:597-605, 1983. Von Deilen AW: Methods of immediate repair after major resections of the face and jaws. Plast Reconstr Surg 11:152, 1952. Washio H: Retroauricular-temporal flap. Plast Reconstr Surg 43: 162-166, 1969. Watson JS, Lendrum J: One stage pharyngeal reconstruction using a compound latissimus dorsi island flap. Br J Plast Surg 34:87-90, 1981. Wilson JS, Yiacoumettis AM, O'Neill T: Some observations on 112 pectoralis major myocutaneous flaps. Am J Surg 147:273-279, 1984. Wurlitzer F, Ballantyne AJ: Reconstruction of lower jaw area with a bipedicled deltopectoral flap and a Ticonium prosthesis: Case report. Plast Reconstr Surg 49:220-223, 1972. Yoshimura Y, Maruyama Y, Takeuchi S: The use of lower trapezius myocutaneous island flaps in head and neck reconstruction. Bf ] Plast Surg 34:334-337, 1981.
Lip Excision and Reconstruction A An incision is made through the mucosa 0.3 to 0.5 em beyond the extent of the leukoplakia.
(Fig. 9-1) Planing of lip Highpoints 1. The entire exposed vermilion of either the lower or upper lip or both may be excised for leukoplakia or erythroplakia with immediate coverage using mucous membrane advanced from the inner aspect of the lip. 2. Obtain frozen section for any area suggestive of carcinoma-toluidine blue stain may be of help. 3. This operation may be combined with the shield type of excision (see later) or the Abbe-Estlander operation (see Fig. 9-4A to 0). 4. Specimen must be labeled "right" and "left" for proper orientation of serial histologic study to rule out carcinoma. Complication • Some flattening
of the natural
contour
of the lip
Shield Excision of lower lip Highpoints 1. Early carcinoma of lip up to 0.5 em in diameter can be excised with adequate margins. 2. Up to one third of lower or upper lip may be excised-1.5 to 2.3 em-and the defect closed with simple approximation of edges. Larger defects require some type of reconstruction flaps. 3. A three-layer approximation is used: mucous membrane, muscle, and skin.
458
B Following the vermilion border, or even including a small amount of skin if the leukoplakia has reached the cutaneous margin, a flap of mucosa is separated from the underlying muscle and excised. C The remaining normal mucosa on the inner aspect of the lip is extensively undermined. DUsing 5-0 nylon, the advanced mated to the skin margin.
mucosa is approxi-
E A "shield" type of incision is outlined with methylene blue. If the lesion is malignant, 1 em of grossly normal tissue must be included on each side. The vermilion edges on both borders are marked by a needle dipped in the dye. This aids in an accurate approximation of the vermilion edges following the excision. The excision is made through and through skin, muscle, and mucous membrane. Grasping the lip between index finger and thumb aids in the excision by stabilizing the lip and controlling hemorrhage. Only after the complete excision are the vessels clamped and tied. F Layer closure is commenced by first approximating the mucosa with interrupted 4-0 or 5-0 nylon. G The orbicularis oris muscle and other deep structures have been carefully approximated using 4-0 chromic catgut. The first skin suture of 5-0 nylon is placed through the dye marks on the vermilion borders. H
5-0 Nylon is used to complete
the closure.
THE UPS
B
f
It
H FIGURE 9-1
THE UPS
Lip Excision and Reconstruction (Continued) (Fig. 9-2) Procedures relative to deformities of the lip as well as more extensive facial paralysis can be found in Chapter 7, pages 384 to 391.
E The lesion with skin, mucosa, and underlining muscle is excised. The muscle is approximated with one or more buried sutures of fine chromic catgut. The initial skin suture is placed at the vermilion border. F
The completed
closure.
Cupid/s Bow Distortion of Mouth Corrected by Z-Plasty
Indication • When the upper lip is so deformed that the initial repair has resulted in a straight horizontal line that makes the reconstruction all the more obvious, restoration of a Cupid's bow is indicated (see Fig. lO-lA for normal anatomy).
A
Triangular skin areas are outlined.
B These areas are excised down to muscle that is superficially incised along the dotted lines at each side of the center of the bow. The mucosa of the lip is elevated from the muscle except in its midportion. C
The completed
G A Z-type incision is made through and through the skin, muscle, and mucous membrane (see Fig. 3-2A to D). H The full-thickness cheek flaps are swung as depicted. A three-layer closure is used. The reverse Zplasty can be used (Gerold, 1960) for a drooping commissure after section of the buccal division of the facial nerve.
Excision of large Benign lesions of Upper Lip with Nasolabial Flap
restoration. Skin incisions are made as outlined.
Elliptical Excision of Benign Lip lesion Indication • Small premalignant
D
lesions and benign lesions
An elliptical skin and mucosal incision is outlined.
J
The flap is rotated and sutured in position. Extension of the incision is made to allow for closure of the donor site. The lateral skin margin is liberally undermined .
K The completed closure. Buried sutures of fine chromic catgut or white silk are used subcutaneously.
THE UPS
A
c
B
K
J FIGURE 9-2
THE UPS
Repair of Large Vermilion Defects (Fig. 9-3) Highpoints
to the upper lip, especially the Cupid's bow, a free split-thickness graft is inserted as depicted. The ragged edges of the defect are trimmed.
1. Use mucous membrane and muscle pedicle flaps. 2. If donor site defect is large, dermal skin graft or free buccal mucous membrane serves as an excellent buccal inlay. 3. Flap and pedicles must be thick to preserve adequate blood supply. 4. Barton bandage is necessary for cross oral pedicles.
C The bipedicle flap is now rotated 90 degrees so that the inner edge of the flap is sewn to the skin margin of the defect, and the outer edge of the flap is sewn to the gingivobuccal margin of the defect. The pedicle is carefully tubed near its base and closed posteriorly so that there are no bare areas. A Barton bandage is applied. The pedicles are severed after 2 weeks.
A A traumatic defect involves the central portion of the lower vermilion. With both commissures evenly retracted a bipedicle mucous membrane/muscle flap is outlined on the upper lip. The outer or upper incision is made about 0.5 em from the vermilion cutaneous border, splitting the entire lip and leaving enough attached at either side for an adequate blood supply. The incision is made 1 to 1.5 em into the orbicularis oris muscle. Another inner parallel incision is made at least 1 to 1.5 em from the first incision depending on the breadth of the defect in the lower lip. This likewise includes the muscle and is directed so that it meets the first incision deep in the muscle. The bipedicle flap thus mobilized contains the superior labial artery (Al). B The donor site can usually be closed by simple approximation. If this is not possible without distortion
D This defect is a partial loss of the lower vermilion. Reconstruction consists of the formation of a bipedicle tube of mucous membrane and muscle from the lower gingivobuccal sulcus, the donor site being covered with a dermal or free buccal mucous membrane graft. E The bipedicle flap is elevated and tubed while the donor site is grafted. F The next stage consists of transposing one end of the pedicle to the edge of the defect, as shown by the direction of the arrow in E. G At the following stage, the defect is bared and the pedicle untubed. The tube edges are now sutured to the edges of the defect. A final stage may be necessary to correct any inequality with the opposite side of the lower lip.
THE LIPS
skin graft
A
B
FIGURE 9-3
THE LIPS
Abbe-Estlander
Lip Operation
(Fig. 9-4) Highpoints
1. One third to one half of the upper or lower lip can be resected for carcinoma with immediate reconstruction. 2. Upper or lower lip defects after unsatisfactory cleft lip repair or trauma can be reconstructed. 3. A full-thickness flap is utilized: skin, muscle, mucous membrane. 4. The labial artery is preserved in the flap pedicle. S. Local anesthesia or general anesthesia can be used. 6. With general anesthesia, extreme care is necessary during the postoperative recovery phase regarding airway obstruction and disruption of suture lines. 7. The vermilion borders are approximated.
A A shield of incision is outlined in methylene blue (alcohol solution) with a minimum of 1 em of grossly normal tissue on either side of the tumor. The vermilion border is marked at the point at which the incisions cross with a needle dipped in the dye. This aids the approximation of the vermilion borders when suturing. Using calipers or another measuring device, a similar triangular area is outlined on the opposite lip, the length being equal to or slightly longer than that of the resected defect while the base or width is one half that of the defect. This achieves a proportionate shortening of upper and lower lips. The pedicle of the flap is usually medial and always contains the labial artery, which must be carefully preserved. It is better to leave a larger pedicle-usually 5 to 8 mm-beyond the vermilion border than to risk injury to the artery. If
the lesion is so located that the safety margin allows preservation of the natural commissure of the lips, this is preferable. Otherwise, the commissure is resected and reconstructed by a double Z-plasty or conversion of V-type incision to a V (see Fig. 9-7H to K). The commissure can also be reconstructed by using the Gillies method (see Fig. 9-5A to D). B The lesion with its borders is excised through and through. Using a clean knife, the flap is mobilized through and through except for the median pedicle. C
Using a stay suture, the flap is rotated.
D One suture of 5-0 nylon is placed through the needle marks of dye at the vermilion edges. It is left loose until a separate three-layer closure is done with mucosa, muscle, and skin. This closure is best begun along the medial margin of the pedicle. The muscle sutures are 4-0 chromic catgut; the mucosa suture is nylon or Dermalene. E All the mucosal and muscle sutures are completed, and the skin is approximated with 5-0 nylon. F A crown-type suture approximates the lateral edges of the lips with the pedicle so that the otherwise exposed border of the pedicle is covered with mucosa of the lips.
G Approximation
is complete. Feeding through a straw may be necessary. The pedicle is left intact for 3 to 5 weeks.
Continued
THE LIPS
FIGURE 9-4
465
THE LIPS
Abbe-Estlander Lip Operation (Continued) (Fig. 9-4)
The completed incisions.
J H In 3 to 5 weeksthe pedicle is transected (1-2), and reapproximation of the vermilion border is accomplished by a modified Z-plasty. An incision (5-6) is made along the previous scar for a distance of 1 to 1.5 cm equal to the width of the pedicle. A lateral extension (3-4) is made that is slightly longer.
Points 2 and 5 approximate one another, splitting the distance along the line 3-4. The vermilion edge is thus exactly realigned (1-6). The same procedure is performed on the upper lip. K
The completed reconstruction.
FIGURE9--4 Continued
THE LIPS
467
Correction of Rounded Commissure of Lips (Fig. 9-5) (Gillies) After major lip surgery in which the commissure has been either resected or displaced, the rounded corner may be corrected by the method of Gillies (Fig. 9-5) or that of May (see Fig. 9-7H to K). Highpoints The Gillies technique
is as follows:
1. Excision of a small triangle of skin 2. Section of underlying muscle 3. Advancement of mucous membrane
A A small triangle of skin is excised at the site of the neW commissure. The vermilion of the lower lip is cut at an angle along the solid line. B The underlying muscle is cut slantwise at the site of the new commissure. The inside layer of mucous membrane is transected in a horizontal line leading to the new commissure. C The lower rotated into the the upper lip. buccal layer of now freed with
vermilion that was freed has been new commissure, forming a portion of It is sutured inside and outside. The mucous membrane of the lower lip is scissors or knife.
D This mobilized mucous approximated to the cutaneous defect.
o
FIGURE 9-5
membrane is now border of the lower lip
THE LIPS
Plication of the Orbicularis Oris Muscle to Repair Partial Paralysis of the Lower Lip (Fig. 9-6)
A An incision is made along the vermilion lower lip of the involved side.
(Mahler et aI., 1982) Indication • Paralysis or weakness of the depressors of the lower lip, usually following sacrifice of the ramus mandibularis of the facial nerve Highpoints 1. Incision is along the vermilion of the lower lip. 2. This procedure includes an overfolding of the orbicularis oris muscle of the lower lip.
of the
B The vermilion is dissected from the orbicularis oris muscle to the commissure and retracted with stay sutures. The muscle is then plicated upon itself, thus shortening and thickening the muscle. Absorbable sutures are utilized. C This cross section depicts the plication. Glenn and Goode (1987) have described another technique for correction of the deformity of the lower lip after either trauma to the mandibular branch of the facial nerve or surgery in which that branch must be removed. Their technique involves a shield-type excision of the lower lip near the commissure, similar to that in Figure 9-1 E.
A B
FIGURE 9-6
THE UPS
Modifications of Abbe-Estlander Lip Operation (Fig. 9-7)
After the usual eXCISion of the lesion, a lateral rectangular flap is advanced to close the center defect.
Reconstruction of Center Lower Lip Defect A Rotation of upper lip flap to close a center lower lip defect. B The commissure of the mouth is preserved. Operative details are in Figures 9-4 and 9-5. When a crossed pedicle flap for center defects may not be tolerated by the patient or when general anesthesia is necessary, this type of transfer flap is used. During reaction from general anesthesia the patient may not be controllable, and the usual crossed pedicle flap (A and B) is endangered. C
D The resulting medial defect is closed with an upper lip flap that includes the commissure. The commissure is preserved by following the technique in Figures 9-4 and 9-5. In any event, an attempt is made to preserve the modiolus (hub) (modus muscularis), which is the site at which the orbicularis oris is blended with other muscles associated with the commissure. The modiolus is located lateral to the commissure along the nasolabial fold. It is important in the maintenance of a normal commissure (see Fig. 7-1). E
The completed closure. Continued
i i
FIGURE 9-7
THE UPS
Modifications Lip Operation
of Abbe-Estlander
(Continued) (Fig. 9-7)
Reconstruction of Upper lip Defect F Defects in the upper lip are closed with a rotation flap from the lower lip. G A new commissure the rotated lower lip.
is formed by the pedicle from
H A double Z-plasty (after May, 1949) is utilized to elongate and to sharpen the commissure. This is done at least 3 to 5 weeks after the initial operation. Excision of a small triangle of skin may be required between flaps 4 and 2. I Flaps 1 and 3 are rotated outward, whereas flaps 2 and 4 are rotated inward; thus, 2 and 4 are exchanged with 1 and 3.
J Correction of Rounded Commissure of lips Indication 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).
Another method of correction for commissure deformity is conversion of a V-type incision to a V. A Y incision is made as depicted. Some skin may require excision on the lateral borders. K
Point 5 is then advanced to point 5'. For the Gillies method see Figure 9-5A to D.
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Reconstruction of Large Defects of Upper Lip In the Figures 9-8 to 9-12, different techniques are depicted for reconstruction of large full-thickness defects of the upper lip. The first procedure is the use of the cheek flap (Paletta, 1954), with a tongue flap for inside mucous membrane lining (Bakamjian, 1971). The other flaps are the fan flaps, lateral flaps (Burow, Gillies), and forehead flaps. Each has its own advantages and disadvantages. Burget and Menick (1986) have described a modification of the Abbe-Estlander flap, at times combined with a rotation flap similar to that shown in Figures 9-9 and 9-11. Reconstruction of Upper Lip with Cheek Flap (Fig. 9-8) (After Paletta,
layers of the upper lip and a portion of columella and floor of the nose. B A horizontal fishmouth incision is dotted along the tongue (Bakamjian, 1971). The cheek flap (Paletta, 1954) is already in position. The inferior tongue flap (1) will form the vermilion and lower portion of the reconstructed lip, whereas the upper tongue flap (2) will form the inner mucous membrane lining. C The cheek flap is fitted into the defect with the tongue flap sutured in position. The cheek lateral to the flap site and portion of skin of cheek are undermined for closure of the donor site. D Cross section depicts the position of tongue flaps.
1954;
Bakamjian, 1971)
Highpoints 1. Wide resection of tumor is possible: this can include a portion of the base of the columella and floor of nose as well as full thickness of the upper lip.
E Close-up view of tongue flaps (1) and (2). A diamond-shaped area of tongue muscle may be excised at the time of the division of the tongue flaps to facilitate approximation of the tongue mucous membrane. 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 reconstructed lip are formed by tongue flap.
A Malignant tumor involves a major portion of the upper lip. The cheek flap is outlined, its medial border following the nasolabial fold. Resection includes all
The flap can be utilized to reconstruct the entire 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 the flap is returned to the donor site. The bare area on the contralateral side of the flap forming the columella can be covered with a full-thickness or split skin graft if necessary (see Fig. 6-230 and E).
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A
B
CHEEK FLAP
c
D
F
FIGURE 9-8
THE LIPS
Fan Flap Reconstruction for Large Defects of Upper Lip (Fig. 9-9)
Al, A2 The mucous membrane is elevated from the inner aspect of a portion (1-2) of the flap. This is advanced and sutured to the skin margin to form a new vermilion for the rotated flap.
Highpoints 1. Main blood supply is through the labial artery using same principle as an Abbe-Estlander flap (see Fig. 9-4A to OJ 2. All incisions are through and through into the oral cavity. Complications
B
The flap is rotated into position.
C With the flap in position, the defect in the nasolabial region is closed in two or three layers. As this is done, the lateral incision (7-8) is made depending on the way the flap lies. D Suturing the flap begins at the most advanced edge (2-3). A two- or three-layer approximation is made. Point 8 along the lateral border of the cheek is lost either by stretching or by trimming the corner.
• Involved procedure • Results in excess scars in cheek
A Two thirds of the upper lip is excised or has been lost as a result of trauma. Skin incisions are made as
E
outlined by the solid lines extending through all layers into the oral cavity. The distal extent of the incision (6)
commissure will require revision in 3 to 5 weeks (see Figs. 9-5A to D and 9-7H to K).
is 0.5 to 1.0 cm from the cutaneous-vermilion
border
to avoid injury to the labial artery. The lateral incision (7 -8) is not made until the flap is rotated.
The
completed
reconstruction.
The
rounded
THE UPS
\
I
I
,
A
B
c
D
E
~,
----FIGURE 9-9
476
THE UPS
Excision and Repair of Large Lesions of Upper Lip (Fig. 9-10) In these drawings two types of operations are depicted. In the first operation the reconstruction is based on Burow's principle of excision of excess skin and muscle with straight horizontal advancement. In the second operation, reconstruction is achieved by a fan flap, as in the Abbe-Estlander procedure, which utilizes the labial artery as the source of blood supply. Gillies has a modification of the fan flap, which facilitates reconstruction of the skin of the columella when this is necessary. A significant drawback to both of these procedures is narrowing of the oral orifice. Paletta's technique may be preferred (see Fig. 9-8).
Burow's Technique Highpoints 1. Full-thickness eXCISiOn of lesion and nasolabial crescents is performed. 2. Adequate mobilization is possible along gingivobuccal sulcus, with preservation of rim of mucous membrane in gingiva.
A An incision is made through and through the upper lip on both sides of the tumor with a horizontal connection at the base of the columella. Crescentshaped arcs are outlined in the nasolabial areas to permit straight horizontal advancement the defect.
of the sides of
B The full-thickness tumor are excised.
areas and the
crescent-shaped
D Three-layer closure is performed: brane, muscle, and skin.
mem-
E The mucous membrane closure is demonstrated. The rounded commissures may be corrected by following the technique of Gillies (see Fig. 9-5A to D) or May (see Fig. 9-7H to K).
Gillies' Technique F The major portion of the upper lip and skin of columella has been excised. Bilateral face flaps are made as follows. A point X is marked on the vermilion border at a distance from the commissure equal to approximately half the length of the defect of the upper lip. About 1.2 em below and slightly lateral to this point, a through-and-through incision is made in the same direction away from the vermilion for a distance of about 2.0 em. The labial artery, vital to this fan flap, is thus preserved. The incision is then carried in an easy sweep along the nasolabial fold to the lateral edge of the nose and then downward to the upper edge of the defect. The entire incision is through and through all layers. The gingivobuccal sulcus is also incised as in C. G The mobilized lip flaps are rotated. Above point 2 on the lateral border of the lip flap, an incision (3-4) is made in the cheek flap to adapt the advanced cheek flap to the lip flap. Thus, point 3 is approximated to point 1 and point 4 is approximated to point 2. Point 5 is rounded or lost as the cheek is advanced. Point 6 is used to reconstruct the columella. H
( Mobilization of the lateral flaps is achieved by liberal incisions on both sides of the upper gingivobuccal sulcus. Sufficient mucous membrane is left in the gingiva for suturing the advanced flap.
mucous
The completed
reconstruction.
THE LIPS
c
H FIGURE 9-10
477
THE LIPS
Repair of Large Defects of Upper Lip (Fig. 9-11) Indications In the rare situation in which the upper lip defect is caused by patient neglect and poor or no treatment of the lip margins, when the defect is not the result of tissue loss but mostly the result of retraction of the lip margin, an advancement with some of the fan flap principles is suitable. The associated cheek defect in this patient was covered with a forehead flap. The other complicating circumstance was the absence of well-vascularized surrounding soft tissue, as the result of radiation therapy. The fact that the lip margins were retracted by cicatrix formation permitted this type of reconstruction with minimum narrowing of the oral orifice.
A A very liberal incision is made in the gingivobuccal sulcus with mobilization of the lip and cheek beyond the nasolabial fold. Another nasolabial fold (1-2-3). B
incision is made in the
The incision in the nasolabial fold is then extended
beneath
the nares from point 4 to 5. This completely
mobilizes the upper lip and cheek. A small triangle of tissue between
'-2-4 may require excision.
C The upper lip flap is then advanced; the cheek is likewise advanced to close the defect in the nasolabial area. Three-layer closure is used if possible: mucosa, muscle, and skin. D The lower lip is mobilized with a through-andthrough incision following the fan flap technique (see Fig. 9-9). E The inferior gingivobuccal sulcus is incised deeply, thus mobilizing the outer portion of the lower lip. F After the opposing ends of each flap are trimmed, a three-layer closure is mandatory. G
The first layer is the mucosa, using nylon.
H The second catgut.
layer is muscle,
using 3-0 chromic
I The skin is approximated using fine nylon, the first suture being placed in the cutaneous-vermilion line. The remaining cheek defect is reconstructed using a forehead flap (see Fig. 8-11) or a microvascular free flap such as a radical forearm flap (see Chapter
24).
THE LIPS
FIGURE 9-11
THE LIPS
Bitemporal ("Visor") Flap for Large Upper Lip and Cheek Defects (Fig. 9-12) Highpoints
1. No delay is necessary. 2. If pedicles cannot be tubed, cover all bare areas with split-thickness grafts. 3. Free microvascular flap would be ideal for reconstruction of this type of defect (see Chapter 24). A After the hair is shaved, a bipedicle temporal flap is outlined, including the major branches of the superficial temporal arteries in both pedicles. It is important to include a non-hair-bearing area for the lip turn-in portion of the flap. An alternate to this turn-in is a free split-thickness skin or dermal graft. A tongue flap can also be used as mucous membrane lining (see Fig. 9-8). No delay is necessary, and the bipedicle full-thickness flap, including the galea, is immediately swung into position over the defect. This is particularly well suited to resections for cancer, because the defect can be covered at the same operation. Another distinct advantage in resection of a malignant neoplasm is that
bearing turn-in fold from the flap itself or with a splitthickness, dermal, or buccal mucous membrane graft or a tongue flap or a combination of both. A horizontal row of sutures is placed along any remnant of the gingivobuccal mucous membrane. The lateral edges of the lip and cheek defect are approximated as well as possible to the bare undersurface of the bipedicle flap. This will require revision at a later stage. C The bipedicle flap is in position with sutures along the upper edge of the flap to the upper edge of the cheek and lip defect. The dotted lines indicate the location of the turn-in fold or split-thickness dermal graft or tongue flap, which forms the inner covering of the upper lip. D The time of section of the pedicles will depend on the blood supply gained from the edges of the defect. Sectioning should be done in stages-one side at a time-and each side may be staged if necessary. The pedicles are then returned to the scalp, removing the split-thickness grafts where necessary. The only scalp defect is in the center, where it may be hidden by proper hair styling.
local flaps are not used; hence, spread of disease is detected more easily and not confused with the scars
of local flaps. Split-thickness skin grafts are used to cover the donor site and the bare areas of the pedicles if tubing of the latter is not possible. B The underside of the central portion of the biped ide flap is covered either with a non-hair-
At a later stage, the vermilion of the upper lip can be restored by using cross-lip grafts of vermilion from the lower lip. For restoration of a Cupid's bow see Figure 9-2A to C. If a forehead defect exists caused by the use of a non-hair-bearing turn-in portion, this can be covered by rotation flaps from the scalp and forehead in place of split-thickness skin grafts.
THE UPS
FIGURE 9-12
482
THE LIPS
Resection of Lower Lip with Bernard Reconstruction (Fig. 9-13) Highpoints 1. Resect adequate margins, especially down to chin. 2. Preserve external maxillary arteries. 3. If neck dissection is necessary, perform as second stage (Martin et a!., 1941). 4. Virtually entire lower lip can be excised. 5. Preserve mucous membrane in lateral triangular cheek flaps-this forms vermilion for reconstructed lower lip. 6. Preserve some mucous membrane in gingivobuccal sulcus for suturing lateral cheek flaps. 7. Tailoring of excess skin and muscle is performed as last stages of operation.
A A rectangular full-thickness excision of the lower lip and entire chin is performed. A narrow rim of gingivobuccal mucous membrane (shown at A in B) is preserved on the alveolar ridge. This serves as suture sites for the lateral cheek flaps. With a suitable dye, two lateral nasolabial triangles are outlined. The base of each triangle is slanted slightly upward, and each base is equal to half of the length of the excised lower lip. The median border of the triangle follows the nasolabial fold as closely as possible, so that with its closure a more natural fold will result. The skin and muscle (1) of these nasolabial triangles are now excised carefully, preserving the underlying mucous membrane
(2 in A, B, and C). This mucous membrane (2) is now mobilized, preserving its base. A small triangle of skin (X) is excised as the mucous membrane flap (2) is tailored to form the new lower lip vermilion. The two triangles (Y) below the chin margin are not outlined or excised until cheek flaps are mobilized.
B It may be necessary to excise some muscle and subcutaneous tissue from the lateral area of this triangle where the cheek is thick. On the right side of the patient, the mucous membrane flap is already sutured. C The cheek flap has been mobilized along the mandible as far lateral as the masseter muscle, taking care not to injure the facial artery (external maxillary artery), which is the principal blood supply to the cheek flap. The anterior margin of the masseter muscle may be freed if additional mobilization is necessary. The closure is begun by approximation of the mucous membrane of the cheek flap to the mucous membrane of the gingivobuccal sulcus left attached to the lower alveolar ridge. These sutures are placed to facilitate the median advancement of the cheek flap. Before all these sutures are tied, the mucous membranes of the edges of the nasolabial triangle are closed. As the cheek flaps are advanced, the two triangles below the chin (Y in A) are excised to adapt the midline closure in a satisfactory manner. Three-layer closure is used wherever possible.
THE LIPS
I
A
,
l
/'
Iv // '/
Y
c
FIGURE 9-13
THE LIPS
Reconstruction of the Lower Lip (Fig. 9-14) (After Dieffenbach, 1834) Although this atlas does not dwell in any detail on the historical aspects of head and neck oncologic surgery, a translation of Dieffenbach's original 1834 article appears worthwhile and at least very interesting.
Reconstruction of the Lower Lip after the Extirpation of a Lip Cancer First Case
A 71-year-old man suffered for many years of a cancer of the lower lip, which subsequently changed into a large, growing, cauliflower-like tumor. The glands near the lower jaw and neck were healthy. An extirpation of the entire lower lip had to be made whereby the incisions began at the corner of the mouth and led across the chin, where they met in an acute angle. To close the distance of the incisions it was necessary to remove the internal organs up to the lower jaw. Then five intertwining stitches were done, which apparently completely closed every point of the incisions. Some days later the upper part of the fissure was closed and the needles were removed, but the lower part festered. The appearing fissure was closed with strips of surgical tape. In the meantime the general health of the patient became worse. A starvation process set in with diarrhea and the patient died in the fourth week after the operation. With the dissection some tubercles in the lungs were found, and the spleen was hardened with its upper area covered with a thick cartilaginoustype skin. Second Case
A 45-year-old country man of huge build suffered for many years from a lip cancer, which gradually increased to such an extent that the largest part of the lower lip to the chin was transformed into cancerous tissue in the size of a fist. All adjacent glands were healthy. After the patient was pretreated, I extirpated the cancer by two crescent-shaped incisions, which started at each corner of the mouth, continued at the outer limit of the tumor, and came together at an acute angle under the chin; then I separated it from the gums and the lower jaw. The periosteum was damaged in several places, and I therefore scraped it off. After that I severed from the lower jaw the cheeks up to the front edge of the masseter, and then put through the center of the edge of the incision a long, strong needle, around which I wound thread ("atraumatic"). After a connection was achieved at that point, the upper part of the fissure was completely connected by three needles, and the lower part by four needles wound with thread.
By using a cooling outer and inner treatment the upper half of the incision healed at the first connection; the lower one, however, started to fester. Saliva and a part of the liquids frequently drained through this opening. But after removal of the needles from the upper part and after the lower incision was connected by firm pulling together with long strips of surgical tape, the incision closed by itself completely within 14 days. After 3 weeks no disfigurement could be seen on the man. Because of the half-circle type of incision on the soft parts underneath the corners of the mouth, two cones were formed, which, when united, helped the appearance of the lower lip. After a year's time the man again came to me. On the area of the operation another cancer had appeared. I gave the patient Zittmann's Decoct (a kind of brand name internal remedy) to drink for 4 weeks and then operated again as in the above described manner. This time I was able to close the incision with five needles. The last of the needles were already removed on the fourth day, but I still taped with long, thin surgical tape around the head and chin, as in a circle from chin to head and back. After the healing process was assured I again gave the patient the Zittmann's Decoct to drink for 4 weeks. I assume that no further problems arose because I have not heard from the man again. Third Case
A strong 60-year-old woman from the country suffered for years from a cancer of the lower lip that encompassed most of the lip. The tumor had a cauliflower type of appearance with the colors of red and white. Especially unfavorable for the operation or success of it seemed to be the solid (firm) connection of the tumor with the jaw, a sure sign of deterioration (degeneration) of the periosteum. By making two cuts in a wide circle around the cancerous growth I gave the wound a shape on the chin that ran to a point. Then I separated the cancerous mass from the bone and removed the loosened thickened periosteum by careful scraping. After this was done, I separated the cheeks on both sides of the lower jaw to facilitate the joining of the edges of the wounds and proceeded to the joining. For that, six atraumatic sutures were necessary. I attached three heavy and three fine needles, one after the other, and was pleased to see this tremendous wound completely joined. Then I ordered an inner and outer cooling treatment; healing took place so rapidly that on the second day already two of the thin needles could be removed, on the third day the uppermost thick needle, and on the fourth day all the others, after which I supported the young scar by two long narrow pieces of surgical tape, which went around the back of the head for several days, and I also ordered poultices of lead water. Only right over the chin
THE UPS
remained for a few weeks a small festering wound that, however, closed completely shortly thereafter. A recurrence of the cancer has not taken place during the last 4 years, and there is no sign of disfiguration to be seen on the patient.
Reconstruction of the Upper lip after an Operation of lip Cancer Fourth Case
Cancer of the lip appears chiefly on the lower lip; if it appears on the upper lip it is usually fungus or a chancre that turned into a cancer or possibly a true cancer of the corner of the mouth stretching to include the upper lip. It could also be cancer of the wing of the nose that affected the upper lip. This was the case of an 83-year-old weaver whose left side of his upper lip was affected. Through careful observation it was quickly determined that this was not a true lip cancer but a skin cancer that began at the wing of the nose affecting the upper lip. Partly because of the advanced age of the patient and partly because of the dangerous nature of the skin cancer I searched for a cure with mercuric chloride and then with "Hellmund's" ointment. But no cure came about and an extirpation of the affected parts of the lip up to the nose had to be made. TWooval incisions encircled the affected area, and after its removal the corners of the wounds were united with five atraumatic sutures. Because of the age of the patient one did not expect a healing process of the wound to occur and yet it occurred. The needles could be removed on the fifth and sixth days and caused no reaction on the surrounding areas. Fifth Case (Lower Lip)
An almost 60-year-old, skinny, but otherwise strong, man suffered for some years with a very large lip cancer, which turned all the lower lip from both corners into a huge carcinoma. The healthy upper lip was so unusually large that one could make two lips out of it. This particular phenomenon was very welcome. After the patient recuperated a little with the help of the Zittmann cure, which took a few weeks, I operated on him. I went with the knife from the left corner of the mouth along the jaw and ended 2 inches below the chin. The cut on the right side was the same and they joined in an acute angle. Now I started to remove the diseased mass; it was a handful of cauliflower type substance. The periosteum of the lower jaw was very large and soft. The rest of the procedures were the following: I loosened the cheek backward over the masseter and on the bottom from the lower jaw. After the blood flow
was stopped I burned the diseased periosteum with a glowing iron. Then I again took the knife and made a diagonal cut from each corner of the mouth an inch into the upper lip toward the direction of the septum but not quite that far. With these incisions I formed two flaps that were meant to form the lower lips. It was to be assumed by the loss of so much substance that the wound would not heal without lateral incisions. First I placed a needle (length of a finger) through the edges of the center part of the wound and with the entwining of the needle and a pulling of the heavy thread I achieved a tension in the cheeks. But there was still an inch between the edges; thus I made a cut on both sides, two inches long, through the cheeks right in the center between the wound edges and the front edge of the masseter. Through each of these openings I was able to place two fingers into the mouth cavity. In this way the tensions were relieved, and I was able, with the pulling of the thread around the needle, to combine (close) the wound exactly. Then I placed a row of needles (I believe about seven or eight) whereupon I was able to close the huge hole. The conclusion of the operation was done whereby I pulled the diagonal flaps of the upper lip downward, combined them, and fastened their outer edges onto the wound edge of the cheek skin, which now has become a lip, with an atraumatic suture. Thus, a lower lip was made through the cheek skin with the red
substance of the upper lip. As one now examined the patient one found his appearance quite adequate. Only the two huge lateral openings made the patient look ugly because one could see the mouth cavity and the tongue. If one separated the jaws, one was able to look through the face as if a cannon ball had penetrated the face, because the lateral cuts, through their tension, appeared almost round. With a cool treatment followed, in a few days in most places, a healing process of the various wounds so that in the third, fourth, and fifth days the needles could be removed. Only on two places a festering occurred: First, densely over the chin and then a little higher where the corners of the red substance of the upper lip came together with the vertical wound. The corners themselves were healing properly, though. The lateral wounds, already in 8 days, have shrunk two thirds in size, and their edges were covered with granulation. Saliva and phlegm still flowed through them. The surgical dressing was made with dry lint and over it, just as across the closed wound parts, long strips of surgical tape. This was done until the two openings in the center of the lower jaw and the lip were healed. In the third week the opening on the left was closed, and in the fourth week the one on the right closed without complication. The appearance of the man was normal; his mouth was a little small but natural with the usual corners and a red lower lip.
THE LIPS
Reconstruction of the Lower Lip (Continued) (Fig. 9-14) (After Dieffenbach, 1834) Reconstruction of the Lower lip from the Cheeks after an Operation of a lip Cancer with the Resection of a Part of the Lower Jaw Sixth Case A 60-year-old man has suffered many years with a cancer of the lower lip. This cancer covered the free parts of the lower lip and did not reach the chin. On both corners of the lip one-quarter inch of the red lip substance was still here. The operation was easily completed. With a knife I first cut the left side of the lip, encircled elliptically the cancer, and enlarged the incision through the healthy lower soft areas to give the wound a good appearance and help with the closure. On the right side I did the same thing. After the cancer was scraped off the bones I loosened the soft areas from the jaw. Now I proceeded with the closure. Even though a tension built up with the entwining of the needle, the edges still combined so completely that lateral incisions were not necessary. The tension became less after I inserted five additional needles. Then I cut the thread very short and the wound was cold bathed. These compresses were continued for some days and I made sure the patient was not allowed to speak. His nourishment was taken with a quill. The success of this operation was excellent. After a few days the needles were removed, whereupon I fastened tape over the chin and lip and washed it with lead water (Goulard). The appearance of the lower lip was completely normal. Seventh Case 44-year-old laborer was admitted to me with one of the largest cancers of the lower lip I have ever seen. The cancer had spread to almost all of the lower part of the face. All of the lower lip, both sides of the upper lip, the soft areas of the chin plus the front and lower parts of the cheeks were affected. The growth was many inches and had an uneven wart type appearance. The color of this growth was various; some humps were pale, others red, some smooth, others with scales. In the areas between the humps a sticky, wet substance was found. The growth had almost fastened itself to the teeth of the lower jaw and the gums were thus affected with this cancer. They were no longer what one could call gums. The soft areas behind the teeth of the lower jaw were healthy. Not one single gland was A
swollen, and no effects were noticed on the parotid gland and the submaxillary glands. This last observation made the operation (one of the most difficult) necessary. It was done in the following ways: The patient was sat in a chair and an assistant pulled his head a little toward the back. I placed the knife on the right side of the upper lip, where the cancer started, and cut first up into the upper lip, encircled the growth with a circular cut, turned outward toward the cheek skin, then immediately went down far away from the ear and chin and ended underneath the chin in the center between the chin and the larynx. The cut on the other side started on the left corner of the mouth, did not go into the upper lip as far as the other one, but went as far outward, and then went along the lower part of the lower jaw and met with the first cut in an acute angle under the chin. These type of cuts encircled the whole areas of the growth. Now with my left hand I grabbed the growth and separated it from the lower jaw. The periosteum was affected just as I thought. It was very thick, hard, and fused with the growth. That there was much blood with such long incisions does not have to be mentioned. All vessels in the areas were greatly enlarged because the blood gushed not only from the larger arteries but also the entire parenchyma spurted with blood. As much as I was able to remove from the periosteum, I did. Then with tweezers I grabbed the inner edge of the wounds of the lips and cheek skin and cut everywhere one-quarter inch off because the affected area of the mucous membrane reached farther than that of the outer area of the face. Now I could find no more trace of diseased spots in the soft areas. The worst part was the lower edge of the chin. It was curiously full of holes. It looked terrible. The upper part of a human face with skin and meat and the lower part was a skeleton. This diseased area, the lower edge of the chin, I sawed off squarely across. To unite the soft parts of the cheek skin, as done in this type of operation, more skin was needed than was available. To make the available skin more pliable I loosened it completely toward the back, not only from the lower jaw but also from the upper lip of the upper jaw. These internal cuts reached beyond the masseter. Now I pulled the facial skin from both sides. Underneath the chin somewhat of a unification was accomplished but from the chin edge to the mouth an area of skin about three fingers wide was still missing. This missing skin had to be gotten from lateral incisions and thus decreasing the tension as well. First of all the closure (unification) of the skin underneath the chin was necessary. This was done completely with five atraumatic needles; then it became tight, and the skin allowed itself only to be pulled over the outermost edge of the chin. Now it was time to cut 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 body of the malar bone, went slightly lower toward the inside until the lower edge of the lower jaw, and separated not only the skin but also the "buccinator" and the mucous membrane of the mouth. Through these openings one could place three to four fingers into the mouth cavity. With these lateral cuts, 2 inches away from the needed closure, I was now able, with the help of strong mounting pins, to close this huge opening so that there was again only one mouth opening. The lateral cuts now really gaped open. They were, so as not to expose such great wounds to the air, gently covered with lint and tape. After the patient was cleaned from the great amount of blood, he was brought to bed and given the most antiseptic treatment possible. On the lower part of the face an ice pack was placed. So that the pressure was not too great and would not cause harm, the pack was hung on a wooden ring. This ring was above the patient's face fastened on both sides of the bed. On the day after the operation the patient was amazingly well. The soft parts were greatly swollen and red, but nothing unusual was to be noticed. The wound edges seemed to be closely glued together. Thirty leeches were attached. Days afterward the swelling was lower, and today I took out the five lowest needles. Everything was closed so tightly that it was not necessary to apply tape. The edges of the lateral openings were hard with growth, and the wound area was still covered with necrosis type of tissue. We again attached leeches. On the eighth day of the operation the condition of
Almost all openings were filled with this granulation, and still mucus and phlegm flowed through when one day this granulation turned brown and changed into a cancer. The skin surrounding the area also turned brown and everything looked very dim. I now applied the glowing iron to this growth and destroyed it. Internally I ordered the "littmann's Decoct" for the patient. His condition improved somewhat and the same procedure is now being used. I will later announce the success of this operation, because this case is very interesting and since it fits so well with these observations that I don't wish to leave it out.
the patient was as follows: The general condition was favorable, and no fever was there. The upper part of the
mandible, if not directly involved, can be resected. 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, fourth, and sixth days) had healed with the first closure. The upper edges of the incision were festering, and with narrow, long surgical tape were kept close together. The lateral incisions cleaned themselves and showed large granulations. The right one did not go through the cheek any longer, since it had filled almost completely. From the left some mucus was still draining, and the water that was sprayed into the mouth to clean pus and mucous still flowed from this wound in thick streams. Both bridges were still inflamed but not as bad as before. To lessen this continuous inflammation and to reduce the festering of the center wound tepid Goulard extract as well as camomile tea was applied. The condition of the patient was very favorable. His strength suffered so little because of the operation that he did not wish to remain in bed a few days after the operation. The upper part of the center wound, at the two lateral incisions, continued to fester strongly, and a large granulation filled the wound more each day.
struction would thus require a distant transferred flap (e.g., pectoralis major myocutaneous flap; see Fig. 8-2) to cover Kirschner wire stabilization of the mandible (see Fig. 14-5). Preservation of both external maxillary arteries is done. Extended mucosal flaps superiorly to the cheek flaps are used to reconstruct the vermilion. A portion of the masseter muscle is used to fill in the defect medial to the masseter muscle. Patency of Stensen's ducts is maintained. Outline the anterior border of the masseter muscles before anesthesia by having patient contract the muscles. Preserve a small portion of lower lip at the commissure. Preserve an edge of mucosa on the gingival side attached to the mandible to facilitate closure. Preserve facial nerve divisions and main branches wherever possible.
Indication • A one-stage procedure for the reconstruction of the entire lower lip. It is obvious that a malignant neoplasm of this size under most circumstances would require at least a unilateral radical neck dissection and contralateral suprahyoid neck dissection and probably a bilateral radical neck dissection. The neck dissection using this technique would require a second stage because a simultaneous neck dissection would sacrifice the external maxillary artery and thus interfere with the major blood supply of the cheek flaps. Depending on blood supply, a free microvascular flap could be an option. Highpoints 1. The entire lower lip and portion of the soft tissue of the chin can be resected. The outer table of the
2. 3. 4.
5. 6.
7.
8. 9.
THE UPS
Reconstruction of the Lower Lip (Continued) (Fig. 9-14) Complications • Contracture of lower reconstructed lip • Facial nerve and/or Stensen's duct injury
A The solid line depicts the skin incisions. The dotted lines indicate the mucosal portion of the flap. The dotted portion above the horizontal skin incision is obtained from the underlying mucosa and left attached to the skin flap. It is this mucosa that will form the new vermilion. The commissures are preserved with the upper lip. The lateral superior incision is made obliquely to
mucosa superior to the skin-muscle flap, as depicted by the dotted lines. Lateral and posterior to the anterior border of the masseter muscle only skin and subcutaneous tissue down to the parotid fascia is included in the skin flap, thus avoiding the underlying facial nerve, Stensen's duct, and parotid gland. The facial artery and vein will require ligation and transection at the superior margin of the cheek flap. C The dotted line on the right cheek flap indicates the l-cm portion of mucous membrane left attached to the cheek flap, which when turned down (arrow) forms the new vermilion of the reconstructed lower lip. The underlying submucosal subcutaneous tissue and muscle may require some trimming to obtain a thin lateral portion of the new reconstructed
The skin flaps are mobilized with care taken not to
lower lip. The solid line below the teeth is a rim of mucous membrane that is left attached to the mandible and is preserved to facilitate closure. This is the incision made along the lower gingivobuccal sulcus. The cheek flap on the left side of the patient demon-
injure the divisions nor main branches of the facial
strates the preserved mucous membrane. This flap is
nerve lateral to the anterior border of the masseter muscle and superior to the upper skin flap. Stensen's
completely mobilized to the submandibular area using blunt dissection. This mobilization is important to permit complete freedom of the flap from the mandible. The
about 3.8 em anterior to the tragus. The vertical limb of the incision is extended to below the mandible, forming an acute angle with the lateral superior incision laterally. B
ducts must likewise be preserved. The skin flap medial and anterior to the masseter
mental nerves usually require transection. The external
muscle is full thickness, including the underlying buc-
maxillary artery and accompanying veins as they cross
cinator muscle and mucous membrane along with the
the mandible
must
be preserved.
Continued
THE UPS
FIGURE 9-14
THE LIPS Reconstruction of the Lower Lip (Continued) (Fig. 9-14) D On the left side of the patient an anterior portion of the masseter muscle is mobilized along the dotted lines and rotated anteromedially to fill in the defect from that portion of the buccinator muscle which was mobilized with the cheek flap. The superior end of the masseter muscle flap is sutured to the lower edge of the remaining portion of the buccinator muscle. E
Closure of the defects to be performed (after May,
1971): 1. Connection of the lateral edge of the new vermilion to form the commissure along with the small flap from the upper lip 2. Closure of the posterior mucous membrane defect as far as possible by mobilization of the posterior mucous membrane
3. Approximation of the mucous membrane of the cheek flaps to the rim of mucosa still attached to the mandible 4. Approximation of both cheek flaps in the midline with three-layer closure 5. Approximation of the lateral portion of the cheek flap to the skin edges without tension 6. Closure of the donor site commencing at the lateral corner, which is an acute angle and thus easily closed. Drains are placed at the lateral lower wound angles. 7. An internal stent may be helpful to decrease the lip and labial contractu res in the edentulous patient. F The vermilion is formed by advancing the retained mucous membrane downward and is sutured to the superior edge of the flaps. The dotted line represents some adjustment to correct any dog-ear or pointing of the skin margins.
THE UPS
D
FIGURE9-14 Continued
THE LIPS BIBLIOGRAPHY Abbe R: A new plastic operation for the relief of deformity due to double harelip: The classic reprint. Plast Reconstr Surg 42: 481-483, 1968. Ashley FL, McConnell DV,Machida R, et al: Carcinoma of the lip: A comparison of five year results after irradiation and surgical therapy. Am J Surg 110:549-551, 1965. Axhausen G: Technik und Ergebnisse der Lippenplastik. Leipzig, Georg Thieme, 1941. Bailey BJ: Management of carcinoma of the lip. Laryngoscope 87:250-260,1977. Bakamjian VY: Personal communication, 1971. Baker SR, Krause CJ: Carcinoma of the lip. Laryngoscope 90:19-27, 1980. Bauer BS, Wilkes GH, Kernahan DA: Incorporation of the W-plasty in repair of macrostomia. Plast Reconstr Surg 70:752-756, 1982. Bernard C: Cancer de la levre inferieur opere par un procede nouveau. Bull Soc Chir Paris 3:357, 1853. Bowers DG Jr: Double cross-lip flaps for lower lip reconstruction. Plast Reconstr Surg 47:209-214, 1971. Burget GC, Menick FJ: Aesthetic restoration of one-half the upper lip. Plast Reconstr Surg 78:583-593, 1986. Byers RM, Boddie A, Luna MA: Malignant salivary gland neoplasms of the lip. Am] Surg 134:528-530, 1977. Clairmont AA: Versatile Karapandzic lip reconstruction. Arch OtolaryngolI03:631-633,1977. Conley]], Donovan B: New techniques for lower lip reconstruction in a melanoma patient. Otolaryngol Head Neck Surg 94: No.3, 1986. Conley], Baker DC, Selfe RW: Paralysis of the mandibular branch of the facial nerve. Plast Reconstr Surg
70:569-577, 1982.
Guerrero-Santos J: Use of a tongue flap in secondary correction of cleft lips. Plast Reconstr Surg 44:368-371, 1969. Jesse RH: Extensive cancer of the lip. Arch Surg 94:509-516, 1967. Lore JM Jr, Kaufman A, Grabau JC, Popovic DN: Surgical management and epidemiology of lip cancer. Otolaryngol Clin North Am 12:81-95,1979. Luce EA: Carcinoma of the lower lip. Surg Clin North Am 66:3-12, 1986. McGregor IA: Reconstruction of the lower lip. Br J Plast Surg 36: 40-47, 1983. Mahler D, Ben-Yakar Y, Baruchin A: Plication of the orbicularis oris muscle to repair partial paralysis of the lower lip. Ann Plast Surg 8:224-226, 1982. Martin HE, MacComb WS, Blady JV: Cancer of the lip. Ann Surg 114:226, 1941. May H: Plastic and Reconstructive Surgery, 3rd ed. Philadelphia, FA Davis, 1971. Meyer R. Failat AS: New concepts in lower lip reconstruction. Head Neck Surg 4:240-245, 1982. Musgrave RH, Garrett WS Jr: Dog bite avulsions of the lip. Plast Reconstr Surg 99:294-296, 1972. Nakajima T, Yoshimura Y, Kami T: Reconstruction of the lower lip with a fan-shaped flap based on the facial artery. Br ] Plast Surg 37:52-54, 1984. Paletta FX: Cancer of the lip. From symposium on cancer of the head and neck. In Gaisford JC (ed): Total Treatment and Reconstructive Rehabilitation, vol II. St. Louis, CV Mosby, 1969. Paletta FX: Early and late repair of facial defects following treatment of malignancy. Plast Reconstr Surg 13:95-108, 1954. Pelly AD, Tan EP: Lower lip reconstruction. Br J Plast Surg 34:83-86,
1981
Dieffenbach Jf: Chirurgische Erfahrungen, Abb, 3, V4, Berlinl 15341
5aemann 0: Die Transplanlations-Methode der Herm, Prof. Dr.
pp 96-110. Earley M]: Peri-alar skin excision and lip advancement in the closure of lip defects. Br] Plast Surg 37:50-51, 1984. Ellis DAF, Miller RB: Rehabilitation of the paralyzed lower lip. J Otolaryngol13:403-405, 1984. Estlander JA: Methode d'autop!astic de la joue au d'une levre par un lambeau emprunte a I'autre levre. Rev Mem Med Chir 1:344, 1877. Filatoff W: Plastic a tige ronde. Westnik Oflalmol Avril-Mai, 1917. Fujimori S: "Gate flap" for the total reconstruction of the lower lip. Br] Plast Surg 33:340-345, 1980. Gage AA, Koepf S, Wehrle D, Emmings F: Cryotherapy for cancer of the lip and oral cavity. Cancer 18:1646-1651, 1965. Gerold F: Personal communication, 1960. Glenn MG, Goode RL: Surgical treatment of the "marginal mandibular lip" deformity. Otolaryngol Head Neck Surg 97:462,1987.
Burow. Dtsch Klin 20:221, 1853. Su CT, Manson PN, Hoopes JE: Electrical burns of the oral commissure: Treatment results and principles of reconstruction. Ann Plast Surg 5:251-259, 1980. Van Dorpe EJ: Simultaneous repair of the upper lip and nostril floor after tumor excisions. Plast Reconstr Surg 60:381-383, 1977. Villoria JMF: A new method of elongation of the corner of the mouth. Plast Reconstr Surg 49:52-55, 1972. van Bruns V: Das Handbuch d. praktisch Chir. Tiibingen, Lauppsche Buchhandlung, 1859. Wilson JSP, Walker EP: Reconstruction of lower lip. Head Neck Surg 4:29-44, 1981.
10
CLEFT LIP AND PALATE ROBERT J. PERRY JOHN M. LORE, JR.
Cleft Lip (see Figs. 10-1 to 10-7) To understand the objectives in cleft lip repair one must evaluate not only the deformity but also its relationship to the normal anatomy.
combined with a cleft palate is not performed for a number of reasons: optimal age is different, and morbidity and mortality are increased, owing to possible airway obstruction and blood loss. Normal Anatomy (Fig. 10-1)
Types of Cleft Lip Deformities Several classifications of cleft lip with or without cleft palate are popular. Generally, a cleft lip may be unilateral, bilateral, or median (rare) and present as a complete cleft or in varying degrees as an incomplete cleft. Clefts of the alveolar process and primary and/or secondary palate may also occur. Simultaneous repair of a cleft lip
(After Millard, 1968)
A Anterior view. The labeled structures and their relationships are the normal landmarks important in cleft lip repair. B Lateral view. An infant's upper lip is often full in its lower two thirds, with a prominent "pout."
RIM
ALA BASE RIDGE}
PHILTRUM
. GROOVE
NOSTRIL SILL CUPID'sf APEX BOW TUBERCLE
.
BASE OF ARCH MUCOCUTANEOUS RIDGE
}
CUPID'S BOW
A FIGURE 10-1
493
ClEfT LIPAND PAlATE Unilateral Cleft lip Repair
Basic Deformities of Cleft Lip (Unilateral Complete) (Fig. 10-2)
rience of the surgeon. As the child grows, the nasal tip, alar cartilage, and nasal septal surgery can be performed at a later time. More than ever is the surgeon's oath of primum non nocere applicable. When not sure, seek help.
There are three main deformities:
Optimal Age for Operation
1. Maxillary defonnity: anterior displacement with external
There is considerable difference of opinion regarding the optimum time of operation. Although the repair can technically be done on the first day of life, the earliest age that is reasonable is 10 to 14 days after birth, provided that the infant has started to gain weight and has otherwise normal signs, especially the hemoglobin and hematocrit. The rule of "over 10" is a good guide: over 10 weeks old, 10 Ib in weight, and 10 g of hemoglobin. Three months of age is believed by others as the most opportune time. Although cleft lip with or without cleft palate most often occurs in isolation, other anomalies may exist. This incidence is 7% to 13% in isolated cleft lip and 2% to II % in cleft lip with cleft palate (Cohen, 1983). It is estimated that 1% of cleft lip with or without cleft palate occurs as part of a syndrome (Bixler, 1981). A complete medical history, family history, and physical examination is mandatory.
(See Figs. 10-2 to 10-4)
rotation of the premaxilla (the central portion of the upper alveolar ridge and maxilla from which the upper incisors arise). 2. Lip deformity: decreased vertical height on cleft side with variable tissue deficiency medially, preserved two thirds of Cupid's bow and non-cleft-side philtral column· and groove, and abnormal orbicularis oris muscular insertion. 3. Nasal deformity: shortened cleft-side columella with attenuated and "slumped" lower lateral cartilage and flared alar base and deviated nasal septum to the side of the cleft with contralateral anterior dislocation. Basic Objectives of Repair
1. Recognize, identify, and preserve normal landmarks and as much tissue as possible. 2. Realign these normal landmarks into their normal position both from the anterior aspect and the lateral aspect: a. Lengthen the lip on its deficient cleft side to the dimensions of the normal side. b. Preserve the philtrum, Cupid's bow, the "pout," and the mucocutaneous junction. c. Reconstruct the orbicularis oris muscular sphincter. d. Correct the distortion of the alar base and columella with undermining and mobilization rather than any cartilage incision. e. Some surgeons favor concomitant nasal tip correction using cartilage repositioning techniques (Salyer, 1986). f. Widely separated maxillary elements may be brought into optimum presurgical alignment with extraoral traction using simple taping techniques. Precautions
In general, do not do the following: 1. Damage or excise any nasal cartilage. 2. Perform simultaneous cleft palate repair. 3. Excise any normal landmarks. There are exceptions to these dicta depending on the procedure utilized as well as the skill and expe-
Anesthesia
General endotracheal anesthesia is preferred with the endotracheal tube brought out through the mouth across the midportion of the lower lip. Care must be taken that no tension is placed on the upper lip or oral commissures. If a local anesthetic containing epinephrine is employed to facilitate a drier operative field and a lighter plane of anesthesia, one must not risk exceeding the maximum recommended dosage of epinephrine for the anesthetic agent used. Recall that a 1:100,000 dilution equals 10 mg/mL. Classification of Types of Repair of Unilateral Cleft Lip
Techniques in cleft lip surgery have evolved slowly, dependent on the analysis of long-term results in the young and growing patient. Several methods of repair are still employed for the correction of the unilateral cleft lip deformity, and with the exception of the straight-line closure, all introduce tissue from the lateral element to fill a deficiency medially. The procedure of choice at this writing for both complete and incomplete forms is the rotation advancement method of Millard, which best preserves the natural landmarks while concealing the incisions within natural lines.
CLEFT LIP AND PALATE
COLUMELLA
~tNON-CLEFT-SIDE R ID.G.? E~ CLEFT-SIDE RIDGE
g:::::! iE
I
GROOVE
/
/ C/J
~ ~
:::>co
REMAXILLA ~\
-JT.
.#
{
APEX
i
()
FIGURE 10-2
ELEMENT
495
CLEFTLIPANDPALATE Triangular Flap Cleft Lip Repair: Tennison-Randall Technique (Randall, 1959) (Fig. 10-3) Highpoints
A "Z" incision is made on the lateral border of the cleft, which is unfolded. 2. An incision is made into the medial border of the cleft, which is opened to receive the triangular flap from the lateral lip element, lengthening the medial lip element. 3. The orbicularis muscle fibers are reoriented into a normal horizontal direction (Randall et aI., 1974). 1.
from point 8 to the ipsilateral oral commissure equals the distance from point 2 to the non-c1eftside oral commissure. 7. Point 10 is approximately the midpoint of 7-13, and point 11 is approximately the midpoint of 9-12. 8. The locations of points 9 and 12 vary according to the size of the cleft and the amount of tissue available. Point 9 is chosen first on a trial basis and adjusted so that the following relationships are true: a. Length 6-9 is made equal to length 5-13. b. Length 4-2 minus length 5-10 equals length 8-11, the distance across the base of the flap or the amount required to drop Cupid's bow into normal position. e. Length 8-12 equals length 9-12.
A The landmarks are identified with methylene blue. 1. The following points are marked on the medial lip
element: Point 1 is the midpoint of Cupid's bow on the vermilion border. Point 2 is the apex of Cupid's bow on the non-cleft side. Point 3 is the apex of Cupid's bow on the cleft side such that length 1-2 equals length 1-3 (poin~ 3 corresponds to point 13). 2. The medial lip element is pushed toward the cleft, straightening the colurpella in the midline. Point 5 is on the vermilion border of the medial element at the base of the columella. Point 4 is the correspon-
3. 4. 5. 6.
ding point at the base of the columella on the opposite nostril sill. Point 6 is a point in the nostril floor of the lateral element with the same relationship to the cleft-side alar base as point 4 has to the non-cleft-side alar base. Line 5-3 is drawn. Point 7 is generally found on the philtral midline such that angle 5-3-7 is approximately a right angle. Line 3-7 is drawn. Point 8 is located on the vermilion border of the lateral element at the point where the mucocutaneous ridge becomes attenuated. The distance
B Full-thickness incisions are now made on the medial side of the cleft extending from point 5 to point 13. Excess lip is trimmed as in the shaded area. The incision 7-1 3 is made, revealing a triangular defect as the Cupid's bow remnant is rotated into normal position. C The markings are rechecked before the construction of the lateral triangular flap: length 4-2 equals the projected length 5-10-3 equals the projected length 6-11-8. Full-thickness incisions are then made on the lateral side of the cleft. Mobilization of the alar base and cheek is performed sufficiently to realign the naris on the cleft side to match as closely as possible the normal naris. The orbicularis oris muscle bundles are carefully dissected from the cleft edges by undermining in both subcutaneous and submucosal planes and releasing them from their abnormal insertions superiorly along the cleft edges. Lip closure is in three layers: muscle, skin, and mucosa with points 6 to 5, 9 to 13, 12 to 7, and 8 to 3. D
The completed repair.
CLEFT LIP AND PALATE
\
\
\ \ \ \
\
A
B
'\
\
c
D
FIGURE 10-3
CLEFT LIP AND PALATE
Rotation Advancement Cleft lip Repair (Millard, 1958, 1976) (Fig. 10-4) Highpoints 1. Downward
2. 3. 4. S.
rotation of Cupid's bow into normal position (flap A). Medial advancement of upper portion of lateral lip element into rotation gap (flap B). Elongation of cleft-side columella (flap C). Independent correction of cleft -side alar flare with alar base flap (flap D). Reconstruction of orbicularis oris muscular sphincter.
A An incision is made at right angles to the vermilion borders into the medial edge of the cleft lip at a point corresponding to the potential height of Cupid's bow
on the cleft side (point 3). From this point superiorly the cleft-edge vermilion is trimmed. The full-thickness incision is then carried upward following the reciprocal curvature and position of the philtrum on the normal side until it reaches the base of the columella. The incision is cut on the bias to preserve as much muscle as possible on the flap. Without crossing into the normal philtrum, the incision curves under the base of the columella and extends toward the normal side as far as is necessary to rotate the Cupid's bow (flap A) into a normal horizontal plane. A small back-cut (point X) directed obliquely downward facilitates this rotation. B A fine hook exerts upward traction on the c1eftside alar rim. This results in a defect at the base of the cleft-side columella to be filled with flap c. An incision is made into the membranous septum following the posterior border of flap c. This flap is subsequently undermined and advanced into position to balance the columella. The medial aspect of flap c is tailored and sewn into the superior aspect of the defect created by the downward rotation of flap A.
A
B FIGURE 10--4
CLEFT LIP AND PALATE
499
FIGURE 10-4 Continued
Complication • The most common iatrogenic complication is underrotation of flap A.
C Flap B is now developed, again cutting on the bias to preserve as much muscle on the flap as possible. The vermilion is trimmed by making an incision at a right angle to the vermilion border at a point (8) at which the vermilion becomes attenuated and at which the resultant preserved length of the lateral element when sutured to the medial element (flap A) will result in a normal balanced upper lip. The distance between this point (8) and the ipsilateral oral commissure (7) generally corresponds to the distance between the apex of Cupid's bow (2) and the oral commissure on the non-cleft side (6). The incision is carried up along the vermilion border to include the most superomedial usable lip tissue and then curved laterally around the alar base. (The reference numbers refer to those shown in A.)
Through an incision in the upper gingivobuccal sulcus, the lateral element is then dissected from the 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 orbicularis oris muscle bundles, freeing them both subcutaneously and submucosally so that when approximated across the cleft the orientation of their fibers will be changed from an abnormal near-vertical direction to the normal horizontal direction. Flap B is then advanced medially and sewn into the defect created by the downward rotation of flap A, and the lip is closed in three layers: muscle, skin, and mucosa. Flap 0 is then advanced medially to close the nostril floor. A portion of this flap may be de-epithelialized and sewn to the base of the nasal septum anteriorly with a permanent suture as a unilateral alar cinch. D
The completed repair.
ClEfT LIP AND PALATE Bilateral Cleft Lip Repair (See Figs. 10-5
to 10-7) Results from the repair of the bilateral cleft lip are generally less satisfactory than those for repair of unilateral cleft lip. Although bilateral cleft lips tend to demonstrate less asymmetry, the greater tissue deficiency in the central element contributes to a more difficult reconstruction. The approach to the bilateral cleft lip varies according to the severity of the nasal deformity. In most complete clefts and in some incomplete clefts, a staged repair is indicated in which the prolabium is shared between the severely short columella and the deficient central lip element. One should become familiar with those techniques in which prolabial tissue is stored or "banked" at the time of the initial lip operation, facilitating later columellar reconstruction without reentry into a healed lip repair (Millard, 1977). The straight-line closure is presented as a popular solution to the bilateral cleft lip; however, because the entire prolabium is used in the lip reconstruction, this method is better reserved for those few cases with adequate columellar length. Techniques derived from unilateral cleft lip repairs have been applied to the bilateral cleft lip and are particularly applicable to the incomplete form. The rotationadvancement technique (Millard, 1960, 1977) is shown in Figure 10-7. Highpoints
1. Restore and maintain the premaxilla in proper position in the upper dental arch. This facilitates bilateral lip repair with minimal tension. (See problem 1, later.) 2. Plan the lip repair with the appropriate nasal correction in mind. (See problem 2, later.) 3. Recognize, identify, and preserve normal landmarks and as much tissue as possible. 4. Reconstruct the central portion of Cupid's bow with vermilion from the lateral lip elements. 5. Restore the orbicularis oris muscular sphincter at the appropriate stage. Basic Deformities of Cleft Lip (Bilateral Complete) (Fig. 10-5) There are three main deformities: 1. Maxillary deformity: separation of the premaxillary
component from the lateral maxillary arches. The
premaxilla may be deflected or rotated to one side and may project anteriorly to a variable degree. 2. Lip deformity: variably sized prolabium containing no muscular elements and demonstrating no Cupid's bow or philtrum and abnormal orbicularis oris muscular insertion in the lateral lip elements. 3. Nasal deformity: very short columella and attenuated and "slumped" lower lateral cartilages with flared alar bases. Precautions
In general, do not perform the following: 1. Excise prolabium or premaxilla. 2. Create more asymmetry by repairing right and left sides in separate operations. 3. Jeopardize prolabial blood supply with simultaneous lip and columella reconstruction. 4. Use the redder prolabial vermilion in the vermilion of Cupid's bow. Problems
1. Projecting premaxilla. Presurgical manipulation of the premaxilla with extraoral traction using simple taping techniques is performed to avoid the growth disturbances often associated with a surgical premaxillary setback. When the premaxilla is in optimal position, the lip closure will then facilitate additional molding of the maxillary arch. For those rare patients refractory to this conservative approach, surgical setback is best delayed to age 6 years. 2. Small prolabium. Because the prolabium is used in the staged reconstruction of both the lip and columella, a preliminary lip adhesion may be indicated. In this procedure, the orbicularis oris muscle bundles from the lateral elements are attached to the cleft edges of the prolabium to expand the prolabial tissue as necessary. Optimal Age for Operation
Gavage feeding techniques and improved neonatal care have reduced the urgency of surgery in the bilateral complete cleft lip and palate patient. Timing for surgery follows the guidelines for the unilateral cleft lip repair recommended earlier in this chapter.
CLEFT LIP AND PALATE
COLUMELLA
ALAR BASE PROLABIUM PROLABIUM VERMILION PREMAXILLA1
\\
I
I
"
LATERAL
"ELEMENT
FIGURE 10-5
501
CLEFT UP AND PALATE
Repair of Complete Bilateral Cleft Lip (Straight-Line Closure) (After Veau) (Fig. 10-6) Highpoints 1. Reconstruct Cupid's bow with vermilion from lateral lip elements. 2. Vermilion of prolabium is preserved and used as oral lining for center portion of reconstruction. 3. Small relaxing incisions are used for the alae nasi.
C The vermilion of prolabium Z is incised along its exterior border. The interior border is preserved. The vermilion of the prolabium is thus hinged and turned downward to serve as mucosal lining. Relaxing incisions are made at the base of the alae nasi along the dotted lines. D The lateral lip flaps are approximated to the central portion of the lip in three layers. The orbicularis oris of the lateral elements is approximated either at this stage (C) or at a subsequent operation.
A Incisions along the vermilion borders are made as indicated by the dotted lines. Note that the flaps indicated by X and Y include the mucocutaneous ridge ("white roll").
E The lateral flaps X and Yare trimmed and transposed beneath the prolabium. The vermilion of the prolabium Z is sutured to the posterior aspect of the reconstructed upper lip forming an intraoral lining.
B
F
Flaps X and Yare mobilized.
The completed
restoration.
CLEFT LIP AND PALATE
FIGURE 10-6
503
CLEFT LIP AND PALATE
Repair of Incomplete Bilateral Cleft Lip (Rotation-Advancement Technique) (Millard, 1960, 1977) (Fig. 10-7) Highpoints
1. Reconstruct Cupid's bow with vermilion from lateral lip elements. 2. Release prolabium from premaxilla. 3. Reconstruct orbicularis oris muscular sphincter. 4. Make incisions within natural lines.
A Incisions are made as indicated by t,he solid lines. The incisions along the vermilion border of each lateral element include the mucocutaneous ridge ("white roll"). The incision around each alar base separates it from the lateral lip element. The vermilion of the prolabium is divided into three flaps: one central flap based superiorly on the subcutaneous tissue of the prolabium, which when reflected forms the posterior wall of the reconstructed lip vermilion, and two lateral flaps based on the premaxilla, which serve as additional premaxil-
lary lining. Note that the rotation incisions in the superior aspect of the prolabium are clearly separated. B Lateral lip flaps are mobilized by incising into the upper gingivobuccal sulci bilaterally, freeing them off of the maxilla. The prolabium (together with the central turn-down flap of vermilion) is dissected off of the premaxilla, and the lateral prolabial vermilion flaps are sewn to cover the raw anterior surface of the premaxilla. Orbicularis oris muscle bundles are dissected from the lateral elements to facilitate a careful three-layer closure. The lateral lip elements are then advanced to the midline and sewn in two layers: mucosa and muscle behind the elevated prolabial flap. C The prolabium is then sewn to the skin margins of the lateral lip elements. The transposed vermilion flaps from the lateral elements are sewn together in the midline beneath the prolabium. The reflected prolabial vermilion forms the posterior lining of the lip. D
The completed
repair.
CLEFT UP AND PALATE
D FIGURE 10-7
505
CLEFT LIP AND PALATE
Cleft Palate (See Figs. 10-8 to 10-12) Clefts of the palate may occur alone or in association with complete unilateral or bilateral clefts of the lip. An isolated cleft palate has an incidence of associated anomalies as high as 13% to 50% (Cohen, 1983), and as many as 8 % of cleft palates occur as part of recognized syndromes (Bixler, 1981). The need for a complete medical history, family history, and physical examination cannot be overemphasized. In many craniofacial centers, this is performed by a geneticist trained in dysmorphology.
Types of Cleft Palate Deformities The incisive foramen divides prepalatal clefts (or clefts of the primary palate) from palatal clefts (or clefts of the secondary palate). Although prepalatal and palatal clefts are embryologically distinct and occur individually in complete and incomplete forms, they frequently are found simultaneously in the same patient.
Reconstructive 1. 2. 3. 4.
Goals
Closure of the oronasal fistula Production of normal speech (normal nasality) Ensure normal occlusion and facial growth Production of normal eustachian tube function
Not only do the clefts vary significantly in width, but often there is a shortage of soft tissue and at times inadequate muscular movement as well as a wider than normal bony nasopharynx.
Optimal Age for Operation The timing and choice of operation for cleft palate repair remain controversial because of difficulties in standardizing speech results, in assessing facia! growth over time, and in comparing patients with clefts who have varying degrees of tissue deficiency. Important considerations influencing timing of repair are as follows: 1. Speechdevelopment. From the viewpoint of the speech
pathologist, the palate should be closed early (I.e., 8 months) to enable the child to develop a competent velopharyngeal mechanism before the onset of speech production. 2. Dental development. From the viewpoint of the orthodontist, palatal closure should be delayed until an optimal relationship is established in the upper dental arch to ensure the development of normal dental
occlusion. In addition, hard palate closure before age 6 years should involve minimal periosteal stripping to reduce the possibility of midfacial growth retardation. At present, narrow to moderately wide palatal clefts are closed at 10 to 14 months of age. For wide clefts ( > 1 cm at the hard/soft palate junction), early velar (soft palate) closure with obturation of the hard palate defect until age 6 years is practiced at our center. Still larger clefts with significant tissue deficiency, such as those found in the Pierre Robin sequence, may require a primary pharyngeal flap to import regional tissue for closure (Stark and DeHaan, 1960). For clefts with a twopiece maxilla (associated with the unilateral cleft lip and palate) or a three-piece maxilla (associated with the bilateral cleft lip and palate), there is a growing interest in presurgical orthopedic manipulation of the maxillary arch. This is an attempt to obtain a favorable alignment of the individual bony elements before palatal surgery.
Repair of Complete Cleft of Secondary Palate (After von Langenbeck, 1861) (Fig. 10-8) Highpoints
1. Use oral endotracheal intubation. 2. Extend head and neck with folded sheet under shoulders. 3. Inject lines of incision with local anesthesia (lidocaine 1% with 1:100,000 epinephrine) for hemostasis. 4. Use tension-free closure of nasal layer. 5. Preserve greater palatine arteries. 6. Adequately mobilize lateral flaps without excessive mucoperiosteal stripping. 7. Reconstruct levator veli palatini sling. 8. Carefully approximate nasal and oral layers, eliminating dead space, which can lead to fistula formation. Positioning
of Patient
1. Position patient for oral endotracheal intubation. 2. Extend head and neck with folded towel beneath shoulders. Recheck breath sounds for possible intubation of right mainstem bronchus. 3. No head drape is used once patient is positioned. 4. If mouth gag is used, recheck breath sounds once gag is opened for possible endotracheal tube compression. 5. Some surgeons prefer sitting at the head of the table with the patient in Trendelenburg position; others prefer standing at the side.
CLEFT LIP AND PALATE
A
507
B
Tensor veli palatini m. Hamulus of pterygoid
Pterygoid bone I
,
.
In!. pterygoid m.
FIGURE 10-8
A The bony anatomy is depicted, showing the origin of the internal pterygoid muscle, which marks the plane of mobilization of the soft palate. This muscle also leads to the identification of the hamulus around
of incision are injected with local anesthesia (lidocaine 1% with 1:100,000 epinephrine) for hemostasis and to facilitate a lighter plane of general anesthesia. The incision through mucosa and periosteum starts
which the tensor veli palatini courses.
medial to the alveolar ridge. When the posterior end
of the alveolar ridge (maxillary tubero~ity) i~reached, B Exposure is achieved with a Dingman or Jennings mouth gag or cheek retractors; the tongue is either
the incision curves laterally and then extends posteriorly to a line drawn through the plane of the uvula.
depressed or pulled forward with a 2·0 silk suture. Lines
Continued
CLEFTLIP AND PALATE
Repair of Complete Cleft of Secondary Palate (After von Langenbeck, 1861) (Continued) (Fig. 10-8)
C With the use of a cleft palate elevator or a nasal freer, a mucoperiosteal flap is elevated from the hard palate. Anteriorly, this extends around the anterior edge of the cleft and medially up to but not through the cleft mucosa. Posteriorly, the mobilization is continued, exposing the tensor veli palatini muscle. The greater palatine vessels are preserved.
D The posterior mobilization of the soft palate is achieved by exposing the internal pterygoid muscle and tendon and opening wide the space medial to it. This maneuver displaces the tonsil and tonsillar pillars
releasing tension on the tensor veli palatini muscle. The attachments of the soft palate to the posterior margin of the hard palate may then be separated by sharp dissection. The lateral releasing incision is packed with a one half-inch gauze strip to control bleeding while surgery is performed on the opposite side. E With a stay suture through the uvula, an incision is made along the medial cleft margin with a No. 11 scalpel blade. Note that this incision is actually made in the oral layer several millimeters lateral to the cleft edge. The cleft-edge mucosa is then reflected with a Cottle elevator or sharp freer, providing increased width to the nasal lining and a tension-free closure of the nasal layer.
medially. The attachment of the flap to the palatine bone near the origin of the pterygoid muscle is then separated, using blunt or sharp dissection.
F Along the edge of the hard palate, two layers are developed: the oral mucosa and the nasal mucosa. Along the edge of the soft palate, three layers are developed: oral and nasal mucosa plus a middle
D1
muscle layer.
Using the internal pterygoid muscle as a guide,
the sharp point of the hamulus is felt and exposed. With a small osteotome, the hamulus is infractured,
Continued
CLEFT LIP AND PALATE
D
Post. palatine vessels Tensor veli palatini m. Hamulus Palatopharyngeus
F
FIGURE 10-8 Continued
m.
509
CLEFT LIP AND PALATE
Repair of Complete Cleft of Secondary Palate (After von Langenbeck, 1861) (Continued) (Fig. 10-8)
Postoperative Routine 1. Use oral suction only with soft catheter. 2. Maintain intravenous fluids until patient is taking adequate fluids by mouth (typically 48 hours). 3. Use open cup feeding for 6 weeks. Do not use bottles, "sippy cups," pacifiers, or straws, which would generate suction across the wound closure. It is advisable for the patient to practice with open cup feeding several weeks in advance of surgery. 4. Use arm restraints for 2 weeks. A variety of products are available consisting of cylinders that fit over the arms, limiting elbow flexion.
Complications • Hemorrhage during surgery and postoperatively • Postoperative airway obstruction • Wound dehiscence • Complete • Incomplete: fistula, most common at the hard/soft palate junction • Velopharyngeal insufficiency. Despite speech therapy, approximately 30 % of patients require additional surgery for hypernasal speech.
G Sharp dissection is usually necessary to develop a clean nasal mucosal layer. Extreme care must be taken not to fragment this mucosa.
H The dissection is continued until all the layers are distinctly developed. This extends from the anterior cleft angle posteriorly to include the uvula. The muscle bundles of the levator veri palatini are carefully delineated and then freed sharply from their bony attachments to the posterior palatal shelves. At this stage all layers of the medial edges of the cleft should approximate one another easily without any tension. Indeed, the packing in both lateral spaces should achieve approximation of the soft palate. (To clarify the anatomy, the packing is omitted on one side in the drawings.) I Progressing anteriorly to posteriorly, interrupted 4-0 absorbable sutures with the knots buried are used to approximate the nasal mucosa. Small tapered urology needles (Ethicon J-434: 4-0 Vicryl TF) are less traumatic to the tissue.
J
The muscle layer is approximated with 3-0 absorbable horizontal mattress sutures. Note that the reconstructed levator sling now assumes a retrodisplaced position.
K The oral mucosa is approximated with 4-0 absorbable interrupted or vertical mattress sutures again using a tapered needle (Ethicon )-434: 4-0 Vicryl TF or the larger Ethicon )-214: 4-0 Vicryl RB-1). The lateral gauze packing is then removed to check for any bleeding. A 2-0 silk tongue suture is placed for emergency airway control. It is removed in the postanesthesia recovery room once the patient is awake. L
Anatomy of normal palate (after Hollinshead, 1954).
CLEFT LIP AND PALATE
TENSOR APONEUROSIS PTERYGOID HAMULUS
L
PALATOPHARYNGEUS GLOSSOPALATINUS M. UVULAE
FIGURE 10-8 Continued
511
CLEFT LIP AND PALATE
Repair of Incomplete Cleft of Secondary Palate (After Veau, 1931; Wardill, 1937; Kilner, 1937; Modified by Peet, 1961) (Fig. 10-9) The "three-flap technique" for closure of an incomplete cleft of the secondary palate is described. For a description of the "four-flap technique" for closure of a complete cleft of the secondary palate or a complete unilateral cleft palate, refer to Peet (1961). Highpoints 1. 2. 3. 4. S.
Perform tension-free closure of nasal layer. Preserve greater palatine arteries. Adequately mobilize lateral flaps. Reconstruct levator veli palatini sling. Lengthen palate with a V-to-Y advancement with theoretical improvement in velopharyngeal closure.
Complications • A higher incidence of maxillary growth retardation has been implicated with this technique secondary to greater periosteal stripping required in the dissection.
A A lateral relaxing incision is made, and the soft palate is mobilized toward the midline (see Fig. 10-8D). An incision is then made into the mucosa along the free edge of the cleft with a No. 11 scalpel. The anterior ends of the two incisions are then connected with an oblique incision, creating a posteriorly based mucoperiosteal flap.
B The flap is then dissected anteriorly to preserve the greater palatine vessels. With the exposure thus provided, all muscular attachments are divided from the posterior palatal shelves (posterior edges of the hard palate), preserving the nasal mucoperiosteum. The nasal mucoperiosteum from the floor of the nose is then elevated from the palatal process (1) (edge of the cleft), beginning with the posteromedial palatal spine (2), to which it is firmly adherent. Using blunt dissection this layer is freed anteriorly and medially. The levator veli palatini is then carefully delineated by sharp dissection from the nasal and oral lining (see Fig. 10-8). C The edges of the triangular mucoperiosteal flap anterior to the cleft are undermined slightly to permit introduction of sutures. The nasal layer is then approximated with 4-0 interrupted absorbable sutures. The sutures are introduced in sequence from anterior to posterior and then tied in sequence from posterior to anterior. The levator veli palatini is then approximated with 3-0 absorbable mattress sutures (see Fig. 10-8). D The lateral flaps are then advanced in a V-to-Y fashion and approximated with 4-0 absorbable sutures from posterior to anterior. At the level of the posterior palatal shelf a 3-0 absorbable suture is introduced into one lateral flap, across the nasal closure, and then out of the opposite lateral flap. This suture is tied last to obliterate dead space between the oral and nasal layers. The lateral flaps are then sewn to the triangular flap to complete the closure.
CLEFT LIP AND PALATE
A
FIGURE 10-9
CLEFT UP AND PALATE
Repair of Complete Unilateral Cleft Palate (Fig. 10-10) Highpoints 1. Repair hard palate with a vomer flap technique (Veau, 1931). 2. Repair soft palate with von Langenbeck technique (see Fig. 1O-8F). 3. Adequately mobilize palatal and septal mucosal flaps. 4. Include periosteum in mucosal flaps. 5. Reconstruct levator veli palatini sling. 6. Carefully approximate nasal and oral layers to eliminate dead space, which can lead to fistula formation. Postoperative Routine I. Use oral suction only with soft catheter. 2. Maintain intravenous fluids until patient is taking adequate fluids by mouth (typically 48 hours). 3. Use open cup feeding for 6 weeks. Do not use bottles, "sippy cups" pacifiers, or straws, which would generate suction across the wound closure. It is advisable for the patient to practice with open cup feeding several weeks in advance of surgery. 4. Use arm restraints for 2 weeks. A variety of products are available consisting of cylinders that fit over the arms, limiting elbow flexion. Complications • Hemorrhage during surgery and postoperatively • Postoperative airway obstruction • Wound dehiscence • Complete • Incomplete: fistula, most common at the hard/soft palate junction • Velopharyngeal insufficiency. Despite speech therapy, approximately 30% of patients require additional surgery for hypernasal speech.
A The lateral relaxing procedures of a cleft palate repair are first performed (see Fig. 10-8A to L). These lateral wounds may be packed with strip gauze. Incisions are then made along the free edges of the cleft of the lateral and medial palatal elements. The mucosal flap from the lateral element is first developed to estimate the amount of septal mucosa that will be necessary for later closure of the defect of the hard palate. The incision in the free border of the medial element is then made along the junction of the pink mucosa of the septum with the whitish mucosa of the palate. B With the use of sharp and blunt dissection, the mucoperiosteal flap from the lateral element is mobilized. The mucoperiosteum of the septum (vomer) is elevated in a similar fashion. Once a plane is established over the bone, blunt dissection with a nasal freer is sufficient. There should be adequate mobilization of the two flaps to permit overlapping contact. The elevation of the mucoperiosteum is carried to the posterior extent of the septum. At this point the soft palate is handled as it is during a von Langenbeck repair (see Fig. 10-8F). C Cross-sectional view depicts the elevated mucoperiosteum of the hard palate and septum. D, E Absorbable 4-0 horizontal mattress sutures are used to approximate the two mucoperiosteal flaps over the hard palate defect. These sutures are placed so that the flaps overlap, being sure that raw surface faces raw surface. F, F1 Final closure of the hard palate defect. Care must be taken that proper approximation of raw surfaces is achieved at the anterior end. If feasible and necessary, a single mucosal suture is placed anteriorly. Three-layer closure is used for the soft palate, including reconstruction of the levator veli palatini muscular sling (Fl) (see Fig. 10-8L). G The completed of the hard palate.
operation.
Note the bare surfaces
CLEFT LIP AND PALATE
A j
c Septum
mucosa Palatal mucosa ~,
,
>
FIGURE 10-10
CLEFT LIP AND PALATE
Pharyngeal Flap in Cleft Palate Repair (Fig. 10-11 ) Indications Pharyngeal flap reconstruction of a cleft palate may be performed either at a second stage or rarely as part of a primary palatoplasty (Stark and DeHann, 1960). It is useful when repeated unsuccessful procedures on a cleft palate have resulted in scarring, loss of tissue, and shortening. When there is significant tissue deficiency of the palate at the initial examination, it may be employed to facilitate a primary repair. Depicted is a Millard (1962) modification of a primary repair using a superiorly based pharyngeal
cleft palate flap.
A A superiorly based pharyngeal flap containing mucosa, submucosa, and superior pharyngeal constrictor muscle is elevated, exposing the prevertebral fascia. Nasal mucosal incisions and palatal releasing incisions are outlined. B The pharyngeal flap donor site is closed with sutures anchored to the prevertebral fascia. Care is taken not to constrict the base of the pharyngeal flap. Nasal mucosal turn-over flaps are developed of sufficient width to provide oral lining for closure. Lateral releasing incisions permit medial mobilization of the soft palatal flaps. C The pharyngeal flap is sewn into the nasal lining defect with close attention not to sew it under tension either along its length or along its width.
Highpoints 1. Single pedicle flap is made up of mucosa, submucosa, and superior pharyngeal constrictor muscle. 2. Reflect nasal mucosal flaps orally to provide additional oral lining. 3. Pharyngeal flap is attached to the nasal surface. 4. Pedicle is left attached permanently.
D
The oral lining is closed, anchoring
the closure to
the pharyngeal flap to complete the repair. The releasing incisions are left open.
Note: In large horseshoe-shaped clefts, such as one finds in the Pierre Robin sequence, the soft palate is closed with a primary pharyngeal flap and the hard palate "roofy")
is obturated
with
a removable
appliance
until 6 years of age.
B
A FIGURE 1 0-11
(a
CLEFT LIP AND PALATE
c
51 7
D FIGURE 10-11
Pharyngeal Flap for Velopharyngeal Insufficiency (Fig. 10-12) The production of normal speech requires periodic closure of the velopharyngeal mechanism, a dynamic process influenced by the length, compliance, and motion of the soft palate (velum) as well as by the coordinated action of the posterior and lateral pharyngeal walls. Different procedures both static and dynamic have been developed in an attempt to correct velopharyngeal insufficiency in the cleft palate patient to reduce both nasal regurgitation and hypernasal speech. The pharyngeal flap (Schoenborn, 1876) remains the most popular surgical correction and is presented here. With improved diagnostic techniques such as nasopharyngoscopy (Pigott et a!., 1969) and multiview videofluoroscopy, the pharyngeal flap can be appropriately designed to obturate many velopharyngeal closure defects. Pharyngeal flaps may be either superiorly based or inferiorly based. Ease of construction of the inferiorly based flap makes it more suitable for patients in whom visualization is difficult. The superiorly based flap can bridge a larger gap and avoids friable adenoid tissue. Recall that the normal action of the levator veli palatini muscle is to elevate and retract the soft palate posteriorly. The inferiorly based flap tends to pull the palate caudad out of the plane of velopharyngeal closure, while the superiorly based flap maintains the palate in a more physiologic position. Pressure flow studies (Warren, 1964) have demonstrated that the threshold for velopharyngeal insuffi-
ciency is a port whose cross-sectional area is approximately 20 mm2• In 1973, Hogan introduced the concept of lateral port control during the construction of a pharyngeal flap, limiting the port opening on either side of the flap to the size of a 4-mm (I2.6-mm2) catheter. Port size can then be adjusted further depending on preoperative measurements of lateral pharyngeal wall motion. Highpoints
1. Prophylactic antibiotics are recommended. 2. Develop a superiorly based flap from the posterior pharyngeal wall and close the resultant defect. 3. Split the soft palate in the midline. 4. Create paired, distally based nasal lining flaps. 5. Sew the nasal lining flaps to the raw caudal surface of the pharyngeal flap. 6. Adjust the lateral ports. 7. Insert a nasopharyngeal airway. Postoperative
Routine
1. Admit the patient to an intensive care unit or stepdown unit for the first 24 hours postoperatively to monitor the airway. 2. A nasopharyngeal airway is placed at the end of surgery and removed on the first postoperative day after verifying airway competency. In children, an uncuffed endotracheal tube is cut down, inserted, and secured to the membranous nasal septum with a 2-0 silk suture.
CLEFT LIP AND PALATE
Pharyngeal Flap for Velopharyngeal Insufficiency (Continued) (Fig. 10-12) Complications • Acute airway obstruction postoperatively • Partial loss or distortion of flap. If flap is sewn under too much tension, partial necrosis will result in excessive scarring. If flap is unlined (some techniques make no attempt to line the raw caudal surface between the posterior pharyngeal wall and the posterior aspect of the soft palate), shrinkage and "tubing" can result in a flap of inadequate size. • Persistent velopharyngeal insufficiency (if lateral ports are too large) • Possible airway obstruction, impaired sinus drainage, eustachian tube dysfunction, and sleep apnea (if lateral ports are too small)
Cautions 1. Down syndrome: because of the increased risk of atlantoaxial (CI-C2) instability, cervical radiographs must be obtained before hyperextending the neck. 2. Velocardiofacial syndrome: because of increased risk of medial displacement of the internal carotid arteries, a magnetic resonance angiogram should be obtained before making incisions into the posterior pharyngeal wall.
A, A 1 The superiorly based pharyngeal flap is designed on the posterior pharyngeal wall with a base slightly above the palatal plane. The length of the flap is calculated to extend well over the soft palate, and its width is determined by preoperative fluoroscopic or endoscopic evaluations of velopharyngeal closure. Typical is a moderately wide, centrally positioned pharyngeal
flap whose width is nearly that of the posterior pharyngeal wall. The flap margins are incised through mucosa, submucosa, and superior pharyngeal constrictor. The flap is elevated off of the prevertebral fascia from below upward. After the distal end of the flap (3) is retracted with a suture, the donor-site defect in the posterior pharyngeal wall is closed with 4-0 absorbable mattress sutures, anchoring the closure to the underlying prevertebral fascia to obliterate dead space. B The soft palate is split in the sagittal midline with a No. 11 scalpel. Traction sutures are placed in each posteromedial corner (1). C, C1 Paired distally based flaps are then developed from the nasal lining, which will be used to cover the raw caudal surface of the pharyngeal flap. The width of each flap is slightly more than half the width of the pharyngeal flap. These flaps are cut thickly and elevated from anterior to posterior. The pharyngeal flap is then sewn to the nasal surface of the soft palate. This may be accomplished with 4-0 horizontal mattress sutures passed through the palate to the flap, then back through the palate and tied on the oral side. Care is taken not to sew the flap under too much tension either along its length or along its width, which would compromise its circulation. The right and left nasal lining flaps are then sewn together in the midline and then onto the caudal surface of the pharyngeal flap. 0, 01, 02 The midline soft palate incision is closed with 4-0 mattress sutures. Lateral ports are then adjusted around a 4-mm catheter (No. 12 French Robinson) passed nasally. At the conclusion of surgery a nasopharyngeal airway is directed through one lateral port and secured in position.
CLEFT UP AND PAlATE
A
B
c
FIGURE 10-12
519
ClEFT LIP AND PALATE BIBLIOGRAPHY Albery EH, Bennett JA, Pigott RW, Simmons RM: The results of 100 operations for velopharyngeal incompetence-selected on the findings of endoscopic and radiological examination. Br J Plast Surg 35:118-126, 1982. Bardach J, Salyer KE: Surgical Techniques in Cleft Lip and Palate. Chicago, Year Book Medical Publishers, 1987, p 83. Berkeley WT: Correction of secondary cleft-lip nasal deformities. Plast Reconstr Surg 44:234-241, 1969. Bernstein L: Secondary reconstructive procedures for cleft lip and nose. Trans Am Acad Ophthalmol Otolaryngol 71:71-80, 1967. Bernstein L: The effect of timing of cleft palate operations on subsequent growth of the maxilla. Laryngoscope 78:1510-]565, ]968. Bixler 0: Genetics and clefting. Cleft Palate J 18:10-]8, 1981. Blocksma R, Leuz CA, Mellerstig KE: A conservative program for managing cleft palates without the use of mucoperiosteal flaps. Plast Reconstr Surg 55:160-169, 1975. Bluestone CD: Eustachian tube obstruction in the infant with cleft palate. Ann 0101 80(Suppl 2):1-30,1971. Brauer RO: A comparison of the Tennison and Le Mesurier lip repairs. Plast Reconstr Surg 23:249-259, 1959. Brauer RO, Cronin TO: The Tennison lip repair revisited. Plast Reconstr Surg 71:633-640,1983. Brown JB, McDowell F, Byars LT:Double clefts of the lip. 5urg Gynecol
and palate. Plast Reconstr 5urg 47:469-470, 1971.
Obstet 85:20,1947, Cohen MM Jr: Craniofacial disorders. In Emery AE, Rimoin DL (eds]: Principles and Practice of Medical Genetics. New York, Churchill
Kernahan DA, Bauer BS, Harris GO: Experience with the Tajima procedure in primary and secondary repair in unilateral cleft lip nasal
deformity. Plast Reconstr Surg 66:46-53, 1980.
Livingstone, 1983, pp 593-607. Craig RDP: The management of complete clefts of the lip and palate. Br J Surg 54:923-931, 1967. Cronin TO, Upton J: Lengthening of the short columella associated with bilateral cleft lip. Ann Plast Surg 1:75-95, 1978. Dempsey WC, Mayhew JF, Metz PS, Southern IE: Malignant hyper-
thermia during repair of a cleft lip in a 6 month old infant, with survival. Ann Plast Surg 1:3t5-318,1978. Dingman RO, Grabb WC: A rational program for surgical management of bilateral cleft lip and cleft palate. Plast Reconstr Surg 47:239-242, 1971. D'Ottaviano N, Baroudi R, Keppke EM: Dental rotation in cleft lip. Ann Plast Surg 1:407-410, 1978. Edgerton MT, Dellon AL: Surgical retrodisplacement of the levator veli palatini muscle: Preliminary report. Plast Reconstr Surg 47:154-167, 1971. Epstein Ll, Davis WB, Thompson LW: Delayed bone grafting in cleft palate patients. Plast Reconstr Surg 46:363-367,1970. Fishman LS, Stark DB: The maxillary arch prior to surgical closure of a cleft lip. Plast Reconstr Surg 42:572-576, 1968. Furlow LT Jr: Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg 78:724-736, 1986. Gahhos R, Enriquez RE, Bahn SL, Ariyan S: Necrotizing
Hollinshead WH: Anatomy for Surgeons, vall, The Head and Neck. New York, Hoeber-Harper, 1954. Holtmann B, Wray RC: A randomized comparison of triangular and rotation-advancement unilateral cleft lip repairs. Plast Reconstr Surg 71:172-179,1983. Hoopes JE, Fabrikant Jl: Objective evaluation of cleft palate speech. Plast Reconstr Surg 42:214-224, 1968. Hoopes JE, Dellon AL, Fabrikant Jl, Soliman AH: The locus of levator veli palatini function as a measure of velopharyngeal incompetence. Plast Recontr Surg 44:155-160,1969. Iregbulem LM: Median cleft of the lower lip: Case report. Plast Reconstr Surg 61:787-789,1978. Isshiki N, Koyama H: Palatoplasty without elevation of mucoperiosteal flap on the cleft side. Ann Plast Surg 4:457-461,1980. Isshiki N, Morimoto M: Anterior cleft palate closure by turnover flaps. Plast Reconstr Surg 42:249-25],1968. Jackson IT, Vandervord JG, Mclennan JG, et al: Bone grafting of the secondary cleft lip and palate defonnity. Br J Plast Surg 35:345-353,1982. Jackson IT, Soutar OS: The sandwich Abbe flap in secondary cleft lip deformity. Plast Reconstr Surg 66:38-44, 1980. Jayapathy B, Huffman WC, Lierle OM: The Z-plastic procedure: Some mathematic considerations and application to cleft lip. Plast Reconstr Surg 26:203-208, 1960. Kernahan DA: The striped Y3/4A symbolic classification for cleft lip
sialometa-
plasia: Report of five cases. Plast Reconstr Surg 71:650-657, 1983. Georgiade NG: Improved technique for one-stage repair of bilateral cleft lip. Plast Reconstr Surg 48:318-324,1971. Greminger RF: Island soft palatoplasty for early reconstruction of the posterior muscular ring. Plast Reconstr Surg 68:871-876, 1981. Hagerty RF: Unilateral cleft lip repair. Surg Gynecol Obstet 106:119-122, 1958. Hagerty RF, Mylin WK: Facial growth and arch symmetry in the surgical prosthetic treatment of cleft lip and palate. Plast Reconstr Surg 68:682-688, ]981. Hagerty RF, Mylin WK, Hess DA: Augmentation pharyngoplasty. Plast Reconstr Surg 44:353-356, 1969. Henderson HP: The "tadpole flap": An advancement island flap for the closure of anterior fistulae. J Plast Surg 35:163-166, ]982. Hogan VM: A clarification of the surgical goals in cleft palate speech and the introduction of the latera] port control (LPC) pharyngeal flap. Cleft Palate J 10:331-345, 1973.
Kernahan DA, Dado DV,Bauer BS: The anatomy of the orbicularis oris muscle in unilateral cleft lip based on a three-dimensional histologic reconstruction. Plast Reconstr Surg 73:875-879, 1984. Kiehn CL, DesPerez JD, Brown F: Maxillary osteotomy for late correction of occlusion and appearance in cleft lip and palate patients.
Plast Reconstr 5m3 42:203-207, 1968, Kiehn CL, DesPerez JD, Maes JM, Kronheim L: Temporal muscle transfers to the incompetent soft palate: A progress report. Plast Reconstr Surg 48:335-338, 1971. Kilner IP: Cleft lip and palate repair technique. 5t. Thomas Hasp Rep 25:117,1937. Kluzak R: Thansplantation of rib growth cartilage: Experimental study and possible use in primary cleft lip repairs. Plast Reconstr Surg 49:61-69,1972. Kobus K: Extended vomer flaps in cleft palate repair: A preliminary report. Plast Reconstr Surg 73:895-901,1984. Langenbeck B: Operation on congenital total cleft of the hard palate by a new method. Plast Reconstr Surg 49:323-324, ]972. Le Mesurier AB: The treatment of complete unilateral harelips. Surg Gynecol Obstet 95:17-27,1952. McCabe PA: A coding procedure for classification
of cleft lip and cleft
palate. Cleft Palate J 3:383-391, 1966. McConnel FMS, Zellweger H, Lawrence RA: Labial pits-cleft lip and/or palate syndrome. Arch OtolaryngoI91:407-411, 1970. McCoy FJ, Zahorsky CL: A new approach to the elusive dynamic pharyngeal flap: Preliminary report. Plast Reconstr Surg 49: 160-164,1972. McEvitt WG: Conversion of an inferiorly based pharyngeal flap to a superiorly based position. Plast Reconstr Surg 48:36-39, 1971. McWilliams BJ: The role of otolaryngological problems in speech disorders associated with cleft palate. Thans Am Acad Ophthalmol Otolaryngol 73:720-723, 1969. Maisels DO: Chronic lip fissures. Br J Dermatol 81:621-622,1969. Manchester WM: How t do it/colloquium: Surgical management of bilateral cleft lip. Ann Plast Surg 1:509-512, 1978. Marcks KM, Trevaski AE, daCosta A: Further observations in cleft lip repair. Plast Reconstr Surg 12:392, 1953. Messengill R Jr, Pickrell K, Mladick R: Lingual flaps: Effect on speech articulation and physiology. Ann Olo! Rhinol Laryngol 79:853,1970.
CLEFT LIP AND PALATE
Massengill R Jr, Walker T, Pickrell KL: Characteristics of patients with a Pass avant's pad. Plast Reconstr Surg 44:268-270,1969. Millard DR Jr: A radical rotation in single harelip. Am J Surg 95: 318-322, 1958. Millard DR Jr: Refinements in rotation-advancement cleft lip technique. Plast Reconstr Surg 33:26-38, 1964. Millard DR Jr: Extensions of the rotation-advancement principle for wide unilateral cleft lips. Plast Reconstr Surg 42:535-544, 1968. Millard DR Jr: Closure of bilateral cleft lip and elongation of columella by two operations in infancy. Plast Reconstr Surg 47:324-331, 1971. Millard DR Jr: A primary camouflage of the unilateral harelook. Transactions of the 1st International Congress on Plastic Surgery. Baltimore, Williams & Wilkins, 1957, pp 160-166. Millard DR Jr: Adaptation of the rotation-advancement principle in bilateral cleft lip. In Wallace AB (ed): Transactions of the 2nd International Congress on Plastic Surgery. London, Churchill Livingstone, 1960. Millard DR Jr: Wide and/or short cleft palate. Plast Reconstr Surg 29:40-57, 1962. Millard DR Jr: Cleft Craft, vol !, The Unilateral Deformity. Boston, Little, Brown & Co, 1976. Millard DR Jr: Cleft Craft, vol II, Bilateral and Rare Deformities. Boston, Little, Brown & Co, 1977. Millard DR Jr: Cleft Craft, vol Ill, Alveolar and Palatal Deformities. Boston, Little, Brown & Co, 1980. Millard DR, Batstone JHF, Heycock MH, Bensen JF: Ten years with the palatal island flap. Plast Reconstr Surg 46:540-547, 1970. Mina MMF: Styloid, velar, and pharyngeal muscles in cleft palate. J. Otolaryngol 8:179-190,1979. Nishimura Y: Cleft lip repair. Chir Plastica 4:109-114, 1978. Noordhoff MS: Reconstruction of vermilion in unilateral and bilateral cleft lips. Plast Reconstr Surg 73:52-60, 1984. Ogino Y, Ishida H: Secondary repair of the cleft-lip nose. Ann Plast Surg 4:469-480, 1980. Orticochea M: A review of 236 cleft palate patients treated with dynamic-muscle sphincter. Plast Reconstr Surg 71:180-186, 1983. Paradise JL, Bluestone CD, Felder H: The universality of otitis media in 50 infants with cleft palate. Pediatrics 44:35-42, 1969. Peet E: The Oxford technique of cleft palate repair. Plast Reconstr Surg 28:282-294, 1961. Pigott RW, Bensen JF, White FD: Nasoendoscopy in the diagnosis of velopharyngeal incompetence. Plast Reconstr Surg 43:141-147, 1969. Potter J: Cleft palate-fifty years on. Ann Plast Surg 10:12-14, 1983. Potter J: As I remember-William Wardhill. Ann Plast Surg 9:344347, 1982.
521
Randall P: A triangular flap operation for the primary repair of unilateral clefts of the lip. Plast Reconstr Surg 23:331-347,1959. Randall P, Whitaker LA, LaRossa D: The importance of muscle reconstruction in primary and secondary cleft lip repair. Plast Reconstr Surg 54:316-323, 1974. Rosedale RS: Pharyngeal flaps. Eye Ear Nose Throat Monthly 46:470478, 1967. Salyer KE: Primary correction of the unilateral cleft lip nose: A 15year experience. Plast Reconstr Surg 77:558-566, 1986. Schoenborn K: On a new method of staphylorrhaphy. Plast Reconstr Surg 49:558-562, 1972. Shirokov EP: Carcinoma of the palate. Am J Surg 100:530-533, 1960. Stark RB: Cleft Palate: A Multidiscipline Approach. New York, Harper & Row, 1968. Stark RE: Cleft lip-a timetable. Ann Plast Surg 8:107-117, 1982. Stark RD, DeHaan CR: The addition of the pharyngeal flap to primary palatoplasty. Plast Reconstr Surg 26:378-387, 1960. Steffensen WH: A method for repair of the unilateral cleft lip. Plas! Reconstr Surg 4:144, 1949. Steffensen WH: Further experience with the rectangular flap operation for cleft lip repair. Plast Reconstr Surg 11:49, 1953. Tennison CW: The repair of unilateral cleft lip by the stencil method. Plast Reconstr Surg 9:115,1952. Thompson JE: An artistic and mathematically accurate method of repairing the defect in cases of harelip. Surg Gynecol Obstet 14:498-505, 1912. Uchida J-J: A new approach to the correction of cleft lip nasal deformities. Plast Reconstr Surg 47:454-458,1971. Veau V: Division Palatine. Paris, Masson, 1931. Veau V: Bec-de-Lievre. Paris, Masson, 1938. von Langenbeck B: Operation der angeborenen totalen Spaltung des harten Gaumens nach einer neuer Methode. Dtsch Klin 8:231, 1861; also Plast Reconstr Surg 49:323-324, 1972. Ward PH, Goldman R, Stoudt RJ Jr: Teflon injection to improve velopharyngeal insufficiency. J Speech Hearing Disord 31:267-273, 1966. Wardill WEM: Technique of operation for cleft palate. Br J Surg 25:117-130,1937. Warren DW: Velopharyngeal orifice size and upper pharyngeal pressure-flow patterns in cleft palate speech: A preliminary study. Plast Reconstr Surg 34:15,1964. Wynn SK: Primary nostril reconstruction in complete cleft lips. The round nostril technique. Plast Reconstr Surg 49:56-60, 1972. Yules RB: Cinefluorography, speech, and dynamic respirometry in preoperative and postoperative pharyngeal flap patients. Trans Am 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) A, B The anatomy of the eye and its relationship the bony orbit are shown.
to
EXT. SECTION MEDIAL CANTHAL
L1G.
lATERAL lACRIMAL
RECTUS M.
GROOVE
ANT. LACRIMAL CREST • RECTUS M.
A
""+ . 9MATIC BONE . NlA'XILLARY BONE INFRAORBITAL NERVE APONEUROSIS OF lEVATOR PALPEBRAE SUP M.
ORBITAL SEPTUM
SUP. OPHTHALMIC V. SUP. RECTUS M. OPHTHALMIC A.
FORNIX
TARSUS SUP. ORBICULARIS M. TARSUS INF. ORBICULARIS
M.
FORNIX ORBITAL SEPTUM
B FIGURE 11-1
523
524
PERIORBITAL REGION
Repair of Lids and Conjunctiva (Fig. 11-2) Wounds of the Conjunctiva A
(4) of 6-0 silk is utilized to approximate the lid margins exactly at the gray line. This suture is left long (2.5 cm or more) to prevent a turning-in, avoiding injury to the cornea.
There are three main types of wounds:
1. laceration at right angle (1) to the fornix requires repair. Meticulously placed 6-0 gut sutures are used; otherwise, scar contractures will occur. 2. lacerations parallel (2) to the line of the fornix usually require no suturing. 3. lacerations of the palpebral (lid) conjunctiva are repaired with 6-0 nylon pull-out sutures (see [3] in B and C). Such lacerations more often than not involve the entire lid. No knots are permissible on exposed conjunctiva to prevent corneal damage. Replacement of missing conjunctiva can be accomplished with conjunctiva from the opposite eye or from the fornices. This has drawbacks; hence, usually a mucosal graft from the inner aspect of the lips, cheek, or nasal septum is preferred. Never use splitthickness skin. A free-foreskin graft (prepuce) can be used to replace bulbar conjunctiva (over the sclera) for large defects. Lip and cheek mucosa are abundant but tend to contract 50% to 60%. Nasal mucosa is best and is obtained ideally by dissecting the mucous membrane from the underlying perichondrium, a different plane from what is used in the submucous resection operation (see Fig. 6-12). If the perichondrium is removed, there is no harm except that the graft is somewhat thick and tends to contract. If only ~he mucous membrane is excised, then the donor site re-epithelializes well by being covered with antibiotic ointment. If the perichondrium is removed with the mucous membrane, it is best to cover the bare cartilage with a split-thickness epidermal or dermal graft.
Repair of Lid lacerations B, C A three-layer closure is performed: conjunctiva with continuous 6-0 nylon pullout sutures (3) that splint the edges of the tarsus together (the ends of this pullout suture are secured with tape as shown)-a small portion of the tarsal plate is included in this suture; orbicularis oculi muscle with only one or two 5-0 catgut sutures (5); and the skin with 5-0 or 6-0 silk or nylon. If nylon is used, the ends should be either very short or very long to avoid injuring the cornea. A small suture
Scar contracture of the lower lid can be corrected by a single or double Z-plasty.
Management Canaliculi
of Disruption of the
D Depicted is a "near-far, far-near" type of suture (Smith) for approximation of lid margins. This aids in the prevention of notching of the lid margins. See also Figure 11-12G.
Reconstruction of Lids
(See Figs. 11-3 to "-'0) Basic Principles These principles can be applied to tissue loss and severe scars resulting from trauma.
1. The upper lid is more important
than the lower lid, because significant defect in the upper lid, especially in the midline, will eventually lead to a corneal ulceration and loss of vision. Hence, do not use the upper lid to reconstruct the lower lid except possibly for the use of a small amount of redundant skin of the upper lid. The lower lid may be used to reconstruct the upper lid. The upper lid must be reconstructed immediately. 2. Twenty-five percent (up to 30% in the elderly) of the vertical lid (full thickness) defect can be closed by primarily approximating the edges if both canthal areas are uninvolved. If the defect is greater, additional length can be achieved by a lateral cantholysis. Hence, a 25 % defect requires no grafting technique. This is the principle of "quarters." 3. Horizontal lid defects are separate problems and, if of any size, require transposed tissue or rotated flaps (see Figs. 11-9D and E and 11-14E and F). 4. Use a three-layer closure, except in situations in which the conjunctiva loss is small and less than the skin and muscle loss. In such cases the conjunctival layer can be omitted (see Fig. 11-3C2 and C3).
PERIORBITAL REGION
D
FIGURE 11-2
PERIORBITAL REGION
Reconstruction of Lids (Continued) (See Figs. 11-3 to 11-10) Alternate and Additional
Concepts
1. Some surgeons believe that portions of the fullthickness layers of the upper lid can be safely utilized to reconstruct the lower lid using the rotated (switch) or pedicle flap technique. This would be the reverse situation as depicted in Figure 11-5L to OJ. With larger flaps from the upper to the lower lid or vice versa, a "sharing" procedure is utilized (Hughes, 1954; Cutler and Beard, 1955; see Fig. 11-6). The important principle in any modification of this technique is that the lid margin of the donor lid is not transected or violated (see Fig. 11-6). This feature may be the reason why Mustarde and other surgeons have abandoned this method-it is actually a failure of 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 from the opposite lid (opposite side if necessary) or from the postauricular region or a thick split -graft (freehand) is used. 3. When utilizing the Fricke upper lid flap (see Fig. 11-90 and E), the entire length of the skin of the upper lid should be used to avoid disparity when closing the donor site. 4. Both these surgeons (McCoy and Smith) avoid the Mustarde technique of a lateral cheek flap (see Fig. 11-4) to reconstruct the lower lid. The lateral cheek flaps may result in a downward pull on the reconstructed lower lid. To aid in the prevention of this problem, refer to Figure 11-4, which demonstrates that the lateral side of the excised parallelogram is longer and more oblique than the medial side. 5. When excising skin of the lower lid, Smith emphasizes the importance of having patients open their mouths widely to evaluate the downward traction on the lower lid to prevent ectropion.
6. In repairing lid defects, the layer closure of the inner and outer incisions should not be directly in the same plane (halving technique). This is more theoretical than practical. Neoplastic lesions of the lower lid are basal cell carcinoma (90%), squamous cell carcinoma, and meibomian gland carcinoma. The operating microscope helps in delineating the extent of a tumor when normal meibomian orifices are visualized. The latter two types can metastasize, but basal cell carcinoma rarely does. Reconstruction of Lower Lid (Fig. 11-3) Figure 11-3depicts in outline fashion the basic principles of lower lid reconstruction for vertical defects following the "quarter" rule of Mustarde. Details of technique for large lower lid defects are shown in Figure 11-4.
A Vertical lid defect and "shield-type" incision are shown. B This horizontal lid defect requires transposed tissue or rotated flaps. See Figures 11-9D and E and 11-14E and F.
Reconstruction of Lower Lid With 25% Defect
For suturing details refer to Figure 11-2Bto D.
C, Cl Shown is primary closure of a 25% defect when both canthal areas are intact. (In elderly patients up to 30% of the lid may sometimes be resected and a primary simple closure performed.) Continued
527
PERIORBITAL REGION
25% DEFECTI
_
c
FIGURE 11-3
PERIORBITAL REGION
Reconstruction of Lower Lid (Continued) (Fig. 11-3) (2 Depicted is a pentagon-shaped excision (leone) that is similar in some respects to the shield-type excision in A. The gross margins are at least 1 to 2 mm for basal cell carcinoma. Frozen sections are obtained on all three margins of the surgically removed specimen as well as from the margins of the surgical wound to be certain that the resection is adequate. If any of these frozen sections are positive, additional excisions are done 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 margins is of great aid to stabilize the lid during the excision.
(3
The completed closure is shown.
Reconstruction of Lower Lid With 25% Defect at Lateral Canthus D, D2 Shown is a 25% defect at the lateral canthal region. This usually requires a lateral canthoplasty (D1). Either the inferior or superior crus or both crura of the lateral canthal ligaments are transected. A medial canthoplasty is not used because of possible injury to lacrimal apparatus. Reconstruction of Lower Lid With 30% Defect E
Shown is a 30% defect.
El
A lateral cantholysis is again usually necessary except in the elderly, in whom there is more tissue laxity.
Continued
PERIORBITAL REGION
C2
C3
25% DEFECT AT LATERAL CANTHUS_I -------------
D2
FIGURE 11-3 Continued
529
PERIORBITAL REGION
Reconstruction of lower lid (Continued) (Fig. 11-3) Reconstruction of Lower Lid With 30% to 50% Defect
F
Shown is a defect of 30% to 50%.
Fl A lateral cantholysis plus an advanced cheek flap is required for closure. Lining of the flap can be obtained from some redundant conjunctiva at the lateral canthal region. Note that the lateral side of the excised parallelogram is longer and more oblique than the medial side to prevent inferior contracture of the reconstructed lid. This principle is applicable to the procedure in steps G and H. Details of the technique are presented in Figure "-4.
Reconstruction of Lower Lid With 50% to 75% Defect
G
A defect of 50% to 75% is presented.
G1 A lateral cantholysis plus a larger rotated cheek flap with cutback incision is required for closure. The lining of this flap will require a free septal cartilage and mucous membrane graft (X). Be sure the mucosal surface is identified and distinguished from the raw undersurface when suturing the graft in place. Pullout sutures of 6-0 nylon are used. Details of this technique are in Figure "-4. Reconstruction of Lower Lid With 100% Defect H
There is a , 00% loss of the lower lid.
Hl A lateral cantholysis plus a somewhat larger rotated cheek flap with cutback incision is required for closure. The lining of this flap will require a free septal cartilage and mucous membrane graft (X). Details of the technique are given in Figure "-4. The use of an extended nasofacial flap, superiorly based to reconstruct lower lid defects, is shown in Figures 6-21 and 6-23.
PERIORBITAL REGION
H1 FIGURE 11-3 Continued
531
PERIORBITAL REGION
Resection of large Basal Cell Carcinoma of lower Lid With Reconstruction Using lateral Cheek Flap (Fig. 11-4) (After Mustarde, 1969) Highpoints
1. A full-thickness resection is used. 2. Immediate reconstruction is done with a lateral 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 cheek flap is done when two thirds or more of the lower lid is resected. 4. Lower lid resection includes an elongated inverted parallelogram or "shield" below the tumor to ensure proper advancement of cheek flap. 5. The sides of this parallelogram or shield are unequal in length and direction: the medial side is shorter and vertical; the lateral side is longer and slanted obliquely downward and medially. This is done to prevent a downward pull of the reconstructed lower lid. 6. The cheek flap is extended slightly upward at the lateral canthus and the release extends 1 cm below the apex of the excised parallelogram. 7. The deep portion of the cheek flap is sutured to the orbital rim, especially at the lateral canthus to prevent downward tension on the reconstructed lid. 8. Lining of the newly reconstructed lid is ideally achieved by utilizing a free-mucosal chondral graft from the nasal septum. 9. Do not injure the lacrimal punctum and canaliculus if this is compatible with adequate resection of the primary tumor; otherwise, resect these areas. Troublesome epiphora mayor may not occur, and this can be corrected later if need be by the utilization of a conjunctival flap (see Fig. ll-llC). 10. Margins of tumor must be adequately identified with sutures or staining with silver nitrate for frozen sections. 11. Refer to page 526 for alternate and additional concepts. Complications
• Nylon pullout sutures may break: take care in removing them . • Downward droop of new lid: perform lateral canthoplasty.
• Fold and edema of rotated cheek flap • Failure of nasal graft, especially the cartilage A Depicted is a tumor requiring resection of almost the entire lower lid, sparing the canaliculus. The area of resection with a large cheek flap and back cut (1) is outlined. A 1 Schematic outline of procedure emphasizes five important features of the incision for the cheek flap. 1. The medial incision of the excised triangle is almost vertical; the lateral incision is longer and oblique. 2. Adequate undermining is done below and especially lateral to the apex of the excised triangle. 3. A cutback (1) incision is made just below the lobule of the ear. 4. A vertical relaxing incision on the cheek flap may be necessary with an excision of small triangles (2) to increase the length of the cheek flap. The cheek flap consists of skin and subcutaneous tissue but not the parotid fascia. The facial nerve and its branches are thus spared. 5. The portion of the incision forming the cheek flap is curved slightly upward toward the level of the brow (3). B The tumor is excised with a full-thickness resection and a free graft consisting of septal cartilage, and attached mucosa is sutured in place as a replacement for the tarsus and conjunctiva. One or two continuous 6-0 nylon pullout sutures (4) are utilized. No knots are tied on the conjunctival surface. To increase support inferiorly 5-0 or 6-0 catgut sutures may be necessary. C The inner subcutaneous tissue of the rotated cheek flap is sutured (5) to the periosteum of the infraorbital portion of the maxilla to prevent a downward pull on the newly reconstructed lower lid. Similar sutures (6) are also used to support the flap at the lateral canthal region by fixing the sutures superiorly along the lateral orbital margin. ~ Long 5-0 silk sutures are used to approximate the cheek flap to the mucocartilage graft. For the remainder of the skin closure 5-0 nylon is used. The pullout sutures securing the septal graft are depicted (4) .
PERIORBITAL REGION
75%-90%
DEFECT -------------------
A
D FIGURE 11-4
PERIORBITAL REGION
Reconstruction of Upper Lid (Fig. 11-5)
(After Esser, 1919; Mustarde, 1969) Highpoints
1. Upper lid reconstruction must encompass the following characteristics: a. Ability to cover and to protect the cornea during sleep b. Ability to elevate if at all possible; hence it must have some neuromuscular function c. Must be lined with smooth mucous membrane to protect cornea d. Must be rigid enough to maintain its shape and curvature to protect the cornea 3. Lower lid or portion thereof is best suited for reconstruction whenever possible. 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 larger flaps 6 mm wide. 6. Suture tarsal plate of rotated lower lid to remaining portion of levator palpebrae superioris muscle or its aponeurosis (see L). 7. As with lower lid, the principle of quarters is applicable (see p. 526). a. Defect up to one quarter (25%) is accomplished by direct closure (no rotated flap from lower lid is necessary). b. Defect greater than one quarter and up to two quarters is reconstructed by up to one-quarter lower lid flap, with direct closure of donor site of lower lid. c. Defect greater than two quarters and up to three quarters is reconstructed by a lower lid flap up
to two quarters of its length, with a rotation of the lateral cheek flap to close the donor site of the lower lid. d. Defect greater than three quarters to total loss is reconstructed by a lower lid flap up to three quarters of its length preserving the medial quarter of the lower lid, thus avoiding any injury to the punctum and lacrimal apparatus. 8. The vascular hinge for lower lid flaps a, b, and c under No. 7 is placed laterally, whereas flap d under NO.7 is placed medially. 9. Avoid kinking of vascular supply in pedicle when flap is rotated. 10. Refer to basic principles of lid reconstruction (see p.526). Reconstruction of Upper Lid With 25% Defect
A A 25% defect repair is depicted. The lidsare divided into quarters for clarity. Direct three-layer closure is performed following the technique in Figure 11-2B to D. Ifthe defect is only slightly greater than 25% of the lid, several additional millimeters can be gained in the elderly patient by a lateral cantholysis (canthotomy) (see Fig.11-3Dl). In a younger patient, it is best to rotate a flap from the lower lid. The completed closure is shown. The 6-0 nylon conjunctival suture (1) and the gray line fine silksuture (2) are depicted. Continued
Al
Refer to Figure 11-6 for an alternate technique.
PERIORBITAL REGION
25% DEFECT
A FIGURE 11-5
535
PERIORBITAL REGION
Reconstruction of Upper Lid (Continued) (Fig. 11-5) (After Esser, 1919; Mustarde, 1969) Reconstruction of Upper Lid With 30% to 50% Defect
B Thirty to 50 percent defect repair is depicted by rotation of the lower lid flap measuring in width one half of the upper lid defect and equal in height (vertical) to the upper lid defect. The excision should be a parallelogram or shield shaped. With the use of fine hooks, the upper lid defect is reduced 25%. The original defect (dotted lines) is thus reduced to the solid lines. The defect is equal to distance X-V, which is equal to distance X'-Y' of the lower lid flap. The midpoint of this defect then locates the point (1) on the lower lid where the vascular pedicle is planned. When the resulting upper lid defect is less than 6 mm in width (using the fine hooks), the lower lid flap width for practical purposes should not be less than 6 mm, because a rotation of a lower lid flap less than 6 mm is too minute. C
The lower flap is outlined and rotated from the lateral portion of the lower lid by first using scissors through the lid margin (along the solid line) and then by using a knife (along dotted line, C1 and (2) up to within 5 mm of the lid margin where the pedicle (1) is located, thus carefully preserving the vascular arcade. The knife cut is made away from the pedicle. This vascular arcade is actually 3 mm from the free border of the lid margin, and thus, if meticulous pains are taken, some additional relaxation of the rotated flap can be achieved by incising the skin and conjunctiva another millimeter or so.
D The flap is rotated and sutured in place using a standard three-layer closure. Depicted is placement of the conjunctival 6-0 nylon pullout suture. One suture (2) is placed in the gray line of the lid margin at the medial border of the defect. When there is not more than a 50% defect of the upper lid, it is not necessary to suture the levator palpebrae superioris to the flap, because there is sufficient attachment to the remaining upper lid. However, if practical, such attachment can be done with 5-0 chromic catgut.
If additional relaxation is deemed necessary, a lateral cantholysis (see Fig. 11-3Dl) is performed. Sutures are placed in such a fashion as not to kink the vascular pedicle. These sutures are removed on the fifth postoperative day, except for the margin gray line suture (2), which is removed 2 days later.
E, El The vascular pedicle is transected in 2 to 3 weeks, and the lid margins are tailored by an excision of small triangles to facilitate good realignment of the lid margins. A near-far, far-near suture may be placed along the gray line to prevent notching (see Fig. 11-2D). This suture is left long (3). F, F1 If the defect is at the lateral canthus, the procedure is modified in that a single triangle (X) from the pedicle can be excised at the lateral canthus to form a sharper lateral canthus and to lengthen the palpebral fissure.
Continued
PERIORBITAL REGION
FIGURE 11-5 Continued
537
PERIORBITAL REGION
Reconstruction of Upper Lid (Continued) (Fig. 11-5) (After Esser, 1919; Mustarde, 1969)
Reconstruction of Upper Lid With 60% to 75% Defect Medially Based Flap (Close to 75% Defect)
Reconstruction of Upper Lid with 50% to 60% Defect (After Mustarde, 1969)
This group is divided into two techniques: 1. Fifty to 60 percent defect is closed with pedicle of flap based and swung laterally. 2. Sixty to 75 percent defect is closed with pedicle of flap based and swung medially. Laterally Based Flap
G A defect somewhat greater than two quarters is depicted. Fine hooks simply put normal tension on the cut edges but do not attempt to decrease the defect by a quarter. Therefore, quite a different mathematical plan is used to calculate the position and width of the flap from the lower lid as compared with the smaller defects. This is first done by marking the corresponding width of the defect on the edge of the lower lid with a dye (points 1 and 2). Then this marked defect is reduced by a distance equal to one quarter the entire length of the lower lid, the subtraction being done on the lateral side of the marked defect. This is the distance between points 2 and 3. Point 3 then becomes the location of the pedicle of the lower lid flap that is to be rotated from the lateral portion of the lower lid. This prevents injury to the lacrimal apparatus.
H The flap is outlined. Distance 3-4 is equal to distance 1-3 in G. Point 4 on the lateral portion of the lower lid flap is to be transposed to point 4' on the medial edge of the upper lid defect.
When the defect in the upper lid is close to 75% loss, a medially based flap is necessary, because there is not sufficient length laterally for a rotated lower lid flap.
J Defect and calculation of the flap are depicted. The calculation is the same as in G, but it is obvious that there is not sufficient length laterally; hence, it is rotated from the medial side. Distance 3-4 is the width of the flap after one-quarter length of the lid has been subtracted (distance 2-3). Point 4 on the medial portion of the lower lid flap is to be transposed to point 4' on the lateral edge of the upper lid defect. Caution must be taken not to involve that portion of the lower lid flap with the canaliculus. At times the outline of the flap must be shifted slightly laterally to preserve this vital apparatus. K The flap is outlined and elevated medially, and the remaining portion of the lower lid with the vascular pedicle is advanced medially by a zygomatic and cheekrelaxing incision, as shown in Figures 11-3F to Hand 11-4. This closes the defect of the donor site. In no case is the canaliculus included in the flap.
Kl The closure is depicted. A standard three-layer closure is performed as described in Figure 11-2B to D. The muscle layer closure must be carefully performed to restore motor function to the transposed flap. It may be necessary to suture the muscle or the connective tissue of the flap to the aponeurosis of the palpebrae superioris muscle (see Fig. 11-5L). The conjunctival pullout sutures (5) are taped to the skin.
I To close the donor site, an advanced lateral cheek flap will usually be necessary (except in the elderly when more lax skin is present). Refer to Figures 11-3F to Hand 11-4. 11 The closure is the standard three-layer approximation (see Fig. 11-2). Transection of the pedicle is performed at 2 weeks (see Fig. 11-50 to E1). The nylon pullout conjunctival sutures (5) are taped to the skin.
Continued Transection of the pedicle is performed at 2 V2 weeks after the technique shown in Figure 11-50 to El.
539
PERIORBITAL REGION
50%-60%
DEFECT
,--~~-~
_
FIGURE 11-5 Continued
PERIORBITAL REGION
Reconstruction of Upper lid (Continued) (Fig. 11-5) (After Esser, 1919; Mustarde, 1969) Reconstruction of Upper Lid With 75% to 100% Defect (After Mustarde, 1969) The lower lid flap in this size defect must always be rotated from the medial side, preserving, however, the medial quarter of the lower lid, thus preventing injury to the canaliculus. Hence, no more than a maximum of three quarters of the lower lid is utilized. No calculations are necessary with a total defect, because the pedicle is always located at the lateral edge of the lower lid. Because the flap is large, the width of the pedicle should be larger-6 mm rather than 5 mm, as in the smaller flaps. The tarsus requires transection, and this will carry the incision farther, leaving only about 4 mm on the inner side of the pedicle. The flap must be sutured to the levator palpebrae superioris muscle.
L Depicted is total loss of the upper lid with an outline of the lower lid flap. Point 2 on the medial side of the lower lid is transposed to point 2' on the lateral side of the upper lid defect. The stippled area on the cheek represents a triangle of skin to be excised to facilitate the advancement and closure of the lower lid defect. Note that the medial side of this triangle is shorter than the lateral side of the triangle. This aids in the prevention of scar contracture and drooping of the reconstructed lower lid. Additional details of this phase are in Figure 11-3F and G and Figure 11-4. The cut edge (X) of the remaining portion of the palpebrae superioris muscle is tagged with two or three fine silk sutures for later approximation to the rotated lower lid flap. A vertical relaxing incision (3) on the cheek flap may be necessary, with excision of small triangles (4) to increase the length of the cheek flap.
M The full-thickness flap is elevated, and the relaxing incision is made with an elevation of the cheek flap down to but not including the underlying muscles. Injury to the branches of the facial nerve is avoided. The flap with pedicle is advanced and rotated into the defect. Care is taken not to kink the vascular pedicle; it is better to leave a bit of a gap on the edges surrounding the pedicle. Any resulting small defect is corrected at the second stage when the pedicle is divided in 2 weeks. Septal cartilage with mucosa (Y) is utilized to line the reconstructed donor site and sutured in place using 6-0 nylon pullout sutures. The rotated lower lid flap is first sutured byapproximation of conjunctiva of the lid flap to the stump of conjunctiva of the upper fornix. If the sutures are clear of the cornea, 6-0 chromic catgut is used; otherwise, a 6-0 nylon pullout suture is utilized to prevent ulceration of the cornea. The next layer is the approximation of the previously tagged stump of the palpebrae superioris muscle to the connective tissue of the lower lid flap using 6-0 chromic catgut. The third layer is the skin closure, taking care to avoid injury to the vascular pedicle. N
The completed
closure is shown.
0, 01 The pedicle is sectioned in 2 weeks, excising two small triangles of lid margin to produce a smooth curved lid margin. This is performed with the patient under local anesthesia. The lid margins are approximated with 6-0 silk sutures, the ends being left long. A near-far, far-near suture can be used on the margins to prevent notching (see Fig. 11-2D).
PERIORBITAL REGION
FIGURE 11-5 Continued
541
PERIORBITAL REGION
Bridge Flap Repair of Large Upper lid Defects, Cutler-Beard Technique (Fig. 11-6) (After Fox, 1958; Smith and Obear, 1967) There is a difference of opinion regarding the reconstruction of upper lid defects. Esser's (1919) technique (see Figs. ll-SA to Kl) has some drawbacks in that the rotation flaps from the lower lid for large defects necessitates a rather formidable procedure to reconstruct the lower lid, which may in turn cause drooping of the reconstructed lower lid and shortening of the length of both lids. The various techniques are the following: 1. Composite grafts 2. Temporal and forehead pedicle flaps 3. Lower lid flaps a. Bridge flap of Cutler-Beard technique b. Tarsal sharing flap of Hughes technique c. Rotation flap of Esser
Highpoints 1. Full-thickness flap is used from lower lid and portion of cheek. 2. Keep lower lid margin with marginal artery intact: a width of 3 to 4 mm. 3. The procedure requires two stages, with up to 2 months between stages; the patient must be informed that the eye will be sutured closed for this period of time. 4. Lash grafting may be performed as a third stage. 5. Protect the cornea with a scleral contact lens during all but the final steps of stage 1. 6. The width of flap equals horizontal width of upper lid defect before resection. 7. Suture transected edge of levator palpebrae superioris muscle to orbicularis oculi muscle and orbital septum at the superior edge of the flap.
contour with the marginal artery. The horizontal width of the flap is determined from the pre-resection measurements of the upper lid defect, because after resection the remaining edges of the upper lid retract. B1
( The lower lid flap has been mobilized as a fullthickness flap. The skin, orbicularis oculi muscle, and orbital septum are cut with a knife, whereas the underlying conjunctiva is cut with a scissors. The skin extending down to the cheek is mobilized to prevent undue tension on the final suture lines. The arrow depicts the course of the flap under the lower lid margin (the bridge flap). Stay sutures or fine skin hooks on the flap facilitate this maneuver. The scleral contact lens is then removed just before approximation of the flap, which consists of the following: 1. Suturing the conjunctiva layers of the upper lid defect and the conjunctiva of the flap with 6-0 chromic catgut with knots buried (not contacting the cornea). 2. Suturing the remnant of the levator to the orbicularis oculi muscle and orbital septum of the flap with interrupted buried 6-0 silk. This facilitates relatively normal function of the levator to the flap. 3. Suturing the medial and lateral borders of the remaining upper lid to the flap with two 4-0 silk mattress sutures without vertical tension. 4. Suturing the skin edges with interrupted or continuous 6-0 silk sutures 5. Suturing the lower lid vertical incision with 6-0 silk after all tension is relieved by an additional release incision, if necessary No sutures are placed in the preserved lower lid margin. Skin sutures are removed in 6 days. Mattress sutures are removed in 10 days. (1
A A scleral contact lens has been inserted to protect the cornea. The width of the area to be resected is measured. This will determine the width of the bridge flap. Resection of full thickness of the upper lid is then performed with adequate margins. Stay sutures are used both on the corners of the resected specimen and on the corners of the remaining lid. The area resected includes the tarsus or a part thereof, depending on adequate ablative surgery. B The lower lid flap is described, preserving 3 to 4 mm of the lower lid margin, which preserves the lid
Cross section is shown at the same stage as B.
Cross section is shown at the same stage as C.
D The flap is transected over a groove director as depicted about 1 to 2 mm below the normal lid margin to allow for some postoperative retraction of the transposed flap. The conjunctiva of the flap is sutured to the skin of the flap with interrupted 6-0 plain catgut sutures or a 6-0 nylon pullout suture forming the upper lid margin. E The remaining stump of the base of the flap is repositioned into the donor site. Its edge is then sutured to the freshened inferior edge of the margin of the
Continued
PERIORBITAL REGION
543
D
E FIGURE 11-6
lower lid. The remaining skin edges and conjunctiva are approximated in two layers after the excision of any redundant skin.
An eyelash graft to the upper lid margin (see Fig. ll-lOA) can be performed 6 weeks after the first stage (2 weeks before transection of the flap) or after the second stage.
PERIORBITAL REGION
Resection of Large Basal Cell Carcinoma Involving Both Lids and Nose (Fig. 11-7) Highpoints 1. Retain as much of upper lid as possible (compatible with good tumor surgery), because this structure is most important to protect the cornea and subsequent vision. The new upper lid must protect the cornea during sleep and ideally be able to elevate while awake. 2. Protect the globe. 3. Resect the entire lacrimal apparatus. 4. Check flap high points. 5. Use septal mucosa graft for upper lid and septal cartilage and mucosal graft for lower lid. 6. Use adequate forehead and scalp flap. 7. Allow for adequate margins (at least 1.5 em) around tumor and resection of underlying periosteum and perichondrium-check margins with frozen sections with careful labeling. This is most important because gross evaluation can be misleading. 8. Once bone is invaded with basal cell carcinoma, radical resection of the osseous structure is often necessary with enucleation. Locally invasive basal cell carcinoma is extremely lethal. Gross extension of disease is no criterion for microscopic extension.
A Outline the incisions for resection and the forehead, scalp, and cheek flaps for reconstruction. The basic principle is the retention of as much of the upper lid as possible to protect the cornea without compromising adequate resection.
Al, A2 An alternate plan would be to rotate the remaining lower lid (3) to replace the defect in the upper lid (see Fig. 11-5L to 01). Only 75% replacement is necessary (Mustarde, 1969). Depicted is a Fricke supraorbital flap (2) to reconstruct the lateral portion of total loss of the upper lid. This flap is lined with septal mucosa. A rotated cheek flap is used for the lower lid (see Figs. 11-3F to Hand 11-4). B A forehead-scalp flap with a back cut (4) is elevated to reconstruct the medial portion of the upper lid. This is lined with septal mucosa. Cartilage is optional, because the flap is quite thick and stiff. The cheek flap is elevated also with a back cut (5) in the fashion described in Figure 11-4. The only modification is the mobilization of the conjunctiva on fhe lower lid, with an incision laterally along the fornix to permit lateral advancement of the entire remnant of the lower lid.
C The lined area on the upper lid indicates the location of the septal mucosal graft, whereas the lined area on the lower lid indicates the septal cartilage and mucosal graft. These grafts are secured in position by 6-0 nylon pullout sutures or 5-0 catgut sutures. Long 5-0 or 6-0 silk sutures are placed along the lid margins. A split-thickness epidermal graft (X) covers the nasal defect. This could also be covered with further mobilization and a larger scalp flap (see Fig. 6-29). If there is undue tension with primary closure of the scalp defect, the defect can be closed with a split-thickness epidermis graft (Y).
Reconstruction sary if epiphora
of a lacrimal apparatus occurs.
may be neces-
The basic principle
of a dac-
ryocystorhinostomy by construction of an outlet into the nasal cavity (see Fig. 11-13) or a conjunctival flap (see Fig. ll-lle) can be used.
PERIORBITAL REGION
FIGURE 11-7
545
PERIORBITAL REGION
Excision of Superficial Basal Carcinoma in Region of lateral Canthus of lower lid
C
The completed
procedure
is shown.
(Fig. 11-8) Although the lesion depicted could be excised by the method described in Figure 11-30, because the lesion is superficial, full-thickness resection of the lid is not necessary.
A Excisian 'Of lesian includes a partian 'Of the underlying 'Orbicularis 'Oculimuscle. Outline 'Of skin flap (Fricke, 1829) from upper lid is shawn. This is permissible because the lid margin is nat disturbed, there is redundant skin present, and na defarmity 'Of the upper lid will result (see basic principles 'Of lid recanstructian, earlier in this chapter). B Ratation 'Offlap is dane and appraximatian pleted with 5-0 silk 'Ornylan.
com-
D Depicted is a superficial basal carcinama belaw the lateral canthal regian. Excisian is perfarmed, including a partian 'Of the underlying muscle. The incisian for the small flap is at 'Or slightly abave the level 'Of the lateral canthus. E After the flap is advanced it is impartant that na dawnward pull is placed an the lawer lid. If necessary, a subcutaneaus suture is placed thraugh the flap inta the margin 'Of the 'Orbit ta prevent tensian an the lawer lid. F
The campleted
pracedure
is shawn.
PERIORBITAL REGION
A
B
E
c
F
FIGURE 11-8
547
PERIORBITAL REGION
Excision of Benign lesion of Upper Lid (Fig. 11-9) When simple approximation of skin edges after resection of a lesion near the medial canthus would distort the medial canthus, an advanced skin flap from the more central portion of the lid may be indicated.
A The line of excIsion with advanced flap is depicted.
lateral extension
for
B The skin flap is advanced. A relaxing incision (dotted line) may be necessary to avoid a dog-ear. C
The completed
skin flap should extend virtually the entire distance of the upper lid to avoid any uneven contractu res that may occur with only a 50%-length flap. Care must be taken not to injure the deeper structures of the upper lid (e.g., the underlying muscle and tarsus), nor the most important lid margin. This must not be violated under any circumstances. E The flap is in place. Depending on the extent of the defect at the lateral canthus, the base of the flap "X" can be returned to the donor area at a second stage. Sutures must be carefully placed to avoid injury to the globe. Edema of the lower lid margin can occur if this margin is too wide.
closure is shown.
Reconstruction of Superficial Horizontal Defect of Portion of Lower Lid (Fricke
[1829], Upper Lid Flap)
When there is a narrow horizontal margin of the lower lid, a bipedicle the upper lid appears preferred, as is 11-14E and F. The conjunctiva of the of the lower lid is freely mobilized
defect of the free flap of skin from depicted in Figure remaining portion
to the lower fornix,
excised, and sutured to the inner portion of the bipedicle
D Depicted is a long horizontal defect of the skin of the lower lid. The dotted line outlines an upper lid skin flap that is to be rotated nondelayed to close the defect. Becausethere is usually considerable redundant skin of the upper lid, this is quite feasible, especially in the elderly. Some surgeons emphasize that the upper lid
flap to form the inner lining. Although is simple, the surgeon
this procedure
must be aware that the skin flap
may curl on itself and later on droop after the pedicles are returned
to the upper lid. It might prove to be fortu-
itous to leave the pedicles period of time. (Fricke's
in Figure 11-7Al.)
attached
supraorbital
for a prolonged flap is described
PERIORBITAL REGION
E FIGURE 11-9
549
PERIORBITAL REGION
Eyelash Reconstruction (Fig. 11-10) There is some difference of opinion regarding the advisability of eyelash replacement for the lower lid; yet, there is less question as to the advisability of upper eyelash replacement. Several methods are described, especially regarding the donor site (e.g., eyebrow, temporal region, or postauricular region). Highpoints
1. Evaluate proper direction of hair and maintain this direction in graft. 2. Do not injure hair follicles-these are upward obliquely and hence an incision deep to skin must follow this angle. 3. Trim excess adipose tissue from graft. 4. Avoid donor site that may become bald later. Complications
• Failure of graft-repeat. • ScarrIng with inturning of new lashes against the cornea; such hair will require removal by electrolysis. Eyebrow Reconstruction 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 and through-and-through sutures are not used. The wider the graft, however, the greater the possibility of
failure. Thus, an island flap of hair-bearing scalp can be used based on a branch of the superficial temporal artery and vein. Avoid a donor site that may become bald later. A Depicted is the temporal region donor site with the incision placed in a relatively horizontal plane. The hairs thus will be in the same plane when transferred to the lid margin. Two or three rows of hairs are excised. B The hair folliclesextend upward in an oblique direction, and care must be taken that the incision (dotted line) for the graft follows this same angle; otherwise, the follicles will be injured. C The free graft (about 2 mm in width) consists of two or three rows of hairs with follicles.Although some adipose tissue is necessarily excised when the graft is removed, as much of this fat istrimmed with fine scissors as is possible. The rounded black protuberances of the follicles must be preserved. D An incision parallel and slightly outside or distal (1.0 to 2.0 mm) to the free lid margin is made deep enough to accommodate the free graft. Care must be taken that the direction of the hair is in the correct plane. Sutures through both lid edges and the graft are carefully placed without injury to the globe. The original hairs may fall out with new growth occurring in about 3 weeks. These hairs will require a periodic trimming.
PERIORBITAL REGION
B
552
PERIORBITAL REGION
Excision of Lesions at the Medial Canthus (Fig. 11-11) When the loss of tissue is at the medial canthal region, a lateral cantholysis usually will not afford enough relaxation, and a free full-thickness graft, which is quite simple without additional scars, or transposed flap will be necessary. If the defect is superficial and the canaliculi are preserved, a free graft is utilized (see Fig. 6-25E to G). However, if the defect is full thickness with loss of the canaliculi but yet quite small, the defect is closed in three layers, as depicted in Figure 11-2B and C. The tarsus is sutured to the medial end of the stump of the canthal ligament or to the periosteum. A lateral can thoplasty may be necessary to gain an additional length for one or both lids (see Fig. 11-301). Either the superior or inferior crus or both crura of the lateral canthal ligament are transected. When the defect is larger, a transposed flap is necessary. A For a moderate defect, the glabella flap is utilized resorting to the V-Vprinciple. The flap is full thickness and must not include the brow. Only a few millimeters' defect of the lids can be reconstructed with this flap. A1 The Vflap is lowered, and the donor site is closed in Y fashion. A three-layer closure is utilized in which the lids approximate the flap, attempting to suture conjunctiva to conjunctiva. For a larger defect a midline forehead flap is necessary (see Fig. 8-12).
The disadvantages of the contra laterally based flap are the horizontal scars plus the fact that the brows may well meet one another in the midline. Mucous membrane lining is usually necessary, and this is obtained from the nasal septum as described in Figures 11-3F to Hand 11-4. Be sure to suture the inner side of the flap to the periosteum, where it dips into the canthal region to produce a concavity. C A somewhat distressing problem may arise regarding tearing associated with the loss of the canaliculiepiphora. To reconstruct a suitable duct at the initial operation isa matter of judgment, because some patients do not develop epiphora. Depicted is Mustarde's method (1969) for construction of a new duct. A flap of conjunctiva along the inferior fornix is rotated medially and sutured to the remaining lacrimal sac if present or into the nasal cavity utilizing principles of a dacryocystorhinostomy (see Fig. 11-1 3). Other surgeons have indicated that skin defects in this region may require no covering, allowing the defect to close by granulations and secondary intention. This entails a rather protracted course. Another method of handling such lesions is by radiotherapy, with extreme care to protect the globe, or by using the technique of Mohs' paste. Warning: In the treatment of basal and squamous cell carcinoma in this area be certain all margins, edges, and depths are free of disease. Squamous cell carcinoma will require a more extensive radical operation, yet basal cell carcinoma at times may be almost as invasive into surrounding soft tissue as well as bone. This tendency is primarily noted, however, in squamous cell car-
8, 81 A modification of the forehead flap (see Fig.
cinoma. If basal cell carcinoma recurs, the subsequent
8-12) with the base at the contralateral side of the nose is depicted. The dotted line represents the discarded tip of the flap. This flap is performed in one stage, whereas the flap shown in Figure 8-12 requires a second stage to transect and to return the pedicle.
resection usually requires a more radical resection. Basal cell recurrences (operated on elsewhere) have led to bone, orbital, and intracranial extensions requiring orbital exenteration and including trans cranial resection of involved dural and frontal bone.
PERIORBITAL REGION
FIGURE 11-11
PERIORBITAL REGION
Medial Canthoplasty and Repair of Related Injuries (Fig. 11-12) Highpoints 1. Disruption of the medial canthal ligament may be associated with other local deformities: a. Naso-orbital fracture b. Injury to the nasolacrimal apparatus: puncta, canaliculi, lacrimal sac, and nasolacrimal duct c. May be bilateral 2. If such injuries are present, all should be corrected concomitantly, including a dacryocystorhinostomy (see Fig. 11-13), if indicated. 3. More seriously, intracranial injuries may be present, and, if so, these take precedence over any repair in the region of medial canthus. 4. Protect cornea during operation.
A Typical deformity in the left medial canthal region characterized by displacement of the medial canthus primarily laterally and slightly downward and forward. The canthus itself is rounded and blunted and may be partially obscured by redundant tissue of the lids. Distances a and b are the normal relationships, whereas distance b' is longer than b and a' is shorter than a. Although this deformity may be entirely and solely due to rupture of the medial canthal ligament, fracture of the medial wall of the orbit can also contribute to this clinical picture. Radiographs are performed and, if indicated, laminograms.
If the trauma is some weeks or months old and associated with persistent swelling at the medial canthal region, especially below the level of the medial canthal ligament, injury to the lacrimal apparatus has occurred
with the probable formation of a mucocele of the lacrimal sac. A dacryocystorhinostomy (see Fig. 11-13) would be indicated. In either event all such associated deformities must be corrected concomitantly. The procedure described in the following illustration depicts only repair of the medial canthal ligament and reduction and fixation of fresh naso-orbital fractures.
B, B1 Surgical anatomy of the medial canthal (palpebral) ligament and associated lacrimal apparatus is shown. Bl is a coronal section through the medial canthal ligament. The medial canthal ligament splits into a thicker anterior section and a much thinner posterior section, thus enveloping the lacrimal sac. Horner's muscle lies just deep to the posterior section of the medial canthal ligament. The anterior section is attached 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 anterior section of the ligament has been ruptured in its midportion. However, other variations of disruption of the ligament can occur. The disruption may be more laterally at a point just over the proximal portions of the canaliculi. Here the ligament is thinner. Repair in this situation must approximate the upper and lower origins of the ligament from the upper and lower lids. Another type of disruption of the ligament may involve an avulsion of a portion of the underlying bone with a small fragment of bone attached to the medial end of the ligament. This affords an excellent point for the 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 frontal process of the maxilla in front of the lacrimal groove.
Continued
PERIORBITAL REGION
A
LEVATOR PALPEBRAE SUPERIORIS MUSCLE AND APONEUROSIS
FIGURE 11-12
PERIORBITAL REGION
Medial Canthoplasty and Repair of Related Injuries (Continued) (Fig. 11-12) C A small curved incision is made on the side of the nose anterior to the medial canthus, avoiding the skin of the eyelid. Care must be taken not to injure the cornea of each globe during the operation. The lids can be temporarily sutured together. With a small periosteal elevator, the bone is exposed at the selected site for fixation of the ruptured ligament. A similar incision is then made on the opposite side of the nose. Two drill holes about 5 mm apart are made in the medial wall of the orbit through the exposed bone bilaterally. A small dental bur or drill is utilized. No. 32 wire attached to the bur or drill is then pulled through the holes, first above and then through the ligament and through the holes below. D Inset drawing depicts detail of wire suture through ruptured ligament. The wire could also be secured with a through-and-through suture to the contralateral nasal bone or the frontal process of the maxilla with drill holes. E The wire is tightened on the contralateral side and carefully twisted. The cut twisted end is then buried in one of the drill holes. When scarring prevents complete approximation, the attachment of the orbital septum (see Fig. "-') to the periosteum along the orbital rim is incised. Section of the lateral canthal ligament (see Fig. "-3Dl) and the tarso-orbital fascia may likewise be necessary.
F
If an associated deformed fracture of the naso-orbital
compound
is present and no intracranial complications
exist, through-and-through
wires similar to those used
to repair the medial canthal can be utilized, if necessary. These are placed slightly more anteriorly, and they pass through the skin and acrylic plates or Silastic guards on either side of the nose. Care must be exercised so that no excess pressure is applied on the acrylic plates or Silastic guards that might cause skin necrosis. G If there is injury to the canaliculi, repair should be done immediately, because secondary repair is extremely difficult. Basically, this entails passing a plastic tube , mm in diameter through the lumen of the canaliculus and approximating the ends with two or three 6-0 or 7-0 catgut sutures. The tubing, acting as a stent, is sutured to the lower lid with fine silk sutures and left in place 2 weeks. Dilatations are usually necessary after removal of the tubing. An operation microscope may be necessary to locate the distal end of the canaliculus. The microscope may also aid in the suturing of the severed ends. If the distal severed end cannot be located with the microscope, methylene blue can be instilled in the other canaliculus if intact. This will usually extrude through the distal severed end of the injured canaliculus.
An alternate technique for reconstruction of the medial canthal ligament consists of using a triangular skin flap as a substitute for the torn ligament. This technique has specific use when sufficient length of the torn medial canthal ligament is absent or cannot be identified. If there is associated depressed fracture of the glabella resulting from a previous injury, a concomitant bone graft is performed. When obstruction of the nasolacrimal duct is present,
a concomitant (see Fig. ll-l3).
dacryocystorhinostomy
is performed
PERIORBITAL REGION
c
F
G FIGURE 11-12 Continued
PERIORBITAL REGION
Dacryocystorhinostomy (Pang, 1971)
(Fig. 11-13)
Indication • Obstruction of the nasolacrimal dacryocystitis
sac with or without
Highpoints 1. Canaliculi must be patent; otherwise, they require reconstruction (see previous figures and Fig. ll-l1C). 2. Any nasal or ethmoidal sinus disease must be corrected. 3. Local (Pang) or general anesthesia can be used. 4. Place skin incision 3 mm medial to the medial canthus to avoid the angular vessels. 5. Do not transect the medial canthal ligament if feasible-if lacerated or torn this requires repair at the same sitting. Refer to previous figures. 6. Place vertical incision in lacrimal sac between the middle and posterior thirds, thus forming a longer (or wider) anterior mucosal flap (see D). 7. Do not injure the canaliculi-at times catheterization may be helpful to identify canaliculi and the lacrimal sac if severe scarring is present. 8. Refer to Figures 11-1 and 11-12A' to B' for anatomic relationships of lacrimal sac.
Postoperative Care 1. Do not blow nose. 2. Use decongestants. 3. Antibiotics are optional.
Complications • Stenosis due to cicatrization An alternate
technique
requires
is described
revision. by lliff (1971).
A Lateral view is shown of the bony framework forming the lacrimal fossa. The lateral portion of the maxilla has been omitted for clarity. Dotted lines indicate bone removal to form a new drainage route from the lacrimal sac into the nose. The bone removed includes the entire lacrimal fossa and a portion of thick anterior lacrimal crest. If need be, the posterior extent can be enlarged by reaching the posterior margin of the lacrimal bone and even up to the lamina papyracea of the ethmoid.
B A vertical 2- to 2.5-cm-long skin incision has been made beginning 2 to 3 mm superior to the medial canthal ligament and 3 mm medial to the medial canthus. This tends to avoid the angular vessels. The muscle fibers of the orbicularis oculi muscle are split. The medial canthal ligament is identified and preserved. Retraction or at times transection of this ligament is necessary. It must be repaired in any event. Using sharp dissection, the fascia attaching the lacrimal sac to the anterior lacrimal crest is transected along the dotted line. Care must be taken not to tear the sac. It is then completely mobilized from its bed by removing the periosteum with the sac. C Using a small trephine saw, an opening is made in the anteroinferior portion of the lacrimal fossa and anterior lacrimal crest. Care is taken not to injure the underlying nasal mucosa. The opening is then enlarged with Kerrison forceps to the shape of an oval-up to 15 mm long and 12 mm wide. D At this point a cotton-tipped nasal applicator (dotted lines) is inserted into the nasal cavity up to the region of the trephine opening. If the nasal mucosa bulges into the opening, all is clear; otherwise, some interposing ethmoidal cells will require removal. For the sake of clarity, the medial canthal ligament is omitted. A vertical incision is made in the lacrimal sac in a plane between the middle and posterior thirds. This results in an anterior flap (1) that is longer (or wider) in the horizontal plane than the posterior flap (2). This is most important since the distance between the posterior flaps of the sac and nasal mucosa is shorter than the distance between the anterior flaps. A similarly placed vertical incision is then made in the nasal mucosa using the cotton-tipped applicator as support to steady the nasal mucosa . Short horizontal incisions are made at each end of the vertical incisions. This aids in the reflection of the flaps. If necessary, because of lacerations and severe scarring, the flaps may be varied and even placed in a horizontal plane. E The posterior flaps are then approximated with three 6-0 or 5-0 chromic catgut sutures. The anterior flaps are then sutured in similar fashion. For the sake of clarity, the medial canthal ligament is omitted. If repair of this ligament is performed, the drill holes are made and sutures are placed (see Fig. 11-12D and E) but not secured until approximation of the flaps is completed. Some surgeons insert a fine plastic tube through the canaliculus and thence into the nose. If the reconstruction has gone smoothly, this seems superfluous.
PERIORBITAL REGION
A
c
FIGURE 11-13
559
PERIORBITAL REGION
Correction of Scar Contracture of the Lids and Ectropion (Fig. 11-14) A Scar contracture of the lower lid. The entire scar must be excised. A Z-plasty is outlined with wide undermining of the surrounding skin as in the stippled area. The Z-plasty is completed as shown. If the scar is exceedingly large, a transposed flap may be necessary from the mid forehead (see Fig. 8-12) or an advanced lateral cheek flap (see Figs. 11-3F to Hand 11-4). B
C Scar contracture of upper lid with ectropion is shown. A Z-plasty is outlined with an additional area of scar excised. D The completed Z-plasty is shown with a full-thickness graft (3) inserted in the large defect. If the defect is small, a simple closure is feasible. Pullout 5-0 nylon sutures through the tarsoconjunctivallayer can be used to aid in the approximation of the flaps of the Z-plasty.
For severe ectropion of the lower lid secondary to scarring and tissue loss, a bipedicle flap (Tripier) from the upper lid may be of help. E A section of skin from the upper lid with some underlying fibers of the orbicularis oculi muscle is mobilized. A bipedicle flap of skin and muscle is thus developed. A temporary tarsorrhaphy is performed (see Fig. 11-16F). F The flap is swung into the defect and approximated with 5-0 nylon sutures. Both pedicles are tubed. The donor site is closed by simple approximation. Sponge rubber roll is sutured over the flap to help prevent curling or bulging of the flap. The pedicles may be left intact for months to act as suspensory slings for the lower lid, or they may be transected and returned to the ends of the donor site.
PERIORBITAL REGION
A
c
D
FIGURE 11-14
PERIORBITAL REGION
Tarsorrhaphy
(Fig. 11-15)
Indication • To protect the cornea
lateral Permanent Tarsorrhaphy or Canthorrhaphy This type of intermargin adhesion is particularly adaptable for paralytic ectropion and drooping of the lower lid that is of a permanent nature. It is used in deformities associated with facial nerve paralysis involving the orbicularis oculi muscle and minor deformities secondary to lower lid surgery. Highpoints 1. The upper lid is made to support the lower lid. 2. Preserve most of the upper tarsal plate.
Temporary Tarsorrhaphy (Weeks) This procedure is utilized when there is facial nerve paralysis after facial nerve surgery or parotid surgery when return of function is expected. A simple temporary method of corneal protection, for example, during surgery, is the use of a contact lens. Highpoints 1. This procedure is used to correct alignment of upper and lower lids. 2. Excise a small longitudinal area (6 to 8 mm) of mucocutaneous intermarginal tissue to form a bare area. 3. Incise the base of each bare area to open wounds.
A The lids are drawn together to the desired position, and the lid margins are marked with a suitable dye. The point is usually 6 to 8 mm from the commissure of the lateral canthus.
B The lids are split along the gray line with a knife, using fine hooks on the lids as traction points. An incision is carried through the canthus for 2 mm (point X). The lids are then separated into two layers for a distance of 3 mm (point V), starting at the dye marks. C On the lower lid the skin and underlying orbicularis oculi muscle are excised, while on the upper lid the conjunctiva and a small portion of the tarsus are excised as per dotted lines. D Using a 6-0 nylon mattress suture, the two bare areas are approximated with a guard of Silastic or cotton over the skin. E A long 5-0 silk suture is placed at the point at which the two lids meet. In 10 days the nylon suture is removed, and in another 3 or 4 days the silk suture is removed. F After the lids have been approximated and the exact opposing sites for the tarsorrhaphy have been marked with the point of a knife, 6- to 8-mm mucocutaneous rectangular areas are excised, leaving a thin strip of epithelium on both ciliary and conjunctival edges of the lid margins. The cilia are thus not injured, and the normal lid contour is preserved. A longitudinal incision 2 mm deep is made in the base of each bare area. When the lid edges are approximated, this incision facilitates flaring of the wounds with more surface area for healing. Through-and-through horizontal mattress sutures of 4-0 silk guarded with small polyethylene tube booties are inserted and tied snugly. The tarsorrhaphy can be sutured above the eyebrow. G The completed tarsorrhaphy. The sutures are left in place for 8 to 10 days, or longer. With return of function, the lids are then separated by a simple incision of the scar tissue.
PERIORBITAL REGION
c
o
E
FIGURE 11-15
PERIORBITAL REGION
Graft for Defect of Infraorbital Rim (Fig. 11-16) Highpoints I. Incision in lower lid is made as close as possible to the eyelashes. 2. Cartilage graft should have some perichondrium left attached. Silastic can also be utilized. 3. Avoid pressure on infraorbital nerve. Complications • Absorption • Ectropion
C Scar tissue around the infraorbital nerve is carefully freed and excised. The edges of the bony defect are cleaned and freshened. Using a small drill point, a hole is placed at an angle in the edge of the defect for a distance of 0.5 to 1.0 em. It does not pass through the bone. D, D1 Another drill hole is placed in the anterior aspect of the zygoma at such an angle as to reach the blind end of the first hole. This is achieved by inserting a straight needle into the first hole to help locate the blind end. The two holes are connected.
of cartilage
A An incision is made through the lower lid just below the lashes. This location of the incision prevents postoperative edema of the lower lid, which would occur if the incision were lower; however, this incision may result in ectropion. B After a temporary tarsorrhaphy, the orbicularis oculi muscle is exposed and split parallel to its fibers. The defect in the infraorbital rim is exposed.
E With the same type of drill holes placed in the medial edge of the defect in the maxilla, a section of costal cartilage (see Fig. 3-5) previously shaped is now sewn into position, using fine tantalum braided wire. An adequate notch is cut to avoid pressure on the infraorbital nerve. It is important to preserve a section of perichondrium on the cartilage. This aids in its "take." Silastic (silicone rubber) cut from a suitable block can also be utilized. F The cartilage graft is in place. The skin is approximated with fine silk, the ends being left long to avoid injury to the cornea. The tarsorrhaphy may be opened immediately or left until the skin sutures are removed.
PERIORBITAL REGION
A
c
E
FIGURE 11-16
PERIORBITAL REGION
Decompression of the Orbit for Exophthalmos (Fig. 11-17) (After Walsh and Ogura, 1957; Ogura and Pratt, 1971) Progressive exophthalmos ("malignant") is usually but not necessarily associated with Graves' disease-toxic goiter. After a subtotal thyroidectomy, the exophthalmos, either unilateral or bilateral, may become stationary or progress. In our experience true total thyroidectomy has been effective in halting and usually correcting exophthalmos in Graves' disease (see also Perzik, 1963, and White, 1974). If the exophthalmos becomes progressive, corneal ulceration, edema of the eyelid and of the conjunctiva, epiphora, diplopia, and finally loss of vision can occur. The cosmetic deformity alone is an indication for an operation to decompress the orbital contents. Exophthalmic Graves' disease can occur, although seldom, in patients in whom the usual clinical signs and symptoms of toxic goiter are absent. 1f the T3 and T4 thyroid hormone tests are normal, then obtain the thyrotropin-releasing hormone level and/or a T3 suppression test. These test results may be abnormal and will aid in the diagnosis. Computed tomography (CT) as well as coronal scans can be helpful in visualizing abnormalities of the extraocular muscles and optic nerve. We have seen one patient who falls into this clinical category with positive CT scan depicting edema of the inferior rectus muscles. Attempts by endocrinologists to halt and to improve exophthalmos, diplopia, and periorbital edema by thyroid suppression using desiccated thyroid have for the most part failed. Because we have very encouraging results regarding the management of exophthalmos with true total thyroidectomy, one speculates whether this operation may be of some help to alleviate the ophthalmopathy. (See Spaeth's Ophthalmic Surgery, 1982, pp. 435 and 439.) To measure the degree of exophthalmos accurately, a Hertel exophthalmometer is utilized. The first step is to test the patient in the same position (sitting position is ideal) and to keep an accurate record of the setting between the two lateral orbital rims so that the followup examination is performed at the same setting. The reference measurement is made from the lateral orbital rim to the corneal apex, using the exophthalmometer. The average normal distance in the adult is from 16 mm
up to 21 mm beyond the orbital rim. 1f it is more than 21 mm, bilateral exophthalmos is suspected. A difference between the two globes of more than 2 mm is an indication of unilateral exophthalmos. Several procedures have been described: 1. Removal of lateral wall of orbit 2. Removal of roof of the orbit, allowing the orbital contents to herniate into the anterior cranial fossa 3. Removal of floor of the orbit, allowing the orbital contents to herniate into the antrum 4. Removal of medial wall of the orbit, allowing the orbital contents to herniate into a cavity formed by removal of the ethmoidal' sinus cells and floor of the frontal sinus 5. Removal of floor and medial wall of orbit-a combination of Nos. 3 and 4 Highpoints
1. When the exophthalmos is severe, gently tease the adipose tissue with forceps, being sure not to grasp the muscle. 2. Do not open the periosteum until all the bone of the ethmoid is resected; otherwise, the adipose tissue herniates through the resected bone area and thus obstructs clear evaluation in the surgical field. Depending on the degree of exophthalmos, either procedure 3 or 5 (above) appears to be the most adaptable. Technique 5 is depicted. Complications
Always alert the patient as to complications, especially blindness or even partial interference with vision. Other complications include the following: • • • • • • •
Intraorbital hemorrhage Damage to the optic nerve (see p. 66) Subcutaneous emphysema Diplopia Cerebrospinal fluid leak Sinusitis Enophthalmos
PERIORBITAL REGION
B
FIGURE 11-17
A The areas excised are shown via a Caldwell-Luc operation (see Fig. 5-2). The opening into the antrum is made as large as possible so that adequate visualization of the ethmoidal labyrinth and roof of antrum is possible. B With the use of various types of forceps, a complete ethmoidectomy is performed up to the anterior wall of the sphenoidal sinus. (This approach is similar to the transantral ethmoidal sphenoidal hypophysectomy.)
A mastoid curet or osteotome may be necessary to excise thicker portions of bone. If possible, leave the anterior and posterior ethmoidal arteries intact. The lamina papyracea is thus also excised. Do not resect bone above the ethmoidal vessels, which approximates the level of the cribriform plate (see Fig. 6-4A and B), or more posterior than the posterior ethmoidal artery, because damage to the optic nerve may result. Continued
568
PERIORBITAL REGION
Decompression of the Orbit for Exophthalmos (Continued) (Fig. 11-17) (After Walsh and Ogura, 1957; Ogura and Pratt, 1971) C With the use of Kerrison forceps, the roof of the antrum is removed, preserving at this stage the superior layer of periosteum; otherwise, premature herniation of orbital fat will obstruct vision. The infraorbital nerve should likewise be saved as well as, if feasible, a narrow strip of bone to support the nerve. The bone
lateral to the nerve is also excised as far as the heavier bone of the zygoma. The foramina of the optic nerve must not be violated. D After all the bone is removed, the periosteum of the floor of the orbit is incised in several locations to allow the orbital contents to herniate into the antrum. A large nasoantral window is then made. The antrum may be packed for 24 hours with strip gauze impregnated with an antibiotic ointment. The incision in the canine fossa is closed with 4-0 continuous nylon.
D
FIGURE 11-17 Continued
PERIORBITAL REGION
Resection of Benign Tumor of lacrimal Gland (Fig. 11-18) (Spaeth's Ophthalmic Surgery, 1982) Highpoints 1. Management is similar to treatment of benign mixed tumor of the parotid salivary gland. 2. Avoid open biopsy. 3. Avoid transection of the lateral canthal ligament. 4. Tag the superior and lateral rectus muscles before resection. 5. Remove and replace the lateral orbital rim if tumor is large; if the tumor is small, the rim is left intact. 6. Resection includes the entire lacrimal gland, capsule, and adjacent periosteum. This follows the same basic surgical principles for resection of any mixed tumor; namely, avoid violation of the capsule of the tumor or any incision of the tumor, with implantation of cells. 7. Differentiate from malignant tumor, especially the adenoid cystic carcinoma.
Discussion The problem facing the surgeon in the evaluation of any intraorbital mass is diagnosis. Needle aspiration may be of some help. The needle puncture site should, if possible, be placed along the line of the anticipated skin incision and marked with India ink. This area is then excised at the time of the resection of the neoplasm. If the mass is suspected to be malignant (e.g., adenoid cystic carcinoma), the most malignant of all tumors of the orbit, then an incision and biopsy via an anterior
569
approach awaiting permanent histologic diagnosis has been recommended if frozen section is not absolutely confirmative of the diagnosis. In this circumstance, the orbital rim is not removed, because a more extensive resection with orbital exenteration is indicated after the confirmed diagnosis of adenoid cystic carcinoma. Obviously, one must be absolutely certain of the diagnosis when orbital exenteration is proposed. Variations of these steps depend on clinical impression as well as findings of CT and magnetic resonance imaging. The signs and symptoms of orbital tumors are ptosis, mass in the lateral superior area of the orbit, proptosis, and downward displacement of the globe.
Complications • Blindness: immediate surgical intervention is necessary to evacuate hematoma and control bleeding (see p. 66). • Recurrence of tumor: recurrent mixed tumor may become malignant.
A Skin incision is made below the unshaven eyebrow . extending laterally 1 cm above the lateral canthalligament along the zygomatic arch. Care is taken to avoid the zygomatic branch of the seventh nerve. A small cross-hatch is made across the skin incision for realignment,Qf the skin edges at the time of skin closure. B Tag sutures are placed on the superior and lateral rectus muscle as an aid for identification during the orbital exploration.
FIGURE 11-18
Continued
PERIORBITAL REGION
Resection of Benign Tumor of Lacrimal Gland (Continued)
the tumor or soft tissue. A thin metal guard can be inserted between the inner periosteum and bone.
(Fig. 11-18) (Spaeth's Ophthalmic Surgery, 1982) C The incision exposes the underlying muscles and fascia. The muscle fibers are separated when possible. The periosteum is elevated from the orbital rim. The underlying periosteum is to be removed with the neoplasm. Drill holes are made before the sectioning of the bone for placement of wire sutures at the close of the resection to replace the resected bone. Care
- D The entire lacrimal gland, benign mixed tumor, periosteum, and capsule are removed en bloc. The wound is copiously irrigated with saline. Hemostasis must be meticulous, because postoperative hemorrhage could cause blindness. The excised orbital rim is replaced and secured with wire. A small drain is preferred.
must be taken when using the drill to avoid entering
FIGURE 11-18 Continued
Resection of Adenoid Cystic Carcinoma of the Lacrimal Gland (Fig. 11-19) Highpoints 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. An outline of the orbital bony resection is shown that is to be combined with exenteration and removal of the lids and all of the contiguous soft tissue and periosteum. Adenoid cystic carcinoma spreads via the nerves and periarterial routes. The dura is carefully elevated and preserved from the imier portion of the resected bone, which has wavy contour with ridges. Preservation of the dura of course is based on evidence that there is no extension of disease to the dura; otherwise the dura would require resection.
Although local flaps (e.g., forehead [see Fig. 8-10]) may be used to cover the surgical defect, the donor site on the forehead may be a significant cosmetic deformity, especially in the young patient. The alternative is the use of a split-thickness graft to cover the defect, rather than the forehead flap.
PERIORBITAL REGION
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