Operative Otorhinolaryngology

EDITED BY N I G E LB L E A C H MB, ChB, FRCS(Otol), FCSHK Consultant Otolaryngologist Heatherwood and Wexham Park Hos...

Author: Nigel Bleach | Chris A. Milford | Andrew Van Hasselt

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EDITED BY

N I G E LB L E A C H

MB, ChB, FRCS(Otol), FCSHK Consultant Otolaryngologist Heatherwood and Wexham Park Hospitals NHS Trust Wexham, Slough, Berks, UK

C H R I S R/11ILFORD BSc, FRCS Consultant Otolaryngologist Department of Otorhinolaryngology The Radcliffe Infirmary, Oxford, UK

ANDREW VAN HASSELT MBChB, FCS(SA), FRCS(Edin), FHKCORL, FHKAM(Otol), MMed(Oto1) Professor of Surgery, Chief of Otorhinolaryngology The Chinese University of Hong Kong Prince of Wales Hospital Hong Kong

FOREWORD BY

ALAN KERR

b

Blackwell Science

0 1997 by Blackwell Science Ltd Editorial Offices: Osney Mead, Oxford OX2 OEL 25 John Street, London WC1N 2BL 23 Ainslie Place, Edinburgh EH3 6AJ 350 Main Street, Malden MA 02148 5018, USA 54 University Street, Carlton Victoria 3053, Australia Other Editorial Offices: Blackwell Wissenschafts-Verlag GmbH Kurfiirstendamm 57 10707 Berlin, Germany Zehetnergasse 6 A-1140 Wien, Austria All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the copyright owner First published 1997 Set by Excel Typesetters, Hong Kong Printed and bound in Great Britain by the Bath Press, Bath The Blackwell Science logo is a trade mark of Blackwell Science Ltd, registered at the United Kingdom Trade Marks Registry

A catalogue record for this title is available from the British Library ISBN 0-632-03747-4 Library of Congress Cataloging-in-Publication Data Operative otorhinolaryngology I edited by Nigel Bleach, Chris Milford, Andrew van Hasselt. p. cm. Includes bibliographical references and index. ISBN 0-632-03747-4 1. Otolaryngology, Operative. I. Bleach, Nigel. 11. Milford, Chris. 111. Van Hasselt, Andrew. [DNLM: 1. Otorhinolaryngologic Diseases-surgery. WV 168061 19971 RF51.0615 1997 617.5’1’059-dc20 DNLM/DLC for Library of Congress 95-47084 CIP

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9 Myringoplasty, 44 Peter-John Wormald

List of Contributors, ix Foreword, xiii

10 Ossiculoplasty, 52 Antony A. Narula

Preface, xv

11 Stapedectomy, 56 Tony Wright

List of Abbreviations, xvii

1 Aspects of General Anaesthesia for ENT Surgery, 1 John R. Lehane

12 Mastoid Surgery, 65 John P. Birchall 13 Surgery of the Discharging Mastoid, 76 Andrew van Hasselt

2 Surgical Outcome Analysis and Audit, 6 Rowena M. Ryan

14 Osseo-integrated Implants, 80 Michael P.Rothera

Section I : Otology (External Ear, Middle Ear and Mastoid)

15 CochlearImplantation, 85 P.Gerard Reilly and Gerard M. O’Donoghue

3 Excision of Lesions of the Pinna, 13 Michael C.F. Tong and Ashraf Zekri

Section 2: Otoneurosurgery and Skull 6ase Surgery

4 Excision of Preauricular Sinus, 18 Hoo-Kwong Leong

5 Excision of Canal Osteomas and Exostoses, 21 Kevin J . Feely

16 Approaches to the Internal Auditory Canal Cerebellopontine Angle, 93 Robert J.S. Briggs

6 Meatoplasty, 25 Robert E. Quiney

17 Surgery of the Facial Nerve, 107 Glen R. Croxson

7TympanostomyTubeInsertion, Peter J.Rob6

32

and

18 Surgery for Vertigo, 120 Michael J . Gleeson and Ben Pahtixxa 19 Approaches to theInfratempora .l Fossa, 137 Tristram H.J. Lesser

8 Approaches to the Middle Ear and Mastoid, 38 Robin Youngs V

vi

Contents

20 Surgery of Glomus Tumours of the Temporal Bone, 14.5

Chris A. Milford 21 Petrosectorny, 1S4 Tristram H.]. Lesser

Section 3: Rhinology

3.5 Surgery for Cerebrospinal-fluid Rhinorrhoea, 249

Chris A. Milford 36 Surgery for Epistaxis, 2.56 John K.S. Woo

Section 4: Endoscopy

22 Surgical Correction of Nasal Fractures, 161 Rodney E. Mountain

37 Nasopharyngoscopy,265 John K.S. Woo

23 Maxillary Sinus Lavage and Inferior Meatal Antrostomy, 16.5

3 8 Pharyngolaryngoscopy and Rigid Oesophagoscopy (including Panendoscopy), 269

John M . Hadley

Simon A. Hickey

24 Surgical Reduction of the Inferior Turbinates, 169 Paul 0 'Flynn

39 Flexible Oesophagoscopy, 276 Charles S. Robertson

2.5 Septoplasty and Repair of Septal Perforation, 173

40 Rigid Bronchoscopy, 280

Victor Abdullah

Charles A. East 26 Rhinoplasty and Septorhinoplasty, 182 Nick S. Jones 27 Functional Endoscopic Sinus Surgery, 193 Vij'ayK. Anand and Mark J. Glasgold

41 Assessment of the Paediatric Airway: Laryngotracheobronchoscopy, 28.5

David Albert

Section 5: The Oral Cavity, Pharynx and Larynx

28 Surgery for Choana1 Atresia, 204 David W. Morgan

42 Adenoidectomy and Tonsillectomy, 295

29 External Operations on the Frontoethmoidal Complex, 208

43 ~vulopalatopharyngoplasty,301 Grant J.E.M. Bates

Peter M . Clarke

ValerieJ. Lund 30 Midfacial Degloving, 216

Valerie J.Lund 31 LateralRhinotomy and Medial Maxillectomy, 220

44 Surgery for Benign Lesions of the Oral Cavity, 308

Robert M.Sudderick 45 Phonosurgery and Microlaryngeal Surgery, 3 1S

Meredydd Harries and Murray Morrison

Nigel R. Bleach 46 Tracheostomy, 326 32 Maxillectomy and Maxillary Swing, 226 Willimn I. Wei 33 Anterior Craniofacial Resection, 233 Robert ].S. Briggs 34 Trans-sphenoidalHypophysectomy, 242

Alan P.Johnson

Victor Abdullah 47 Surgery of Paediatric Laryngotracheal Stenosis, 332

David Albert 48 Surgery of Hypopharyngeal Diverticula, 342 Alexander C. Vlantis

Contents 49 Surgery for Malignant Lesions of the Tongue, Floor of the Mouth and Alveolus, 349

vii

59 Branchial Cysts, Sinuses and Fistulae, 424 Robert W.T. Slack

Nicholas D. Stafford 50 Surgery for Malignant Lesions of the Oropharynx, 357 John Waldron 51 Total Laryngectomy, 365 R. Theo Gregor

60 Thyroid Surgery, 428 Nicholas P. McIuor 61 Surgery of the Parotid Gland, 436

John C. Watkinson

62 Radical and Conservative Neck Dissections, 444

Andrew C. Urquhart

52 Vertical Partial Laryngectomy, 373

Kerry D. Olsen

63 Surgery for Parapharyngeal-space Tumours, 454 Keith J. Dauidge-Pitts

53 Horizontal (Supraglottic) Laryngectomy, 3 83

R. The0 Gregor 54 Pharyngolaryngectomy and Pharyngolaryngooesophagectomy, 3 87 Christopher F. Perry 55

Surgical Voice Restoration, 396

Nigel R. Bleach and Andrew J.G. Batch

Section 6: The Neck, Thyroid and Major Salivary Glands 56 Lymph-node Biopsy in the Head and Neck, 409 Philip J. Robinson

57 Surgery of the Submandibular and Minor Salivary Glands, 4 15 Christopher A. Joseph 58 Excision of Thyroglossal Cysts, 420

D. Gareth John

64 Deep-neck-space Infection, 462 Graham J. Cox and Bippon C. Vinayak

Section 7: Plastic and Reconstructive Surgery 65 Pinnaplasty, 471

Chris J. Inglefield 66 Facial Reconstruction with Local Cutaneous Flaps, 476 Keith W. Cullen and Ian W.R. Holten

67 Principles of Head and Neck Reconstruction, 489 Timothy E.E. Goodacre Index, 505

This Page Intentionally Left Blank

VICTOR ABDULLAH BSc, FRCS, FCS(HK), FHKCORL,

Otolaryngology, Southampton University Hospitals, Tremona Road, Southampton, UK

FHKAM(OtoL), Senior Medical Officer, Division o f Otorhinolaryngology, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong

GRAHAM J. COX MBBS, BDS, FRCS, Consultant Otolaryngologist, Department of Otolaryngology, Stoke Mandeville Hospital NHS Trust, Aylesbury, Bucks, UK

DAVID ALBERT FRCS, Paediatric Otolaryngologist,

GLEN R. CROXSON MBBS, FRACS, Visiting Medical

Hospital for Sick Children, Great Ormond Street, London, UK

Officer, Suite 407, Royal Prince Alfred Hospital, 100 Carillon Avenue, Newtown, Australia

VIJAY K. ANAND MD, FACS, Surgeon Director,

KEITH W. CULLEN BSc, FRCS(Ed), Consultant Plastic and

Department of Otolaryngology, Manhattan Eye Ear and Throat Hospital, New York, USA

Reconstructive Surgeon, The Queen Victoria Hospital, East Grinstead, West Sussex, U K

ANDREW J.G. BATCH BSc, FRCS, FRCS(ENT),

KEITH J.DAVIDGE-PITTS MB, BCh, FRCS(Edin),

Consultant ENT Surgeon, City Hospital NHS Trust, Dudley Road, Birmingham, UK

FCS(SA), FACS, Ear Nose and Throat Surgeon, Morningside Clinic, Rivonia and Hill Roads, Sandton, South Africa

GRANT J. BATES BSc, BM, BCh, FRCS, Consultant

CHARLES A. EAST FRCS, Consultant ENT Surgeon, Royal

Otolaryngologist, Department of Otorhinolaryngology, The Radcliffe Infirmary, Oxford, UK

National Throat Nose and Ear Hospital, Gray’s Inn Road, London, UK

JOHN P. BIRCHALL MD, FRCS, Professor o f

KEVIN J. FEELY MB, BS(Qld), FRACS, Consultant

Otorhinolaryngology, Department of Otorhinolaryngology, Queen’s Medical Centre, Nottingham, UK

Otolaryngologist, Head and Neck Surgeon, Mater Medical Center, JessieStreet, Rockhampton, Australia

NIGEL R. BLEACH MB, ChB, FRCS(Otol), FCSHK,

MARK J. GLASGOLD MD, Clinical Assistant Professor,

Consultant Otolaryngologist, Heatherwood and Wexham Park Hospitals NHS Trust, Wexham, Slough, Berks, UK

Division of Otolaryngology, Head and Neck Surgery, Robert Wood Johnson Medical School, New Jersey, USA

ROBERT J.S. BRIGGS MBBS, FRACS, Diplomat American

MICHAEL J. GLEESON MD, FRCS, Professor of

Board of Otolaryngology and Senior Lecturer, Melbourne University, Department of Otolaryngology, Melbourne, Australia

Otolaryngology, Department of Otolaryngology and Skull Base Surgery, Guy’s Hospital (UMDS), and Skull Base Surgeon to Guy’s, King’s and St Thomas’s Hospitals, London, UK

PETER M. CLARKE BSc, FRCS(ORL), Senior Registrar in

ix

x

List of Contributors

TIMOTHY E.E. GOODACRE BSc, FRCS, Consultant Plastic Surgeon, Department of Plastic and Reconstructive Surgery, The Radcliffe Infirmary, Oxford, UK

R. T H E 0 GREGOR MB, BCh, PhD, FRCS, FACS, Professor and Head of Department of Otorhinolaryngology, University of Stellenbosch and Chief Otolaryngologist, Tygerberg Hospital, Tygerberg, South Africa

JOHN M. HADLEY MA, FRCS, FRCS(Orl), Consultant ENT Surgeon, West Middlesex University Hospital NHS Trust, Isleworth, Middlesex, UK

MEREDYDD HARRIES BSc, MBBS, FRCS, Consultant ENT Surgeon, The Royal Sussex County Hospital, Eastern Road, Brighton, UK

SIMON A. HICKEY MA, BM, BCh, FRCS, Consultant ENT Surgeon, Torbay Hospital, Lawes Bridge, Torguay, Devon, UK

IAN W.R. HOLTEN MBBS, FRCS, Registrar in Plastic Surgery, Department of Plastic Surgery, Queen MaryS University Hospital, Roehampton, London UK.

CHRIS J.INGLEFIELD BSc, FRCS, Senior Registrar in Plastic Surgery, Plastic Surgery Department, Wexham Park Hospital, Wexham, Slough, Berks, UK

D. GARETH JOHN BSc, MBBS, FRCS, Consultant ENT Surgeon, Department of ENT Surgery, Poole Hospital NHS Trust, Poole, UK

ALAN P. JOHNSON MB, ChB, FRCS, Consultant Otolaryngologist/Headand Neck Surgeon, Department of Otolaryngology, The Queen Elizabeth Hospital, Edgbaston, Birmingham, UK

NICK S. JONES BDS, FRCS, Consultant Otorhinolaryngologist, Departmentof Otorhinolaryngology, Queen’s Medical Centre, Nottingham, UK

CHRISTOPHER A. JOSEPH MB, BCh, FRCS, FCS,

MMED, ENT Surgeon, River Club, Gauteng, Johannesburg, South Africa

TRISTRAM H.J. LESSER MS, FRCS, Consultant ENT Surgeon, Department of Otorhinolaryngology/Headand Neck Surgery, Walton Hospital, Liverpool, UK

VALERIE J. LUND MS, FRCS, FRCS(Ed), Professor in Rhinology, Institute of Laryngology and Otology, Royal National Throat Nose and Ear Hospital, Gray’s Inn Road, London, UK

NICHOLAS P. McIVOR MBChB(Otago), FRCS(Ed), FRACS, Otolaryngologist/Headand Neck Surgeon, Green Lane Hospital, Auckland, New Zealand

CHRIS A. MILFORD BSc, FRCS, Consultant Otolaryngologist, Department of ~torhinolaryngology, The Radcliffe Infirmary, Oxford, UK

DAVID W. MORGAN BSc, M B , ChB, FRCS, FRCS(Otol), Consultant ENT Surgeon, ENT Department, Birmingham Heartlands Hospital, Bordesley Green, Birmingham, UK

MURRAY MORRISON MD, Professor and Head of Otolaryngology, Vancouver General Hospital, Vancouver, USA

RODNEY E. MOUNTAIN MB, ChB, FRCS(Ed), Consultant Otolaryngologist, Departmentof Otolaryngology, Ninewells Teaching Hospital, Dundee, UK

ANTONY A. NARULA MA, FRCS, Consultant Otolaryngologist, Departmentof ENT, Leicester Royal Infirmary, Leicester, UK

GERARD M. 07DONOGHUEMCh, FRCS, FRCSI, Consultant Otolaryngologist/SkullBase Surgeon, Department of Otolaryngology, Queen’s Medical Centre, Nottingham, UK

PAUL O’FLYNNE MBBS, FRCS, Consultant ENT Surgeon, The Royal National Throat Nose and Ear Hospital, Gray’s Inn Road, London, U K

KERRY D. OLSEN MD, Consultant, Department of Otorhinolaryngology, Mayo Clinic and Mayo Foundation, Professor of Otolaryngology, Mayo Medical School, Rochester, Minnesota, USA

JOHN R. LEHANE MB, ChB, MRCP(UK), FRCA, Consultant Anaesthetist, Nufield Departmentof Anaesthetics, The John Radcliffe, Headington, Oxford,UK

€300-KWONG LEONG MB, BS, FRCS, FAMS, Senior Lecturer and Consultant Otolaryngologist, Departmentof Otolaryngology, National University Hospital, Lower Kent Ridge Road, Singapore

BEN PANIZZA FRCS, Clinical Fellow to Department of Otolaryngology, Guy’s and St Thomas’s Hospital, London, UK

CHRISTOPHER F. PERRY MB, BS(Qld), DTM & H(L’pool), FRACS, Consultant Otolaryngologist/Headand Neck Surgeon, Watkins Medical Centre, Brisbane, Australia

List of Contributors ROBERT E. QUINEY FRCS, Consultant Otolaryngologist, Royal Free Hospital, London, U K

xi

BIPPON C. VINAYAK MBBS, FRCS, Clinical Lecturer in Otolaryngology, Department of Otorhinolaryngology, The Radcliffe Infirmary, Oxford, U K

P. GERARD REILLY BSc, FRCSEd(ORL), Consultant ENT Surgeon, York District Hospital, York, UK

PETER J. ROBB BSc, MB, FRCS, FRCS(Ed), Consultant Otolaryngologist and Clinical Director of Surgery, Epsom Healthcare NHS Trust, Epsom, Surrey, U K

CHARLES S. ROBERTSON MB, BS, DM, FRCS, Consultant General Surgeon, Worcester Royal Infirmary, Worcester, UK

PHILIP J. ROBINSON FRCS, FRCS( Otol), Consultant Otolaryngologist, Department of Otolaryngology, Southmead Hospital, Westbury on Trym, Bristol, U K

ALEXANDER C. VLANTIS MB, BCh, DA(SA), FCS(SA)ORL, Consultant ENT Surgeon, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong

JOHN WALDRON FRCS, Consultant ENT Surgeon, Royal United Hospital, Bath, U K

JOHN C. WATKINSON MSc, MS, FRCS, DLO, Consultant OtolaryngologistlHead and Neck Surgeon, Department of Otolaryngology, The Queen Elizabeth Hospital, Edgbaston, Birmingham, U K

WILLIAR/I: I. WE1 MBBS, MS, FRCS, DLO, FACS, Professor MICHAEL P. ROTHERA FRCS, Consultant ENT Surgeon, Department of Ear Nose and Throat Surgery, Hope Hospital, Salford, U K

of Otorhinolaryngology, Departmentof Surgery, The University of Hong Kong, Queen Mary Hospital, Hong Kong

JOHN K.S. WOO FRCS, DLO, Consultant ENT Surgeon, ROWENA M. RYAN MB, BCh, BAO, BA, FRCS, Consultant ENT Surgeon, Northwick Park and St Mark’s NHS Trust, Harrow, Middlesex, UK

ROBERT W.T. SLACK BSc, MB, ChB, FRCS, Consultant ENT Surgeon, Royal United Hospital, Bath, U K

NICHOLAS D. STAFFORD MB, ChB, FRCS, Professor of Otolaryngology and Head and Neck Surgery, Academic Department of Head and Neck Surgery and Otolaryngology, Hull Royal Infirmary, Hull, U K

Division of Otorhinolaryngology, Departmentof Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong

PETER-JOHN WORMALD FCS(SA)ORL, FRCS(Ed), Consultant Surgeon in Otolaryngology, Groote Schuur Hospital, Cape Town, South Africa

TONY WRIGHT LLM, DM, FRCS, Professor of Otolaryngology, Institute of Laryngology and Otology, Royal National Throat Nose and Ear Hospital, Gray’s Inn Road, London, U K

ROBERT M. SUDDERICK FDSRCS, FRCS, Consultant OtolaryngologistlHead and Neck Surgeon, Royal Surrey County Hospital, Guildford, Surrey, U K

MICHAEL C.F. TONG MB, ChB, DLO, FRCS, Senior Medical Officer and Honorary Lecturer, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong

ANDREW C. URQUHART MB, ChB, MMED, FCS(SA), FACS, ENT Surgeon, Department of Otolaryngology, Marshfield Clinic, Marshfield, Wisconsin, USA

ANDREW VAN HASSELT MBChB, FCS(SA), FRCS(Edin), FHKCORL, FHKAM(Otol), MMed(Otol), Professor of Surgery, Chief of Otorhinolaryngology, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong

ROBIN YOUNGS MD, FRCS, Consultant ENT Surgeon, West Suffolk Hospital, Bury St. Edmunds, Suffolk, UK

ASHRAF ZEKRI MS, FCPS(Fr), FHKCS, Consultant Plastic Surgeon, A1 Mataria Teaching Hospital, Cairo, Egypt and Visiting Associate Professor, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong


Foreword

Examinations are a necessary evil and in Britain we seem to multiply these in a way that our surgical colleagues from other parts of the world find difficult to understand, but which some secretly envy. Given competent Higher Surgical Training in a satisfactory programme, this textbook shouldbe more than adequate to enable the candidate to pass the Intercollegiate Examination in Otolaryngology, either in its present form or in the modified form that is likely to appear in the next few years. In addition, the fact that this book has been written by young Otolaryngologists brings a freshness of approach that more than compensates for anylack of experience over time. This, again, should be helpful for those studying for this examination. Theinternationalnature of theproductionshould widen both the appeal of the book and the horizons of those who read it. I have no hesitation in offering my congratulations to the editors and contributors of this excellent book and commending it to all trainees, and others, in Otolaryngology.

I agree withthe editors that therehaslong been a need for a single volume textbook of Operative Otorhinolaryngology and I am delighted to be able to say that this need has now been fulfilled. The editors have been able to gather together many of the active, enthusiastic and progressive young surgeons currently in British Otolaryngology, and with the assistance of others from abroad, have produced a work of which they, and our specialty as a whole, can be proud. There already are some excellent textbooks of operative surgery available to our specialty but they do not meet the specifications that the editors haveset for themselves. Now, inone volume, thetrainee can see the whole of our specialty and get an understanding of all aspects of the surgery which we perform.There is a consistency of layout and illustration that makes foreasy reading. It is acknowledged that the more specialised textbooks willbe necessary forthemore specialised procedures, but then the trainee will not be attempting these duringthecourse of generalotolaryngology training.

Alan G. Kerr

xiii


....... "........"

Preface

This volume was initially conceived from my dissatisfaction with the textbooksof operative ENT surgery available in the UK, in terms of their content, their outdated style of presentation and their high price for the trainee surgeon. A detailedplan of theproposedbookwas discussed initially with Andrew van Hasselt fromHong Kong and then with Chris Milford from Oxford, both of whom shared the same sentiments. Our purpose was to producea comprehensive, single volume textbook of OperativeOtorhinolaryngology, written by young surgeonsand with a continuity of style and artwork throughout. The book was to be aimed primarily at the trainee specialist surgeon in the UK, Australasia, Asia, India and Africa with authors to be drawn froma correspondingly widevariety of countries and institutions. It was also hoped that the book would be detailed enough to be a valuable and practical reference fortheyoungconsultantsurgeon.Theconcept was successfully presented to Blackwell Science, and the project slowly began to gather momentum. This book does not aim to compete with major subspecialist texts in Otoneurosurgery, Skull-Base Surgery, Head and Neck Surgery, Endoscopic Sinus Surgery or Facial Plastic Surgery. Nevertheless, basic and fundamental procedures within all these categories have been included, ashave chapters onAspects of General Anaes-

thesia in Otorhinolaryngology,Reconstruction in the Head and Neck,and Surgical Outcome Analysis and Audit. A standardised format for the operative procedures hasbeen adhered to as closely as possible throughout the text, although a minorityof chapters do notlend themselves to such strict criteria, in which case the format has been relaxed. The original operative diagrams have all been redrawn by a single artist, Mike Elms, in order to aid clarityand toimprove theoverall continuity of the book. By thesametoken,commonandnonspecific complications have not been repeated endlessly in the text, and standard medical abbreviations have been utilised as appropriate. As editors wehave tried, as far as possible, not to interfere with each contributing author's personal style and descriptive prose.Althoughthetechniques described, and opinions or recommendationsexpressed by the authorshave not always corresponded with thoseof the editors, we have not seen fit to alter the text radically, as there has been little of substance with which we have strongly disagreed. The result, we hope, is an informative and practical guide forENT surgeons that will contribute to the sound delivery of Operative Otorhinolaryngology. N.R.B.


List of Abbreviations

A-P ABR ACHA ACTH AH1 AI AICA AIDS AJV BAHA BAAE BCC bd bid BIPP

anterior-posterior auditory brain-stem response air-conduction hearing-aid adrenocorticotrophic hormone apnoea-hypopnoea index apnoea index anterior inferior cerebellar artery acquired immunodeficiency syndrome anterior jugular vein bone-anchored hearing-aid bone-anchored artificial ear basal-cell carcinoma twice a day every two days bismuth, iodoform and paraffin paste

BNF

British National Formulary

BP CCA CFR CNS c02 CPA CPAP CSF CSOM CT dB DVT EAC EAM ECA ECG EMG EMLA ENG

blood pressure common carotid artery craniofacial resection central nervous system carbon dioxide cerebellopontine angle continuous positive airway pressure cerebrospinal fluid chronic suppurative otitis meatus computed tomography decibel deep vein thrombosis external auditory canal external auditory meatus external carotid artery electrocardiogram electromyographic eutectic mixture of local anaesthetic electronystagemography

ENOG ENT ESR ET EUA FESS FG FNAC FRC GA GI GP GSPN H 2 0 2

H20 HL HIV HPL IAC IAM ICA ID IgA IJV IM ITU iu IV IVC kHz KTP LA LAIJP LP0 LTB

xvii

electroneuronography ear, nose and throat erythrocyte sedimentation rate endotracheal tube examination under anaesthetic functional endoscopic sinus surgery french gauge fine-needle aspiration cytology functional residual capacity general anaesthetic gastrointestinal general practitioner greater superficial petrosal nerve hydrogen peroxide water hearing loss human immunodeficiency virus horizontal partial laryngectomy internal auditory canal internal auditory meatus internal carotid artery inferior dental immunoglobulin A internal jugular vein intramuscular intensive therapy unit international units intravenous inferior vena cava kilohertz potassium-titanyl phosphate local anaesthetic laser-assisted uvolopalatoplasty laryngopharyngo-oesophagectomy laryngotracheobronchoscopy

xviii

List of Abbreviations

LTS MCF MRI N,O NBM Nd-YAG NHS NSAID OME OPG Paco,

Pc02 PE PEG PET PICA P02

PORP PTA PTA PVC qds RBC rpm

laryngotracheal stenosis middle cranial fossa magnetic resonance imaging nitrous oxide nil by mouth neodynium-yttrium aluminium garnet National Health Service non-steroidal anti-inflammatory drug otorrhoea of the middle ear orthopantomogram partial pressure of arterial carbon dioxide partial pressure of carbon dioxide pharyngo-oesophageal percutaneous endoscopic gastrostomy positron emission tomography posterior inferior cerebellar artery partial pressure o f oxygen partial ossicular replacement prosthesis pure-tone audiogram pure-tone audiometry polyvinyl chloride four times a day red blood cells revolutions per minute

RNTNEH

RT SCC SMAS SMD SMR SOHND SRS SVR TB tds TE TEP TM TMJ TORP TPLO T s and As TSH TPLO UPPP URTI VT YAG

Royal National Throat, Nose and Ear Hospital radiotherapy squamous-cell carcinoma superficial musculo-aponeurotic system submucosal diathermy submucous resection supraomohyoid neck dissection slowreacting substance surgical voice restoration tuberculosis three times a day tracheo-oesophageal tracheo-oesophageal puncture tympanic membrane temporomandibular joint total ossicular replacement prosthesis total pharyngolaryngo-oesophagectomy tonsillectomy and adenoidectomy thyroid-stimulating hormone total pharyngolaryngo-oesophagectomy uvulopalatopharyngoplasty upper respiratory tract infection ventilation tube yttrium aluminium garnet

Aspects of General Anaesthesia for ENT Surgery J O H N R. LEHANE

very soluble and well buffered in the body, the arterial Pco, rises steadily at about 0.3kPa/min so that at 2min the Pco, will be 5.6 kPa. Within 3min hypoxaemia will cause cardiacarrestor severe braininjury while the change in Pco, remains unimportant. Now consider the effect of apnoea while breathing Respiratory gases 100Yo oxygen. While breathing oxygen the only gases in the alveoli The pathology requiring ENT surgery or the requireare oxygen, CO, and water vapour. The total pressure ments of the surgery itself mayseriously compromise the in the alveoli is 100 kPa (1atm). The partialpressure of patient’s airway. The important consequence of loss of water vapour is 6kPa and that of CO, is 5 kPa. The airwaypatency is hypoxaemiaand/orhypercapnia. balance, 89 kPa, must be the partial pressureof oxygen. While the pattern of blood -gas disturbance is influenced by the extent and rate After 2min of apnoeathe Pco, will rise by 0.6 to of onset of obstruction, itis critically dependent on the composition of the gas that 5.6 kPa so the alveolar Po, will have fallen to 88.4 kPa. After 30min of apnoea the alveolar Pco, will be 15 kPa the patient breathes. This may be air, 100% oxygen or mixtures of oxygen with nitrous oxide, air or helium. and the PO, 79 kPa. Thereis no hypoxia, although there is a respiratory acidosis. The total amount of oxygen stored in FRC and blood was only about 2.4L and yet Air versus oxygen therapy and the mitochondria will have consumed between 7 and prevention of hypoxaemia 1OL. In order to understand the circumstances where this apnoeic oxygenation fails it is necessary to know Anaesthesia increases the alveolar -arterial oxygen tenhow the additional oxygen is supplied. sion gradient and most patients would become During ventilation CO, enters the alveoli at the same hypoxaemic with an inspired oxygen concentration of 21 Yo. However, an interruption to ventilation may prerate itis produced (about 250 mllmin). However, during cipitate catastrophic hypoxaemia so it is important to apnoea most of the CO, produced isbuffered within understandhowsuchincidentsimpairarterialblood the body and only about 2.5% (6 mllmin) enters the gases. First consider theeffect of apnoea while breathing alveoli. Oxygencontinues to be absorbedfromthe alveoli at 300ml/rnin.Inthissituationoxygen is abair. sorbed at 50 times the rate that CO, is evolved and so Resting oxygen consumption is 250-300ml/min in a typical adult. At the onset of apnoea the oxygen availalveolar pressure falls. This causes convective gas flow ableforvitalorganfunction is almost entirely that (not diffusion) through the conducting airways to the stored in the functionalresidual capacity (FRC) (200 ml) alveoli. Provided the patient’s airway remains connected and that combinedwithhaemoglobin (800ml). After to the oxygen supply, oxygen is passively drawn down 2min about half this store is exhausted and the arterial the airway at a rate of about 295ml/min toreplace that consumed. Po, will be less than 4 kPa. In contrast, because CO, is

This chapter will cover aspects of oxygen therapy and the effects of various gas mixtures, airway and ventilatory management, airway fires, ‘bloodless-field’ anaesthesia and postoperative analgesia.

I

There are two situations where apnoeic oxygenation fails. 1 If the patient is disconnected from the oxygen source, forexamplethe face mask is removed to permit laryngoscopy, then room air instead of oxygen is drawn down the trachea at about 295ml/min and in about 30s nitrogenstarts to enterthe alveoli. Since therate of extraction of oxygenfrom an alveolus is determined by its perfusion, air (with its nitrogen) is directed preferentially to the best perfused alveoli. These are located in thedependentparts of thelungwherethe alveoli are not so well inflated and so the oxygenis rapidly diluted in these alveoli andthetime to significant hypoxaemia maybe as little as 2-3 min.This is still substantiallybetter than if thepatienthadnot been preoxygenated. 2 If the airway becomes completely obstructed, then no gascan flow intothe alveoli as oxygenis absorbed. Alveolar volume therefore decreases at 295ml/min. The lowermost alveoli rapidly completely collapse (absorptionatelectasis) and venousblood issuing fromtheir capillaries causes arterial hypoxaemia. By the time onethird of alveolar volume is lost (2-3 min)theshunt fraction will have risen above 50% and hypoxaemia will be severe. These considerations explain why, with careful use of oxygen, it is often possible to allow an extended period of apnoea while a surgical procedure is performed while at other times loss of airway control or ventilation may require urgent intervention to maintain safety. Helium=oxygen versus oxygen therapy in airway obstruction

Heliox (80% helium, 20% oxygen) is about one-third the density of air and would reduce theresistance to gas flow by this amount when gas flow is turbulent. However, even in severe upper airway obstruction the predominant gas-flow regimen is usually laminar. In these cases heliox would increase resistance to gas flow since it is 8% more viscous than air. Air -oxygen mixtures or 100% oxygen aremoreappropriate while definitive therapy to correct the obstruction is established. On the rare occasions when gasflow is predominantly turbulent in the obstructedsegment of the airway,resistance will be inversely proportional to the fifth power of the radius (Fanning’s law) so the range of narrowing associated with serious rather than total obstruction is tiny. Such patients usually cross this range very quickly so do not have timeformuch CO, accumulation to occur. Within this range theuse of heliox may permit a higher minute ventilation and therefore less CO, reten-

tion than wouldbe the case with either airor oxygen but this is notthemainthreat to the patient’s life. The principal risk is that total obstructionwill rapidly supervene and severe hypoxaemia will rapidlyfollow if breathing 20% oxygen (either as helioxor air).In anticipation of this the patient is likely to be safer on high concentrations of oxygen rather than a helium-oxygen mixture while preparationsaremade to relieve the obstuction. Airoxygen versus N,O=oxygen in middle ear surgery

Because N 2 0 is muchmoresoluble than nitrogenit rapidly enters and inflates air-filled cavities. If the cavity is closed and rigid then the pressure rises; hence a partially fluid-filled middle ear may appear dry after induction of anaesthesia with N,O. This may result from the increase in gas volume orthe fluid may actually be expelled from the Eustachiantube along with gasby the high pressure generated by the N,O. Following placement of a tympanic membrane (TM) graft, the middle ear pressure mayrise at about 1-10 cm H,O/min. At the end of anaesthesia absorption of N,O may produce a subatmospheric pressure and retraction of the graft. In the author’sexperience use of N,O does notappear to cause problems,perhaps because the packingtechnique used by his surgeons effectively isolates theexternalsurface of the T M fromatmosphericpressure. In circumstanceswherethesurgeon feels that these pressure changes may be significant the anaesthetist should be informed well in advance. If these effects are to be avoided, N,O should notbe used during the whole procedure and special arrangements may be required to permit the use of an air -oxygen-volatile anaesthetic mixture. Inpatientswithpreviousstapedectomythere have been a few reports of deafness followinganaesthesia (usuallyfornon-otologicalsurgery). Thesehavebeen ascribed to pressure changes leading to dislocation of thestapesprosthesis,either by diffusion of N,O or inflation of the middle ear by positive pressure ventilation by face mask prior to tracheal intubation.

Airway management 1 The airway maybe open and not connected to an anaestheticbreathing system, forexamplewiththe patientbreathingthrough anoperatinglaryngoscope. This is mostoften used to permitsurgerywithinthe larynx or trachea. It may also be appropriate for brief, minor procedures. Reduction of nasal fracture may be

Aspects o f General Anaesthesia forENT Surgery included in this group but this is probably unsafe because of the risk of a brisk nasalhaemorrhage and inhalation of blood. 2 A face mask may be used, with or without a pharyngeal airway (Guedel or nasopharyngeal). 'This approach is suitable for some minor procedures not involving the airway. 3 The laryngeal mask airway is suitable for minor and intermediatesurgery not involving theairway. It can be useful in assisting trachealintubation in selected patients in whom intubation may be difficult by conventional means and for airway maintenance during percutaneousdilatationaltracheostomy. Many anaesthetistsareexperimentingwithits use forroutine pharyngeal, nasaland sinus surgery. It is not certain that itadequatelyprotectsagainstinhalation of blood or other debris, orthat itprovidesa sufficiently secure airway. It will take some years to establish whether the laryngeal mask is as safe as tracheal intubation. 4 Intubation of the tracheaby oral ornasal routes using tubes such as the Magill (standard or armoured),RAE, microlaryngoscopy or flexible metallic LaserFlex tube is the mostwidely used method of airway management for head and neck surgery. While oral intubation isused fortonsillectomy in children (to allow access to the adenoids)it is conventional to use anasaltubefor tonsillectomy in adults. Nasotracheal intubation is significantly more traumatic and the author prefers the oral route for adult tonsillectomy. 5 Tracheostomy or cricothyroidostomy maybe performed and tubes such as plain or fenestrated (speaking) tubesor alaryngectomy (Montando)tube maybe inserted. The severely compromised airway

Whether due to tumour, infection, trauma, a congenital abnormalityor bleeding intothe airway,ventilatory obstruction may requireimmediatetracheostomy or cricothyroidotomy under local anaesthesia. In the most urgent cases even localanaesthesia will be omitted. In less pressing cases it may be appropriate to attempt to secure theairwaywithatrachealtube (awake or undergeneralanaesthesia) ortoattemptto provide general anaesthesia for tracheostomy. In such cases it is essential that the surgical teamis prepared to perform tracheostomy or cricothyroidotomy immediately if control of the airway is lost. When this occurs it must be understoodthat, if theanaesthetisthas not been successful in maintainingoxygenationas described above,theairwaymust besalvaged in amatter of seconds.

3

Ventilatory management Themethod of ventilation usually dependsmore on patient than surgical considerations. 1 Spontaneous ventilation. This is suitable for younger, more robust patients for shorter procedures where moderate hypercapnia will not cause poor operating conditions. 2 Intermittent positive-pressure ventilation (mechanical or manual). Thisis most widely used, particularly where muscle relaxants are used to facilitate placement of the tracheal tube. 3 Low-frequency jet ventilation, e.g. witha Sander's injector. 4 High-frequency jet ventilation alone or superimposed on spontaneous ventilation. Jet ventilation allows positive-pressure ventilation and control of blood gases when an open airway technique is required. Jet ventilation injectors for either high- or low-frequency use may be proximal (mounted on operatinglaryngoscope or rigid bronchoscope)ordistal (e.g. Benjamin andCardentubesandcricothyroid cannulae). These are designed to inject oxygen through an end hole and to entrainair to augmentthetidal volume.

Airway fires Withthediminishing use of flammable anaesthetic agents, airway fires had become rare.However,the introduction of powerful lasers into ENT surgery has caused a re-emergence of this problem. Biological tissues, being waterlogged, do not supportsustained combustion even in anatmosphere of 100% oxygen. Problems arise because the surgeon or anaesthetist introduces extraneous flammable materialssuchas tracheal tubes orcotton swabs,particularly if their flammability is enhanced by high concentrations of N,O or oxygen. To minimise the risks an open airway technique may be used (i.e. notrachealtube).Thepatientmay be allowed to breathe room air spontaneously, although this may be associated with significant hypoxaemia and CO,retention.Furthermore,airwayobstruction (a likely accompaniment to thistype of surgery) will rapidlyprecipitatecatastrophichypoxaemia. Adding oxygen reduces these risks but does not prevent CO, retention. If saline-soaked swabs are placed to protect the distal airway from accidental laser strikes, then the inspired gas may dry them and render them flammable. Even without added oxygen the risk is significant; with oxygen the result can be spectacular.

4

Chapter 1

Anotherproblemwith this technique is that the patient will inhale smoke, blood and aerosolised tumour or virus particles generated by the action of the laser. This may be avoided by jet ventilation using a special jet cannula. The cannula is made of stainless steel and is long enough to be placed through the larynx and distal to the site of surgery. It has side holes and no end hole so does not entrain air. This ensures that gas flow at the operation site is outwards throughout the respiratory cycle and smokeinhalation is thus prevented. The very high gas flows associated with this technique make it imperative that saline-soaked swabsare not used, as they will quickly dry out. Jet ventilation can prevent CO, retention and hypoxaemia,particularly as 100% oxygen is themostcommonly used driving gas. Scavenging of the smoke, tumour and virus particles is required to prevent them being inhaled by the operator. The use of a powerfully oxidising atmospherefor laser surgery is controversial. In this context it should be remembered that N,O is a powerful oxidant and its use mixed with oxygen is no safer than 100% oxygen. Adding even small amounts of oxygen to air greatly increases the risk of a flash fire and 25% oxygen is likely to rapidly accelerate combustion. The risks from hypoxaemia in the anaesthetised patient are less spectacular, although probably much more significant than the risk of fire. It maybe that the most appropriate solution is to avoid introducing potentially flammable material rather than limiting the oxidising potential of the gas mixture. Where surgical access permits, a flexible stainless-steel (LaserFlex) tracheal tube may be used to maintain the airway. The respired gas is kept away from the surgical field so that the above considerations are less relevant. Unfortunately, these tubes are not entirely nonflammable since they are equipped with PVC cuffs to seal the airway. The cuffs are inflated with saline, which serves to .quench a fire in the event of the cuff being struck inadvertently by the laser. This will be less effective with second or subsequent strikes since much of the saline will have drained away after the first. To avoid a fire it is essential to stop surgery and change the tube immediately a cuff is ruptured. Rapidrecognition of cuff rupture is facilitated by adding methylene blue to the saline used for cuff inflation.

4€3100dless-field9anaesthesia f o r ENT surgery Excessive bleeding may make any surgery more difficult and particularly so with operations on the middle ear,

endoscopic sinus surgery and exploration of the neck or base of the skull. It used to be considered that deliberate induction of arterialhypotension was effective and often necessary. However,the need to avoid hypotension when grafting free flaps with microvascular anastomoses and the quality of surgical field that can be obtained during such procedures demonstrates that other factors are more important. These include selection of premedicant drugs, induction technique and timing of tracheal intubation toavoid inducing a tachycardia and increasing cardiac output. Positioning the patient head-up and avoiding extreme positions of the neck will minimise venous bleeding. Locally, vasoconstrictors such as cocaine and adrenaline can be used. Theanaesthetistshould always be informed when these agents are used, not so much because some volatile agents may contraindicate them (such contraindicationsareprobablyoverstated),butmore because ECG and blood-pressure monitors need to be closely observed duringtheir use and haemodynamic and respiratory stability should have been established before they are used. Thisshould apply even to the preanaesthetic use of cocaine where ECG, bloodpressure and pulse oximetermonitoringshould be used.

Perioperatiwe analgesia for ENT surgery and related pharmacological topics Among themore painful ENToperationsarethroat procedures such as tonsillectomy and uvulopalatopharyngoplasty (UPPP). Useof acombination of an opioid such as morphine, a non-steroidal anti-inflammatory analgesic (NSAID) such as diclofenac, paracetamol and infiltration of the tonsillar bed with a local anaesthetic is usually very effective. The use of NSAIDs may be of concern because their effects on platelet function may possibly contribute to post-tonsillectomy haemorrhage. However, inadequate analgesia may also increase the risk of haemorrhage by impairing swallowing and predisposing to infection. Obviously the usual cautions and contraindicationsfor NSAIDs must be observed. Rather less well recognised is that patients with sleep apnoeasyndromescan become very sensitive to the effects of opioids and require less than one-fifth of the normal dose. Some patients requiring tonsillectomy or UPPP belong to this group. Opioids are rarely required for middle ear and labyrinth surgery and can aggravate the postoperative nausea and vomiting associated with this surgery. If they can be avoided then it is often unnecessary to give a

Aspects of GeneralAnaesthesia for ENT Surgery prophylactic antiemetic, although it should be given early if the patient develops nausea. Prochlorperazine is often preferred as an antiemetic, especially after labyrinthectomy, although itis probably not superior to any other antidopaminergic antiemetic. When agents of this class prove ineffective there is a tendency to try newer agents such as ondansetron. This is a pity since hyoscine is probably the most extensively tested antiemetic drug and canbe very effective. If large doses are given (0.8 rng or more in an adult), orin the elderly, there is a small risk of precipitating a confusional state or hallucinations.Wherethis needs treatment, small

5

doses of physostigmine given intravenously are more effective than sedative drugs. Premedication withopioidsand/or anticholinergic drugs is now rarely used. Opioidsare given during anaesthesia according to anticipated need for analgesia postoperatively. Anticholinergic drugs may cause a tachycardia.This may cause myocardial ischaemia in patients with coronary arterydisease or increase cardiac output, thereby compromising a ‘bloodless-field’. They may be givenwhen necessary during surgery when vagal bradycardia is induced by, for example, instrumentation of the ear canal or pressure on the carotid body.

Surgical Outcome Analysis and Audit R O W E N A M. R Y A N

Introduction

come measure, the methods in common use for analysis of outcomes (Table 2.1), the differences between auditand research and finally the role of audit of outcomes.

Research into outcomes of all types of health care, including surgery, currently excites great interest from providers, purchasers, politicians and patients. Surgeons have, of course, always been interested in the outcomes of the procedures they offer, both positive (e.g. myringoplasty take rate) and negative (e.g. morbidity and mortality data). But now alongside a growingmedical interest in the field is a sharp increase in the use by purchasers of outcomes data to inform purchasing decisions. A recent survey by the UK Clearing House for Information on the Assessment of HealthOutcomes (Frater & Dixon, 1994) found that 84% of purchasers were using some sort of information on outcomes for this purpose.Although only 22% of thetotal were influenced by outcomes data in deciding where to place contracts, many used outcomes data in deciding what care to purchase, and expressed a desire for more information about how touse outcomes data to make comparisons between providers. It is essential that those using outcomes data and those generating them should be aware that most outcome studies do not ‘measure’ outcomes in such a way that clear-cut comparisons can be made between treatments or providers. Some studies will do this (randomised controlled trials), but most will not. Consequently results need to be interpreted in the knowledge of the factors whichmay have confounded them; otherwise the scope fordrawinginaccurate conclusions is huge. Now more than ever, individual surgeons need to be aware of the methods in use for outcomes analysis and the virtues and limitations of each. This chapter will discuss thefundamentals of choosing an out-

Choosing an outcome measure Choosing an outcome measure is an essential preliminary to good research and to audit of outcomes. Measures must be chosen with care, precisely defined and validated. For many operations, simply choosing the appropriatetype of outcome measureis difficult. For example, after endoscopic sinus surgery, should symptom relief or endoscopic appearance be used or both? For some operations a simple, objective, easily quantifiable measure will be obviously suitable, such as audiometric data afterstapedectomy.However,formany interventions, themost relevant outcome measure is symptom relief, and some ‘instrument’ such asa questionnaire must be found to quantify that symptom relief. The type of questionnaire in commonest use in surgery is referred to as a ‘measure for specific disease’ (e.g. one relating to symptoms of sinusitis), but many other types have been developed in other specialties, such as measures of pain and ‘multidimensional health status profiles’ (e.g. the recently popular SF-36 questionnaire): Well-documented techniques(McDowell, 1987) exist for quantifying the essential characteristics of a questionnaire designed for use as an outcome measure. These include reliability (whether it produces the same results if reapplied to thesamesituation), validity (whether it measures what it purports to measure) and responsiveness (whether it can identify small but clinically significant changes). 6

Surgical Outcome Analysis and Audit Table 2.1 Methods in common use for outcome analysis.

Methods in CO outcome analysis The randomised controlle

The double-blind randomised controlled trial remains the ‘gold-standard’ methodfor establishing acausal relationship between process and outcome (e.g. does a saccus decompression have a greater effect than placebo on Menikre’s disorder?). In any other type of study, the risk of a goodor a bad outcome may not be totally equal between groups of patients treated with different operations or by different surgeons, and so differences between the outcomes may not mean true differences in process. The only totally unambiguous way of equalising risk between groups (despite ‘case-mix variables’ seeFig. 2.1-and inaccuracy, bias andchance) is through randomised controlled trials. However, these are expensive and time-consuming and indeed unsuitable for many treatments, while some patients will always be too ill or too old or have coexisting disease which requires their exclusion (Greenfield, 1989). This means thatother methods must often be soughtfor practical reasons. Furthermore, before it can be ethically justifiable to mount a randomised controlled trial there

Fig. 2.1 Relationship between case-mix, process and outcome.

7

must be true uncertainty about the issue at question; to establish that such uncertainty exists will often require prior investigation with less formal methods.

These studies do notallow the difference between treatments or providers to be ‘measured’ accurately, but they are used because they are applicable to a wide range of clinical situations rather than just narrow research settings. In these studies patientsare observed and outcomesdocumented,but noattempt is made to randomise, so interpreting the results is extremely difficult as allowances must be made for so many variables. While elaborate ‘risk stratification systems’ have been designed using sets of variables to stratify patients according to risk in particular situations (e.g. the APACHE scoring system (Knaus et al., 1991) for estimating risk of mortality in intensive care), in most circumstances it is impossible to control for all relevant factors. One type of observational study which is so simple that it can be used to trackresults in all surgical patients (rather than just in small subgroups) hasbeen piloted in theRoyalNational Throat Nose and EarHospital (RNTNEH), London.Theapproach involves simply ‘monitoring’ whether or not patients’ operations have achieved their individual goals (Ryan et al., 1994). Before surgery is offered, the patient’s subjective goal (e.g. relief of nasal obstruction) is documented in the notes (Fig. 2.2), as well as an objective goal chosen by the surgeon. Later, at postoperative review, bothpatient and surgeon ask themselves, ‘Has this operation achieved its goal?’ The question may be asked again after a longer interval, by post if necessary. Analysis can

8

Chapter 2 Analysis of mortality rates and 6outcome indicators’

Fig. 2.2 Admissions stamp used at the RNTNEH specifying goals of surgery.

yield some interesting results (e.g. only 40% ‘success’ following antral washouts compared with greater than 70% following endoscopic sinus surgery).However, these results can under no circumstances be used as endpointsin themselves, butonlyaspointers to further study. Complication-rate comparisons

Comparison of rates of specific complicationsafter specific operations may throw a little light on differences between providers, if interpreted with due attention to case mix and other relevant variables. However, many major methodological pitfalls exist. Sample size will be inadequate except with common complications of very common procedures, and the method of data collection will have a profound effect on reporting rates. It has been shown that documenting complications prospectively rather than retrospectively can almost quadruple the numbers reported, while comparisons can be made meaningless by lack of standardisation of issues such as the following: 1 Should the term ‘complication’ include failure of an operation to achieve its end? 2 Should complications of a general anaesthetic be recorded? 3 Should unavoidable consequences of surgery be included, such as facial palsy after total parotidectomy for malignancy? 4 Should all complications be recorded or only the most severe per patient? 5 How severe does each complication have to be to be worth recording (e.g. how much bleeding after a tonsillectomy is ‘significant’?)?

Theterm ‘indicator’ refers to figures calculated from routinely collected data, such as reoperation within 1 year after specific surgical procedures, which might be considered to vary with quality of care. ‘Indicators’ and mortalityratesare widely examined at a national or regional level. While analysis of such data gives informationfor little cost because the dataare collected anyway, suitable ‘indicators’ are few and far between, and results may be confounded not only by case-mix differences, inaccuracy, bias and chance (as with observationalstudies)but also by irrelevant variations in local practice. For example,adeathrate based on finished consultant episodes may appear up to50% less thanone based on in-patient admissions (McKee & Hunter, in press) if moribund patients are referred from oneconsultant to another during an admission, thus completing multiple ‘episodes’ per admission. As finished consultant episodes are at present the denominator in mortality-rate calculations, departments where widespread ‘episode inflation’ occurs will appearto have a significantly lower mortality rate!

Audit Aims and methods

Audit should not be regarded as a tool for defining a causal relationship between process and outcome. This is the province of pure research, which in essenceis ‘concerned with discovering the right thing to do, while audit is concerned with ensuring that it is done right’ (Smith, 1992).Other very important differences between research and audit are outlined in Table 2.2. Rather than lookingfora causative link between process and outcome, audit will investigate process or outcome independently. Where the relationshipbetween Table 2.2 Differences between audit and research.

SurgicalOutcome process and outcome has already been well established (by research), an index of process may even be used as a proxy for outcome. For example, we know that early diagnosis of congenital hearing loss is associated with improved acquisition of speech and language, so it might be reasonable to audit rates of early diagnosis as a proxy outcome measure in these children for the sake of simplicity. Audit methods must be tightly defined and controlled if wastage of funds on poor research, dressed upas audit, is to be avoided. Audit projects are expected to involve the setting of a standard, examinationof current practices against thatstandard, a search for changes which might improve the match with the standard, and re-examination of practice to assess whether or not the changes have brought about an improvement. Audit as practised in this way works well for issues of process (e.g. does every letter to a GP contain a working diagnosis?) andsome issues of outcome (e.g. are we succeeding in discharging 98% of plannedday cases on the same day as surgery?). However, the method is clearly not appropriate forestablishing causative links between process and outcome. An extreme exampleof the sortof methodological sloppiness that can occur if the purpose of audit is misunderstood is for a department to review results following two proceduresdoneforthesame condition, without controls or randomisation, and to conclude on thebasis of the results that oneprocedure is better than theother.Thissort of mistake must be avoided at all costs if audit is not tofall into disreputeby association with valueless pseudoresearch.

Fig. 2.3 Sample comparative audit ranking chart (reproduced with permission o f the Surgical EpidemiologY and Audit Unit at the Royal College of Surgeons of England).

Analysis and Audit

3

Cornparatiwe audit

This has more to do with comparison of processes and outcomes than with audit as defined above. Surgeons pool data fromtheirown practices regarding basic workload (e.g. cases operated on per year, number of theatre lists per week) and special topics (e.g. process and outcome of surgery for sinusitis). The answers from all surgeons for any one question (e.g. percentage take rate after myringoplasty) are then ranked in numerical order,asin Fig. 2.3, so that each surgeon can see whether hidher answer lies around the mean or in a grossly outlying position.Whereindividualsurgeons find they are an outlier with respect to any one question, they may be stimulated to return to their own department and carry out true audit to investigate the cause and bring about an improvement if possible. Comparativeaudit data make little allowance for case-mix factors and none for bias, chance or sample size, so they can only properly be interpreted by the surgeon returning data who knows how these factors might have affected hidher results. For this reason data and rankings are kept strictly confidential.

The future There is no doubt thatthe ‘outcomes industry’ is here to stay. This will be welcomed by doctors provided the emphasis is genuinely on improvingoutcomesrather thanwitch-hunting‘bad apples’, and provided those using outcomes data show a sufficient grasp of the prin-

IO

Chapter 2

ciples outlined above for them to be able to interpret outcomes data sensibly. In particular, the point cannot be emphasised too firmly that outcome indicators and observational studies of outcome do not provide sharp enoughinformation to clearly define therelationship between process and outcome, and therefore should be used very cautiously, if at all, to makecomparisons between providers. The future of outcomes research should include more attention to defining and validating outcome measures, a greater drive towards getting results of good research into day-to-day practice, and a more widespread effort to analyse outcomes in a cooperative, constructive and non-confrontational way. Doctors are far morelikely to be able to influence the direction of outcomes initiatives from a position of experience within the field, and this should addto the satisfaction derived by individual surgeons from the intelligent informed use of their own outcomes data.

References Frater A & Dixon P (1994)Purchasers’ survey. Outcomes Briefing 3, 2.5-6. Greenfield S (1989) The stateof outcome research: are we on target? N.Engl. J.Med. 320, 2142-3. Knaus WA, Wagner DP, Draper EA etal. (1991) APACHE 111 prognostic system: risk prediction of hospital mortality for critically ill hospitalized patients. Chest 100, 1619-36. McDovvell I (1987) A Guideto Rating Scales andQuestionnaires. Oxford, Oxford University Press. do they McKee M & Hunter D (in press) Mortality league tables: inform or mislead? Quai. Health Care (in press). Ryan R, White C & East C (1994) Global monitoring of positive outcomeaftersurgery:afeasibilitystudy at the Royal National Throat Nose and Ear Hospital. Ann. Roy. Coll. Surg. Engl. 76,759. Smith R (1992) Audit and research. BT. Med. J.305, 90.5-6.

Otology Middle Ea


Excision of Lesions of the Pinna M I C H A E L C.F. T O N G A N D ASHRAFZEKRI

lndications Surgical excision of partor whole of thepinna is indicated for both benign and malignant pathologies. Benign lesions of the pinna include hypertrophic scar, keloid, seborrhoeickeratosis,solarkeratosis,pilomatricoma, solar lentigo (lentigo seniles), benign melanocytic naevus, pyoderma gangrenosurn, papilloma, lipoma, lymphangioma, leiomyoma, chondroma, haemangioma and keratoacanthoma. Malignant lesions include squamous-cell carcinoma (SCC), verrucous carcinoma (rare), basal-cell carcinoma, malignant melanoma, Kaposi sarcoma and metastatic tumours. A small benign-looking lesion isremoved with primary closure for histological examination to look for possible malignancy. Centrallylocated moderate-size lesions (around 1cm in diameter) can be taken with the defect covered by a split or full-thickness skin graft. For cosmetic reasonsreconstructionwitha randomor vascularised flap isnecessary for large benign lesions and most malignant lesions. Alternatives to surgical removal, including shave excision, lasering, electrodesiccation and cryosurgery, will be briefly outlined.

Preoperative management Clinical diagnosis of most lesions of the pinna can be accurately madeby careful examination noting the characteristics of its growth, colour, shape, edges and consistency. Preoperative diagnostic biopsy is indicated for largedoubtful lesions to allowforbetteroperative planning. In patients withsuspected SCC or melanoma, theregionallymphatics-preauricular,postauricular andupper cervical nodes- have to be palpatedfor metastases. It is advisable to discuss andthoroughly

explain to patients the various options for reconstruction and the cosmetic outcome of the planned operative procedures.

Relevant anatomy Understanding of the basic cartilaginous framework of thepinna is an essential prerequisite (Fig. 3.1). If a majorreconstruction is planned,moulding or photographic imaging of the contralateral normal earmay be helpful during the operation.

Operative techniques Most lesions can be removed under local anaesthesiaby subcutaneous infiltration of 0.5 -1 % lignocaine without adrenaline (to avoid the possibility of ischaemic necrosis). As premedication, 5-10 mg of diazepam (Valium) can be given. Formalignant or infected lesions with perichondritis, general anaesthesia is recommended. Planned incisions aremarked precisely before infiltrationandthedrapedareashould allowadequate exposure of the ear and the potential areas for reconstruction.

Procedures The patient is positioned comfortably slightly head-up and the ear canalprotected by cotton wool or asilicone ear plug. The technique of closure and reconstruction depends on the size and site of the lesion. 1 For small benign lesions (less than 5 mm in diameter) whena 1-:!mm margin is adequate, simple elliptical excision and primary closure with 5/0 non-absorbable sutures (Ethilon, Dermalon) will suffice (Fig. 3.2a).

14

Chapter 3

2 For centrally located moderate-size lesions (5-10mm in diameter), with preservation of the perichondrium, split or full-thickness skin graft can be applied with a bolster dressing (Fig. 3.2b). 3 For peripherally located small-size lesions, anadvancement helical flap can be applied (Fig. 3 . 2 ~ ) .

Fig. 3.1 Anatomy of the anterior surface of the right pinna: 1, helix; 2, triangular fossa; 3, scapha; 4, antihelix; 5, concha; 6, tragus; 7, antitragus; 8, lobule.

Chondrocutaneous flaps (Antia & Buch, 1967’) can be used for larger helical-rim defects (Fig. 3.3). This’technique necessitates total freeing of the entire helix from thescapha by incising throughthe cartilage. The posteromedial skin is dissected away from the perichondrium, mobilising the two ends of the helical remnants to close without tension. 4 Large benign lesions or malignant lesions require a safety margin. Closure of the resulting defect depends on its location at the upper, middle or lower third of the conchal area. Aresection margin of 2-3 mm is adequate for basal-cell carcinoma, whereas at least 5 mm clear full-thickness ‘skin-cartilage-skin’ margin is necessary for squamous-cell carcinoma. 5 Upper-third lesions are excised using a wedge incision (Orton, 1986; Furnas, 1990). The closure is either primary anteriorly with a skin graft or posteriorly with a postauricular flap (Fig. 3.4a). A free composite skincartilage graft may be used from the opposite ear (Fig. 3.4b). 6 Middle-third and conchal defects can be closed by a postauricular flap with or withouta cartilage graft(Fig. 3.5). A stent or an acrylic mould must be placed in the external auditory canal (EAC) opening for 4 months to prevent subsequent stenosis (Brent, 1990). 7 Tumours of the lower third or earlobe can be excised using primary closure. Soft-tissue reconstruction alone is adequate.Themethod of Converse (Converse & McCarthy, 1977; Brent, 1990) for ear-lobe reconstruction can be applied (Fig. 3.6).

Fig. 3.2 Method for excision and closure of small benign lesions. (a) Simple elliptical closure; (b) circumferential excision with skin graft; (c) advancement helical flap.

Excision of Lesions

Fig. 3.3 Chondrocutaneous Antia and Buch flap for large helical-rim defects.

Fig. 3.4 Closure of large upper-third lesion of the pinna. (a) Postauricular flap. (b)Free composite skin-cartilage graft.

of

the Pinna

I5

i-

\

Fig. 3.6 Converse’s method of ear-lobule

reconstruction.

Fig. 3.7 Examples of geometric wedge and crescent excisions of the pinna.

8 Geometric wedge and crescent excisions. There are numerous ways of partially excising theearwitha predesigned geometric pattern of excisions. Examples are given in Fig. 3.7(Converse & McCarthy, 1977; Brent, 1990; Furnas, 1990). If the basic rules of plastic reconstructionareapplied,thepostoperativeappearance using any of these designs will be similar. 9 Reconstruction of a total or subtotal auricular defect utilises the same principles as for the management of congenital atretic or microtic ears. The soft-tissue defect must be well covered during the initial surgery to allow for subsequent reconstruction. Options include plastic reconstruction or an auricular prosthesis secured on an osseo-integrated framework.

Compressive gauze bolster dressings are kept in place for 7-10 days postoperatively with stitches removed at

the same time. Oral antibiotics (ampicillin and cloxacillin) aremaintainedfora period- of 1 week postoperatively. A protective dressing is to be worn during sleep to avoid ischaemic necrosis.

i~ati Early postoperative complications can involve the wound or the donor area. Faults in surgical planning result in inaccurate positioning of the reconstructed ear (Furnas,1992). Apoorly designed framework is reflected in an obviously deformed ear. Skin necrosis from random flaps, haematomas and seromas predispose to secondary infection. Bleeding and haematomaformation usually result fromrebound effects of topical adrenaline, which should be avoided. Cautious haemostasis by the use of fine-tip bipolar electrocautery is recommended. Allergic responses to dressing or conformer materials sometimes hamper graft success.

Excision of Lesions of thePinna

Rarely a pneumothorax with atelectasis might occur as a complication of obtaining rib graft for reconstruction. Late complications include failure of reconstruction as the cartilaginous framework is absorbed and organised. Secondaryreconstructionmight benecessary to improve the cosmetic outcome. Hypertrophic scars and keloids at the primary surgical site or postauricular scars rnay be a sequel to the operative trauma. Triamcinolone injection into the scarred area rnay prevent further deterioration of hypertrophic scars. Psychological considerations should not be neglected and preoperative counselling should be thorough.

s

Laser scalpel

The carbon dioxide laser offers little advantage when excising mostcutaneous lesions. For benign warty growths where the histology is not in doubt, laser vaporisation can be an alternative to simple excision. Haemangiomatous lesions

Tunable dye laser (577 or585 nm), copper vapour laser (578 nm) or argon laser (540nm) is effective in the treatment of these lesions and provides an excellent cosmetic result as an alternative to extensive local excision.

ee

17

esie

Low-power monopolar diathermy can be employed to ablate benign superficial lesions. Shave excision or cryosurgery serves the same purpose.

Intralesional excision with preservation of the epithelial lining followed by postoperative splinting and steroid injections offers a good result in the treatment of these lesions (Converse & McCarthy, 197’7).

Antia NH & BuchVI(1967) Chondrocutaneousadvancement of flap forthemarginaldefect of theear. Plast. Reconstr. Surg. 39, 472. Brent B (1990) Reconstruction of the auricle. In: McCarthy J G (ed.) PlasticSurgery, Vol. 3. Philadelphia,W.B.Saunders, pp. 2094152. Converse J M & McCarthy JG (eds) (1977) Reconstructive Plastic Surgery, Vol. 3. Philadelphia, W.B. Saunders. Furnas DW (1990) External ear. In: Jurkiewicz MJ, Krizek TJ, Mathes SJ & Ariyan S (eds) Plastic Surgery: Principle and Practice. St Louis, C.V. Mosby, pp. 171-206. Furnas DW (1992) Otoplasty. In: Peck GC (ed.) Complications and Problems in Aesthetic Plastic Surgery. New York, Gower Medical Publishing, pp. 8.1-8.13. Orton C (1986) Lesions of the pinna. In: BallantyneJ C & Morrison A Surgery-Ear. London, (eds) Rob C.+ Smith’s Operative Butterworths, pp. 1-10.

It is not necessary to excise all preauricular sinuses. Many may be kept quiescent by regular expression of retainedsebaceousmaterial. Some, however, become infected and causerecurrentpain, swelling, offensive discharge and even abscess formation when the sinus becomes blocked. Preauricular sinuses which manifest symptoms of infection should be excised. Repeated infections causing fibrosis around the sinus make complete excision more difficult, and increase the chancesof leaving behind squamous epithelium resulting in recurrence. Incomplete surgery causes similar problems.

Preauricular sinus is usually situated with its opening in front of the ascending limb of the helix. From here it extends into the subcutaneous tissue but usually remains superficial to the plane of the parotid fascia, which is an upward extension of the investing layer of deep cervical fascia. The parotid fascia also lies in the same plane as the superficial temporalis fascia, the twobeing separated by the root of the zygoma. The parotid fascia therefore serves as a useful landmark in this operation so that, whenever there is difficulty in identifying the sinus, excision of all the soft tissue between this fascia and the overlying skin helps ensure removal of all the buried squamous epithelium. As long as the surgeon stays superficial to this fascia, damage to the facial nerve is avoided. With experience, thewhitishcolour of this fascia is quite easy to recognise, However, if difficulties arise, the temporalis fascia should be identified initially andthen followed inferiorly to reachtheparotid fascia.

A history of previous infection should be confirmed. It is notuncommon to have bilateralpreauricular sinuses and thisshould be noted even if asymptomatic. If a contralateral sinus is present, bilateral excision is only offered if the above-mentioned indications exist. Complete examination of theear, including tuning-fork tests, should be performed to exclude other congenital malformations. If the patient is first seen during an acute infection of the sinus, antibiotic therapy shouldbe given and elective excision delayed until the infection has subsided. Sometimes, the patient presents with a preauricular abscess. Initial treatment would then consist of drainage via a small stab incision, Eusol dressing and antibiotic therapy. At this stage attempts at complete excision of the sinus are associated with a high rate of recurrence as the friable sinus wall is liable to tear at multiple sites, leaving residual squamous epithelium behind.

r

.

1 Anaesthesia. General anaesthesia with endotracheal intubation is requiredfor all children andanxious adults. Local infiltration anaesthesia withlignocaine 2 % with 1 in 80000 adrenalinecan beused forroutine 0.1 mg/kg adultoperations.Sedationwithmorphine body weight isgiven intramuscularly 30min before commencement of operation. Even in patients operated under general anaesthesia, infiltration with 2ml of the lignocaine-adrenaline solution isuseful to promote 18

Excision of Preauricular Sinus

19

Fig. 4.1 An elliptical incision around the opening of the sinus.

Fig. 4.2 Dissection of the anterior skin flap.

vasoconstriction and ensure arelatively bloodless operative field. 2 No prophylactic antibiotic is required when operating on a non-infected sinus. 3 The patient is placed in a supine position with head turned away from the side of operation. 4 A small amount of methylene blue is injected gently into the sinus with a blunt needle at the start of the procedure. The blue discoloration of the sinus tract will warnthe surgeon if this is breached. Injection with excessive pressure may rupture the sinus and the resultant leakage of dye will discolour theoperative field, making the procedure more difficult.

skin, leaving the subcutaneous tissue containing the sinus tract undisturbed. 2 Withan assistant providing goodretraction using skin hooks, the exposed subcutaneoustissue is dissected off the underlying parotid fascia. If there is difficulty in identification, the incision can be extended for a further centimetre superiorly to identify the temporalis fascia, which is then traced inferiorly to the parotid fascia. One should always be on the lookout for the bluish coloration of the methylene blue in the sinus. 3 The elliptical island of skin around the openingof the sinus together with the dissected subcutaneous tissue is then held with Allis tissue forceps (Fig. 4.3). Dissection is continued posteriorly until theperichondrium of the helical cartilage is reached. It is not uncommon for the fundus of the sinus to be densely adherent to the perichondrium and a segment of the latter should be excised together with the whole specimen. 4 Meticulous haemostasis must be maintained throughout the whole procedure by electrocoagulation of all bleeding points so as to provide optimum visualisation of residual squamous epithelium and the blue coloration of the sinus tract.

Incision

An elliptical incision is made around the openingof the sinus, as shown in Fig. 4.1. This incision can be extended superiorly and inferiorly as indicated, depending on the individual situation. Procedure in stages 3. Using a scalpel with a no. 15 blade, the anterior skin flap is dissected for about 2cm (Fig. 4.2). The posterior flap is elevated to the perichondrium of the helical cartilage. Care should be taken to limit the elevation to the

Closure/drainage/dressing

The wound is closed with interrupted 4/0

prolene su-

Fig. 4.3 Skin retracted and tissue held with Allis tissue forceps.

Fig. 4.4 Closure with prolene sutures.

tures (Fig. 4.4). If there is a risk of oozing at the end of the procedure, a twisted nylon drain is placed at the inferior end of the wound. A pressure bandage is then applied.

Allternatiu

ostoperative management The dressing and drain (if used) are removed after 24 h. A fresh gauze dressing is applied. Stitches are removed after 1 week.

ompllications l Haematoma -when haemostasis is inadequate and drainlpressure bandage not used. 2 Abscess-when the haematoma becomes infected. 3 Recurrence -when excision of the squamous epithelium of the sinus tract is incomplete; these cells collect underthe skin and breakthrough, resulting in sinus formation.

A supra-auricular approach has been described (Prasad et al., 1990) in which the sinus is approached via a supra-auricular incision, the temporalis fascia routinely identified and all tissue superficial to this removed. The use of the operating microscope has also been used to enhance the identification and dissection of the sinus tract (Raman, 1990).

Prasad S, Grundfast K & Milrnoe G (1990) Management of congenital preauricularpitand sinus tract in children. Laryngoscope 100, 320-1. Rarnan R (1990) Excision of preauricular sinus. Arch. Otoluryngol. Heud Neck Surg. 116, 1452.

a te stose

s

KEVIN J. FEELY

Relevant anatomy Indications for surgery for both osteomas andexostoses of the external auditory canal (EAC) relate to the following: 1 canal obstructive symptoms: (a) recurrent wax impaction; (b) water entrapment; (c) conductive hearing loss; 2 recurrent otitis externa; 3 access for unrelated surgery, e.g. stapedectomy. While exostoses arecommon,the need for surgical treatment is uncommon. Relative contraindications include the following: 1 asymptomatic lesions; 2 advanced age or general debility; 3 involvement of an only hearing ear.

Exostoses and osteomas are distinct and separate conditions involving the tympanic plate(Fig. 5.1).This is a Cshaped bony plate larger and thicker anteriorlyand inferiorly. The plate is open superiorly at the notch of Rivinus. Bony osteomasarerare and typically solitary and unilateral. They are of variable size, presenting at any age in either sex and pedicled in the lateral canal at the tympanosquamous or tympanomastoid suture. Smaller lesions are not uncommon and may arise in the deep canal,oftenadjacent to thetympanicannulus. These smaller lesions rarely cause problems. Bony exostoses, on theotherhand,arecommon, typically bilateral, symmetric, sessile thickenings of the tympanic plate, occurring predominantlyin adult males. Size of individual lesions varies, but usually the anterior exostosis is the larger one.The sessile thickening extends from the tympanic annuluslaterally to involve the whole width of the plate. Theextent of surgery is limited by thetemporomandibularjoint (TMJ) anteriorly,the facial nerve posteriorly and the eardrum medially. Complications of surgery relate to these structures and in particular the variable relationship of the facial nerve to the posterior tympanic annulus is of great importance. In at least onethird of cases, the facial nerve will come to lie lateral to the plane of the tympanic annulus in its vertical descent to the stylomastoid foramen. The nerve lies closest to the posterior wall of the deep bony canal adjacent to the posteroinferior quadrant andmay be separated from the external canal by only 2-4 mm in this region (Litton et al., 1969; Williams, 1988). It is for this reason that the surgical approach should be designed to give optimum

In the case of exosfoses where staged bilateral surgery may be necessary, it is simply a case of deciding which is themostproblematicearfor initial surgery. Regular preoperative suction ear toilet and possible topical antimicrobial agents may be required to resolve any associated otitis externa. The ears should be kept dry. For osteomas it may be possible on initial examination to determine the locationand thickness of the bony pedicle. This may influence choice of permeatal or endaural approach as well as the use of local or general anaesthesia. Specific preoperative investigations are limited to a baseline audiogram. Radiological assessment and bacterial culture are unnecessary as a routine. 21

22

Chapter 5 ably occurs (Fagan, 1990). Good exposure is essential for the preservation of the delicate external canal skin over the exostosis. Procedure

Fig. 5.1 Normal tympanic plate. Note thickness o f tympanic plate anteriorly and interiorly.

access posteriorly, and drilling should never extend posterior to the vertical plane of the posterior annulus.

Operative tec Preparation

1 General anaesthetic (GA) (local anaesthetic (LA) may be adequate for a small osteoma). 2 Antibiotics are not routinely used. 3 Thepatient is positioned supine onthe operating table, with 20" of head-up tilt. The head is turned away from the surgeon, with the operated ear uppermost. 4 Infiltration withmarcaine 0.5% withadrenaline 1:200000 aroundtheexternalmeatusandpostauricular region is performed after anaesthetic induction and prior to scrubbing and draping.

1 Thepostauricular incision extends well forward superiorly to allow exposure of the root of the zygoma. The incision continues down to 6 o'clock and is taken A deep to theperiosteumwithcuttingdiathermy. subperiosteal flap is raised anteriorly with a Freer's or Howarth elevator to expose the lateral bony meatus. A self-retaining retractor is placed and haemostasis achieved. 2 The lateral external canal skinis mobilised circumferentially from the bony canal with a Freer's and Rosen elevator to create a sleeve of skin. This sleeve is developed medially as far as theexostoses permit. The externalcanalskin sleeveis transected completely asfar medially as possible and reflected anterolaterally with the pinna under the self-retaining retractor. This step allows good exposure of the entire circumference of the bony meatus, allows access to the lateral aspect of the exostoses and protects the lateral canal skin from-accidental injury from the high-speed drill working in the deep canal (see Fig. 5.2). 3 The anterior exostosis is approached first as it is the largest and furthest removed from the facial nerve. Removal of the exostosis allows easy access to and improved exposure of the posterior lesion where drilling puts the facial nerve theoretically at risk.

Incision

Osteomas

These can often be removed permeatally by snapping the fine pedicle with light pressure applied tothe osteoma with aFreer's knife. For a thicker pedicle which does not snap easily, a fine-gauge or small cutting burr may be necessary to cut across the pedicle. In the rare case of a large osteoma medial to the canal isthmus, it may be necessary to enlarge theisthmuswitha drill from a postauricular approach (Sheehy, 1981-82). Exostoses

The author always uses a postauricular approach. This allows wide access to the whole of the external canal, especially anteriorly where the larger exostosis invari-

__.

Fig. 5.2 Postauricular approach to right ear.

Excision of Canal Osteomas and Exostoses

23

Fig. 5.3 (a) Maximum length of lateral canal skin sleeve is reflected out of canal. (b)Anterior exostosis is ‘cored’ out.

Theanterior exostosis is ‘cored’ out using a highspeed drill and medium cuttingburr. No attempt is made to elevate thethin overlying canal skin, which is protected by maintaining a thin bony cortex as the exostosis is hollowed out. Working from within the exostosis a gutter is created superiorly and inferiorly in the thickest areas of thetympanic plate, withthe drillworking between these guttersbackwards and forwards over the prominence of the TMJ, all the time looking for the bluish sheen of the TMJ through the hard white exostotic bone to avoid entering the joint. As one proceeds medially the white line of the anterior annulus indicates the medial depth of drilling. Once these twolandmarksare identified, the exostosis is continuallythinnedsuperiorly and inferiorly until an egg shell veneer is all that is left. This cortex is then snapped off and either removed or reflected medially withthe still attached overlying skin to form an additional protective layer for the eardrum (Fig. 5.3a). Should there still be a thin lip of bone obscuring the anterior drum, this may safely be taken down with afine sharp bone curette or small diamond burr. The author prefers a curettebecause in this area the eardrumis most at risk of perforation from asmall burr if it skids off the bony lip. 4 Some authors suggest approachingthe smaller remaining posterior (and possibly thethirdsuperior) exostosis ina similar coring-outfashion.The author finds that, once the large anterior exostosis is removed completely, there is sufficient exposure to elevate the posterior canal skin medially and forward to add another protective layer to the eardrum (Fig. 5.3b). The remaining posterior exostotic prominenceis then simply drilled down to a vertical plane in the line of the posterior annulus. This plane marks the posterior extent of

drilling so as to protectanylateral underlying facial nerve. The entire circumference of the drum should now be easily seen. 5 Theanteriorandposterior deep meatalskin flaps overlying the drum are now lifted up and incised along their length witha sickle knife or microscissors to allowredraping over the widened deep bony canal. Semicrushed gelatin sponge strips are used to pack the skin of the deep canal down on to its new bed. The lateral skin sleeve is freed from the self-retaining retractor and likewise incked longitudinally and laid over the lateral bony meatus. This is held in place with one or two Pope sponge otowicksintroducedintothecanal permeatally. Water-soluble antibioticlsteroid drops are used regularly to moisten and expand the wicks. Closure/drainage/dressings

The postauricular incision is closed in layers with 3/0 chromic gut and nylon sutures. No drains are used but a pressure dressing is applied for 48 h.

Postoperative management The patient is reviewed at 7 days when the sutures and canal dressing are removed, and the canal filled with an antibiotic ointment. Completehealing of the canal takes 4-6 weeks.

Compiications 1 Inadequate removal. 2 Perforation of tympanic membrane (TM). 3 Canal stenosis.

24

Chapter S

4 Facial palsy. 5 Deafness: (a) conductive from ossicular or drum injury; (b) sensorineural injury fromtransmission of drill vibration through the ossicular chain.

Acknowledgements The author’s technique as described was developed from the work and teachings of Dr Paul Fagan and Dr Barry Scrivener. The authorwishes to acknowledge their great contribution to his otological education and to express his sincere gratitude.

References Fagan PA (1990)The surgical removal of aural exostoses. J. Otoluryngol. Soc. Aust. 6, 220-1. Litton W, Krause C, Anson B & Cohen W (1969) Relationship of facial canal to the annular sulcus. Laryngoscope 79, 1584-604. Sheehy JL (1981-82) Exostoses and osteomata of the external auditory canal: a report of 100 patients. J.Otolaryngol Soc. Aust. 5,437. Williams B (1988) TEe relationship of the facial nerve to the tympanic annulus of the external auditory canal.J.Otolaryngol. Soc. Aust. 6, 95-6.

ROBERT E. QUINEY

llndications 1 Meatoplasty is most frequently performed at the time of modified radical or radical mastoidectomy. One of the major reasons for the failure of a mastoid cavity to become a dry skin-lined bowl is poor meatoplasty technique. A narrow entrance to the mastoid cavity gives poor ventilation to the skin of the mastoid bowl and poor access for suction clearance of accumulated debris. Poor ventilation of a skin-lined cavity leaves the outer skin layers moist, which leads to increased surface-layer desquamation. This, in a moist environment, quickly becomes infected. 2 Collapsed ear canals. This can occur with ageing. The pinnacontinues to slowly enlarge throughoutadulthoodand,astheconchal well expands, this hasthe effect of collapsing the cartilaginous (lateral) partof the ear canal to a vertical slit. A collapsed cartilaginous canal can also occur some years after a postaural incision for previous mastoid or myringoplasty surgery. Whenthe periosteum of the mastoid that is adherent to the posterior ear-canal skin has not been sutured back, the posterior canal wall may migrate forwards. 3 Acquired meatal stenosis: (a) following chronic inflammation, e.g. chronic otitis externa; (b) idiopathic; (c) postsurgical meatal stenosis; (d) exostoses or isolated osteoma of the ear canal. 4 Congenital meatal stenosis of varying severity. This may be unilateral or bilateral, or associated with developmental abnormalities of the pinna and the middle and inner ear.

Differing surgical techniques are required for all these various types of stenosis. The surgical methods used can be usefully divided into two groups, dependiag on the presence or absence of normal deep meatal skin that has the ability for lateral migration: 1 In meatoplastyformastoid surgery, collapsing ear canals and some forms of acquired meatal stenosis, e.g. exostoses, chronicotitisexterna and minimal deep meatal stenosis, there is some normalmeatalskin present. If this is preserved, then migrating epithelialisation will occur after meatoplasty to cover the exposed soft tissues and bone. 2 In severe deep meatal stenosis where there is no normal deep meatal skin or in congenital meatal stenosis (where meatalskin has never formed), new skin must be brought into the ear canal, preferably by means of skin flaps rather than asplit skin graft, forepithelialisation to have any chance of success.

Preoperative mana No specific preoperativemanagement is required for simple meatoplasty at the time of mastoid surgery. A lateral oblique mastoid X-ray showing the size of the mastoid air-cell system helps in planning for a large or small meatoplastyandthe type of skin incisions, endaural or postaural. In acquired deep meatal stenosis a coronal CT scan will help define the presence of a middle ear cleft, the presence or absence of a normal eardrum, the depth of stenosis and its relationship to the tympanic membrane (TM) *

26

Chapter 6

Relevant anat The lateral third of the external auditory canal(EAC) is formed by a cylinder of cartilage in continuity with the cartilage of the concha. Thiscartilage is covered by thick hair-bearing skin. The inner two-thirds of the EAC is formed by the bone of the tympanic ring, into which fits the cartilage of the outer third as two cups, fitting one into the other. Inthis transitional region the skin of the earcanal is non-hair-bearing, much thinner and has migratory properties. In the deepest third of theear canal migrating skin is directly adherent to the underlying bone and the skin is at its thinnest. Successful meatoplasty needs to addressboththe bony and the cartilaginous part of the ear canal,and the technique to achieve success in these two regions is different.

Operative tec~nique Meatoplasty at the time of mastoid surgery

Preparation

Normally general anaesthesia with patient supine, head rotated and supported on a head ring. Infiltration with a vasoconstrictor, such as adrenaline, at the begining of the operation will have lost its effect whenthe time comes to perform the meatoplasty.After finishing all the bone work, infiltrate the whole of theconchal well between skin and cartilage with 1 in 80000 or 1 in

Fig. 6.1 (a) Relationships of mastoid bowl to pinna. Lateral projection. (b) Conchal well cartilage. Excision margins for single flap meatoplasty. (c) Inferior-based single-flap meatoplasty. (d) Posterior-based single-flap rneatoplasty.

200000 adrenaline. This not only provides some haemostasis for what is often a ratherhaemorrhagic procedure but also helps separate the tissue planes for ease of dissection. Once the mastoid bowl is lined and mostly packed with dressing, then the meatoplasty can be performed without disturbing the mastoid or middle ear tissues. Incision

With either a postaural or endaural incision, allow the pinna to fall back to its naturalposition and use a marking pen to plan the correctsize of meatoplasty. The annulus at the tympanic membraneis often superiorand posterior to the position of the meatus entrance when the ear is inspected from the side, and the surface landmark of the mastoid bowl, attic and antrum is often over the root of the helix or even over the antihelix of the pinna (see Fig. 6.1a). It is cosmetically disfiguring and unacceptable to remove a large amount of the root of the helix so an adequate meatoylasty must be marked out in the well of the ear with only minimal disruption to the root of the helix. Use one or twoneedles entering theskin of the well of the ear, passing through the pinna posteriorly, to mark out from behind how much soft tissue and cartilage needs to be excised via thepostaural incision (Fig. 6.1b). The cartilage is thickest furthest away from the meatus and is most easily identified here by cutting with a knife through the softtissues to the cartilage with one finger held in the concha. Once the cartilage is incised,

Meatoplasty the free edge of the cartilage canbe held with skin hooks while small sharp-pointed scissors dissect the skiQ crf the conchal well andposteriorcanal wall of themeatus away from the cartilage and the underlying soft tissues. There is always a temptation to remove too little cartilage but often a good half of the conchal cartilage must be removed to provide a good-sized rneatoplasty, which with time will inevitably become smaller. It is easiest to remove the cartilage as a single piece before cutting the skin flaps. Theauthor prefers to use a single skin flap based either inferiorly (see Fig. 6.lc), which drapes over the facial ridge, or posteriorly, which runs into the posterior aspect of the mastoid bowl (see Fig. 6. Id). The threeflap and five-flap Portman meatoplasty is well described and a variation with four or five flaps extending far out into the conchal well is shown in Figs 6.2 and 6.3. With a single-flap technique there is often quite a lot of exposed cartilage at the edge of the rneatoplasty and thisshould be trimmed back 1-2mm, preserving the overlying skin, which can then drape over the exposed cartilage edge. This is best done using skin hooks and small sharp-pointed scissors to remove the cartilage piecerncal. The removal of proud cartilage is particularly important if theroot of the helix has been exposed. Sometimes the root of the helix will run right across the concha to end almost at the antitragus, and this inevitably means part of this cartilage is cut through.Thiscartilage is always thick andanextra

Fig. 6.3 (a) Skin incision for five-flap meatoplasty. (b)Classic three-flap meatoplasty skin incision.

27

millimetre or so must be removed to allow the skin to drape over and cover the bare area of cartilage. If the skin does not fold over this area neatly, a single suture can be used to approximate the skin edge and

Fig. 6.2 Skin flaps for four-flap meatoplasty.

28

Chapter 6

thereby close off the exposed cartilage of the helix root. With an endaural incision which has been made between the tragus and the root of the helix, a posteriorly or inferiorly based conchomeatal flap can be dissected out in a similar fashion. However, the cartilage in this surgical approach is often more easily identified along the superior incision of the meatoplasty flap, which is inevitably in continuitywiththeendaural incision. Again, fine sharp-pointed scissors are used to carefully separate thecartilage and underlying soft tissue from the meatal and conchal well skin that will be used to fashion the meatoplasty flap. In planningmeatoplasty incisions inthe skin, it is important to remember the simple rule of random-pattern flap design, where, to avoid significant necrosis of the flap tip, the base: length ratio should be approximately 1:1. With a single flap that is posteriorly based it is very easy to exceed this ratio if the base of the flap is made too narrow by trying to avoid the root of the helix (for this reason an inferiorly based flap is often preferable to one based posteriorly). The deep meatal skin is the migrating epithelium and this must be preserved on a flap with an adequate base if it is to survive and proliferate. In the case of a three-, four- or five-flap meatoplasty,base: length ratio isless important,but again meticulous care must be taken to preserve skin from thedeep meatus, which is then used to fold into the mastoid bowl and promote epithelialisation. Closure, drainage, dressings

Once the meatoplasty has been made and haemostasis secured, the pinna is placed back in its normal position. Packing of themastoid bowl continuesthroughthe meatus itself ensuring that the skin flaps lie on top of any mastoid bowl lining, such as temporalis fascia. The packing of themeatusmust be firm enough to hold the flaps in position and also at its most lateral to hold the meatus wide open at the entrance. Tagging sutures of 410 catgut can be used to hold skin flaps in position but are not used routinely. They should not be used to hold open a meatal flap that fails to stay in position because inadequate cartilage and soft tissue have been removed. With an endaural incision the skin of the endaural incision can be loosely closed and there is no need to continue this closure into the meatus. Leaving the endaural incision open at its most inferior point and then packing themeatuswith dressing also helps to produce a larger meatoplasty. When a postaural incision has been used and a large meatoplasty created, the posterior edge of the meatoplasty will often come close to thepostaural

sulcus. In such cases (where it is knownthere is the possibility of a large mastoid cavity), thenan initial skin incision 1cm behind the postaural sulcus makes closing the wound easier. Periosteum over the mastoid canbe sutured to the soft tissue of the pinna behind the edge of the meatoplasty. This will not only hold the meatoplasty open but provides a sound two-layer closure, reducing the chance of a postoperative postaural fistula occurring. The author prefers to leave a bismuth, iodoform and paraffin paste (BIPP) pack in place for 4-6 weeks witha large meatoplasty technique. Not only does this allowthe meatoplastyentrance to stabilise butitalso allows epithelialisation of a large mastoid bowl to proceed without disturbance. Complications

If cartiiage is exposed, postoperative perichondritis is possible, particularly if therewas an active mastoid infection or if inadequatehaemostatishas been obtained. Prophylactic postoperative antibiotics should be used in such cases. Granulation tissue at the free edge of the meatoplasty incision is more likely if exposed cartilage has not been well trimmed back. Persistent granulations at the entrance to the meatus can be either removed or cauterised with silver nitrate. If exposed cartilage persists, this should be trimmed back asa minor procedure underlocal anaesthetic (LA).Persistent granulations also result in increased cicatricial scarring, which with time will reduce the size of the meatoplasty entrance. Meatoplasty for collapsed ear canals

Indications

Occasionally a collapsed ear canal requires a meatoplasty to prevent impacted wax forming, to prevent recurrent otitis externa or to allow fitting of an adequate hearing-aid. Operative technique

Normally general anaesthesic (GA),with patient supine, head rotated and supported on a head ring. If the deeper part of the canal is normal and no bone work is required, this procedure can be performed under LA. An endaural split may or may not be necessary for access. The surgical method is not very dissimilar to that of meatoplasty at the time of mastoid surgery. A marking pen isused to plan the size of meatoplasty and infil-

Meatoplasty tration separates the skin from the cartilage in the region of theconchal well.Because only a relatively small meatoplasty is required, a posteriorly based skin flap is the ideal. Cut along the superior and inferior incisions down to cartilage within the conchal well and, using skin hooks for retraction, find the cartilage where it is thick in the posterior part of the concha. The superior and inferior incisions can thenbe followed forwards and medially into the meatus, joining together at the end of themeatalcartilage deep withintheearcanal.The whole posteriorly based skin flap can then be separated from cartilage and lifted out of the way to allow direct access to theexposed cartilage. This can thenbe excised, along with the underlying soft tissue, back to the mastoid cortex bone if required. The skin flap is then repositioned and held in place with a BIPP pack for 2-3 weeks. Meatoplasty for mild meatal stenosis

Indications

Chronic otitis externa, previous ear surgery, previous fracture to theearcanal and radiotherapy may all cause mild meatal stenosis, in which the bony and cartilaginousmeatusarebothnarrowed. Cases of stenosis following radiotherapyshould be considered for surgery as a last resort due to possible the postoperative complication of osteoradionecrosis occurring. In the case of mild meatal stenosis there is normally a small amount of deep meatal migrating skin present and it is therefore unlikely that an external skin flap will be required to be brought into the meatus to provide new skin. Operative technique

An endaural or postaural approach can be used. The endaural approach has the advantage of minimal disturbance to thepinnaposition and allows anapproach directly onto the site of the stenosis so that the cartilaginous and bony meatoplasty canbe seen in direct relationship to each other. After an endaural incision, plan a large posteriorly based conchomeatal flap down towithin 5-8 mm of the annulus.Thisshould be lifted well out of the bony meatus and held away by a small two-pronged selfretaining retractor so that it is not damaged by highspeed drilling for the bony meatoplasty. If there is gross bowing of the anterior canalwall, this should be drilled back first via a separate skin flap lifted off the abnormal anterior canal bone. The skin flap is

29

protected by silver foil during drilling, taking care not to enterthe capsule of thetemporomandibular joint (TMJ). This occurs with ease in meatoplasty following a fractured tympanic ring, particularly if the head of themandiblehas been forced backwardsduringthe injury. The posterior bony meatoplasty should be along the full length of the meatus from annulusto spine of Henle. The latter should always be removed to allow the soft tissues to fall back adequately. It is important to drill from medial to lateral. Drilling can proceed until mastoid air cells are reached but these should not be opened and should ideally be left with a thin-plate of bone over them. Drill witha high-speed cuttingburr, which is irrigated to prevent sequestered bone being left behind, as this will prevent skin growing back over it with any ease. The cartilaginous meatoplasty mustinvolve removing cartilage of the lateral part of the external canal butnot necessarily cartilage of the conchalwell, unless the canal is collapsed at its entrance. The conchomeatal flap is cleared of cartilage and soft tissue and returned to the canal. Any large area of exposed bone can be covered by temporalis fascia, on which the conchomeatal flap then rests, and the flap is held by packing of the canal with BIPP for 2-4 weeks. Meatoplasty for deep and severe meatal stenosis

Indications 1 Conductive hearing loss.

2 Congenital ear anomalies. In these cases there is no deep epithelial skin with migratingproperties and askin flap musttherefore be rotatedintothecanal. Such cases present a difficult challenge to the otologist because: (i) there may be no tissue plane between the tympanic membrane (TM) and the core of scar tissue forming the stenosis; and (ii)there may be abnormalities of the ossicular chain and middle ear cleft, and removing the stenosis of theearcanal may make little difference to the conductive hearing loss. The longer the length of the stenosis, the poorer the prognosis from surgery. Coronal CT scan may be very useful in assessing the length of the stenosis in an ear canal where there areno useful landmarks. The decision to operate is different for unilateral and bilateral cases. In the latter, with a markedbilateral conductive hearing loss, successful meatoplastycanallowthepatient to dispense with hearing-aids. Alternatively, an adequate

30

Chapter 6

ear canal allows a hearing-aid fitting to the ear rather than use of a bone conductor, especially of value if there is also a sensorineural hearing loss. In unilateral cases, patients need to be fully informed about the chances of success and failure. Congenital unilateral cases in children are rarely benefited by surgery. The option of bone-anchored hearing-aids (BAHAs) should be considered before embarking on such surgery, which may require more than one revision for success, particularly if there is also middle ear disease/abnormality. Thecombination of BAHA and bone-anchored prosthetic ear will almost certainly provide a better result than multiple ear operations for congenital meatal atresia with middle ear abnormalities. Operative technique

Endaural or postaural incisions can be used, or these incisions can be joined together to lift the whole pinna inferiorly to allow skin flaps to be rotated in from both in front and behind the pinna (see Fig. 6.4). If the pinna is abnormal, these incisions will have to be modified to the individual case. Skin flaps must be planned to ensure that they are long enough to reach close to the annulus, and thatthey have an adequate base :length ratio so that the tipof the flap does not necrose. They must also allow theresulting defect to be closed in a cosmetically acceptable way. Split skin alone does not do well in severe meatoplasty cases and, toensure asmuch covering of the ear canal as possible, two skin flaps may need to be rotated into the

ear canal. Using the endaural approach, a further flap of skin can be made by using a rotation flap of the conchal well but this seldom reaches the annulus unless some of the lateral meatal skin can be saved. Superiorly based anterior and posterior skin flaps are much thicker than meatal skin even after thinning, so the bony meatoplasty must be performed to its maximum limits to allow the flap to sit in the canal with space for packing. Asharp edge between canal and mastoid cortex should be drilled away so that the skin flap falls smoothly into the ear canal. Once the flaps have been cut and rotated into position, the pinnaneeds to be returned to its normal position. If the pinna covers the skin flap, as inevitably occurs with a posterior flap, then the part of the flap buried by the pinna needs to be de-epithelialised. In the case of an anterior flap, this can often be broughtintoposition betwea theendaural incision, so remaining uncovered. Temporalis fascia can be used to line large areas of exposed bone and will promote epithelialisation from the flap to therest of the canal.The authorprefers to use temporalis fascia asa lining to cover exposed bone rather than a split-skin graft, which rarely ‘takes’ directly over cut bone. Closure, drainage, dressings

Good haemostasis is required to prevent haematoma and secondary infection. A Silastic roll is placed in the canal at the end of theprocedure before packing in order to prevent adhesions developing across the deep

Fig. 6.4 (a) Posteriorly situated superiorly based rotation flap for severe meatal stenosis. (b) Anteriorly situated superiorly based rotation flap with endaural split for severe meatal stenosis.

~ ~ a t o p l a s t y 3I canal. A BIPP pack is inserted firmly into the canal and ideally should be changed underashort GA at 3-4 weeks and replaced with a new pack. This allows the oedema of the skin flaps to settle before repacking with a firmer pack for another 3-4 weeks. If the meatus has not become stable by this time, it is likely that restenosis will occur slowly no matter what is left in the canal to prevent it.

Postoperativ Postoperativeantibioticsshould

be employed in any

case of meatoplasty associated with: (i) extensive cartilage resection; or(ii) infected mastoid cells or cavity. This is in order to prevent perichondritis or cellulitis, both of which increase the likelihood of a stenosis. After removal of thepack,granulation tissue may require local cauterywith silver nitrate. An antibiotic earspray such asOtomise used once daily helps keep the canal free of infection until healing is complete.

Tympanostomy Tube PETER J.ROBB

introduction Theinsertion of tympanostomytubes (‘grommets’) is now the most frequently performed surgical procedure in children in England and Wales. Surgery for serous otitis media (‘glue ear’) should be considered only after failure of conservative management or natural resolution over a period of 3 months or more (Robb, 1993).

indications 1 Chronic secretory otitis media of childhood. Surgery is indicated for persistent effusion confirmed by otoscopy, tympanometry and audiometry: (a) bilateral symptomatic disease persisting for3 months or more with hearing loss 32SdB HL; (b) unilateral or bilateral disease complicated by severe atelectasis, recurrent and/or painful acute otitis media or symptomatic hearing loss (speech, language or learning difficulties); (c) chronic secretory otitis media with underlying sensorineural hearing loss, to facilitate amplification with hearing-aids; (d) cleft lip and palate-at the time of palatal repair. 2 Recurrentacuteotitis media, usually in younger children (c2years at age of onset and often associated with maturational IgA deficiency). Frequent attacks that arepoorlycontrolled by antibiotics,with associated perforation(s),purulentotorrhoeaor febrile seizures may require surgery. 3 Acute otitis media with acute facial nerve palsy due to a dehiscent Fallopian canal, or persistent suppuration, pain and pyrexia despite adequate antibiotic treatment. 4 In adults,serousotitis media may follow an acute suppurativeotitis media or sinusitis or be associated

with allergic or vasomotor rhinitis. It is mandatory to exclude nasopharyngealcarcinomaas an underlying cause of middle ear effusion in an adult: this may necessitate examinationunderanaesthetic (EUA) and biopsy of the nasopharynxat the time of grommet insertion.

Contraindications 1 General considerations including fitness for surgery and for anaesthesia apply. 2 Surgery is contraindicated to an only hearing ear and this should apply to even a minor procedure such as myringotomy and grommet insertion forfear of producing an irreversible hearing loss. 3 Local infection in the external ear canal is a relative contraindication. 4 Anatomical constraints may make grommet insertion impossible if the external meatusis abnormally narrow. If surgery is essential then a postauricular approach to the tympanic membrane (TM) is recommended.

Preoperative management History 1 Severity of symptoms should be assessed with respect to hearing loss, otalgia, recurrent acute otitismedia and speech and language delay. 2 It is important to consider the possibility of a mixed hearing loss, andenquiry relating to the pregnancy, perinatal period and general development is important. A family history of hearing loss should be considered. 3 Associated nasal obstruction, whether due to allergy or adenoidal hypertrophy, is important and will affect

Tymp~nostomyTabe Insertion whether or not surgery to the adenoid or turbinates is appropriate at the time of grommet insertion. Repeated tonsillitis is relevant if the attacks invariably precede documented attacks of acute otitis media. Examination

Examination of theears, nose, throatand neck is followed by pure-tone audiometry (PTA) and tympanometry. For children under the age of about 34 years, hearing assessments may need to be made by distraction testing or conditioning. These facilities are not routinely available in the ENT clinic and referral to an audiology assessment clinic will be required. Hearing assessment may be repeated on more than one occasion over a 3-6-month period to allow spontaneous resolution of the middle ear effusion to occur (Leeds University, 1992). Thresholds greater than 25dE HL in both ears represent a significant loss of hearing in the context of serous otitis media. Tympanometric measurements may show a lack of middle ear compliance witha flat type E reading or marked negative middle ear pressure (type C2 curve). Clinical examination of the nose andpharynx may be supplemented by radiological examination of the postnasal space and sinuses if indicated.

Fig. 7.1 Middle ear anatomy (adapted from Mawson & Ludrnan, 1979).

33

Figure 7.1 depicts diagrammatically a vertical section through the right middle ear cavity to show the structures at risk during myringotomy (Mawson & Ludman, 1979). Figure 7.2 shows the right tympanic membrane(TM) as viewed through the operatingmicroscope ( X10). The myringotomy incision for inserting agrommet in the anteroinferiorquadrant is line ‘a’. Line ‘b’ outlines the incision for aspiration of pus from an acutely infected middle ear. The T M bulges laterally and this is generally the region of maximum dependence. Special care is required to avoid damage to structures as shown in Fig. 7.1.

Operative t Preparation

Anaesthesia For surgery on young children, general anaesthesia is preferred: IV induction is through skin where topical anaesthesia, (e.g. eutectic mixture of local anaesthetics (EMLA) or Ametop), has been applied for the recommended period of time. IV thiopentone or propofol with lignocaine followed by gaseous maintenance with nitrous oxide and oxygen via a laryngeal mask (size 2 or 2.5), using an Ayres T-piece breathing system, is suitable for most children. A recent innovation is the Humphrey’s circuit which meets therequirements of paediatric anaesthesia with intrinsic gas scavenging. A

Fig. 7.2 Right tympanic membrane viewed through microscope (X 10). See text for explanation.

34

Chapter 7

laryngeal mask may not be appropriate for very small children, when a face mask or endotracheal tube will be indicated (Johnston et al., 1990). Routine monitoring of oxygen saturation, end-tidal carbon dioxide, ECG and non-invasive blood-pressure measurements aremade throughout the procedure. Peroperative diclofenac, 1mg/kg is administered rectally asroutine analgesia except where relatively or absolutely contraindicated (e.g. asthma). This regimen is adapted where other procedures are performed under the same anaesthetic; for adenoidectomy, tonsillectomy andother procedures, endotracheal intubation will be required. In adults, a broadly similar technique for induction and maintenance of general anaesthesia is employed. Where no otherprocedure is performed at thesame time, a size 3-4 laryngeal mask is used. A volatile agent is added to the gases for maintenance of anaesthesia, delivered via a circle system withcarbondioxide absorber. Alternatively, continuous IV infusion of propofol 6-10 mg/kg/h may be employed. Peroperative analgesia is with fentanyl 1mcg/kg. Where other procedures are performed under general anaesthesia, intubationwithaRAE-pattern cuffed tube may be necessary. In adultswhennootherprocedure is required, myringotomy and insertion of ventilation tube(VT)may be performed under local anaesthesia with or without sedation. Topical anaesthesia, (e.g. EMLA or Ametop), is applied to the T M and after the recommended period of time a painless myringotomy may be made. In an anxious adult, midazolam or propofol may be administered intravenously to provide sedation, such that verbal contact with the patient is maintained. Continuous IV access and monitoring as for general anaesthesia is recommended if sedation is employed. Prophylactic antibiotics/steroid cover Systemic prophylactic antibiotics are not routinely required.Whereacardiac lesion exists, prophylaxis is recommended as laid down in the British National Formulary (BNF)guidelines. Systemic and topical antibiotics are recornmended postoperativelyfor 1 week if infected middle ear fluidis found at thetime of myringotomy. (These may be modified depending on subsequent bacteriological findings.) Corticosteroid cover may be indicated where systemic steroids have been administered for otherreasons (e.g. asthma) within 6 months prior to surgery. Patient positioning Thepositioning

is the same foradultsand

children,

whether under general or local anaesthesia. The patient is positioned supine on the operating table with the head resting on a head ringto prevent movement. The head is turned away from the operator toprovide the optimum view of the T M withtheoperating microscope. The head should not be turned without the assistance and supervision of the anaesthetist in order to prevent the laryngeal mask or endotracheal tube (ET) from becoming displaced with subsequent hypoxia of the patient. Whereotherproceduresarecarried out underthe same anaesthetic, the insertion of grommets is usually performed first. Operative procedure Figure 7.3 showsthe stages of myringotomy and grommet insertion. With the patient positioned as described above, the T M is viewed with the operationed microscope set at x 10 through an aural speculum. The ear canal is cleaned of wax and skin debris, taking care not to cause trauma or bleeding to the delicate skin of the canal wall. The view obtained is as shown in Fig. 7.2. A disposable myringotome blade is preferred as the sharpness of the blade is guaranteed. A blunt blade will tend to tear and traumatize the TM. Figure 7.3a shows the approach to the T M seen in vertical section. The incision proceeds centroradiallyintheanteroinferior quadrant,takingcarenottoscratchthe middle ear mucosa, which may cause significant bleeding. Following the incision, fluid is aspiratedfromthe middle ear (Fig. 7.3 b), using Zoellner a suction piece with a size l 8 fine end attached. It is not essential to aspirate every last portion of fluid fromtheear, andcontinuous suction may cause bleeding, vacuum damage or noise-induced cochlear damage if prolonged. A Teflon Shepard-patterngrommettubewithout wire is held with aural crocodile-ear forceps so that the grommet is angled with its leading edge pointing forwards (Fig. 7 . 3 ~ ) .At this stage, only the leading edge of thegrommet is placed in themyringotomy 1nclsIon. Thegrommet is then gently manoeuvredintothe incision (Fig. 7.3d), using an Ironside needle. This needle is not too sharp to impale the grommet, but fine enough to gently place the grommet in the incision with the minimum amount of pressure on the TMand ossicular chain. The grommet is then in place, and if necessary, the lumen may be gently cleared of secreti0n.s or blood, using a size 22 fine end attached to the Zoellner suction apparatus (Fig. 7.3e). Finally, a few antibiotic drops may be instilled into

Fig. 7.3 Stages of myringotomy and grommet insertion. See test for explanation.

36

Chapter 7

the ear canal before putting some cotton wool in the meatus (Fig. 7.3f) (Shah, 1991).

Children and adults undergoing grommet surgery are generally fit to be discharged home on theday of operation and to return to normal activities the following day. Avoidance of excess water, particularlyif soapy or dirty, in the ears is advised, although normal swimming without immersion of the head is not prohibited (Pringle, 1992).

1 Injuries to the middle ear structures should be rare and avoidable. Therare dehiscent high jugular bulb should be borne in mind when the T M appears dark or unduly pulsatile. 2 Otorrhoea may be early or late. In the postoperative period,contaminationatthe time of surgery or the presence of infected middle ear fluid may result in discharge. Late otorrhoea may result from an upper respiratory infection, nasal allergy or autoinfection by the child resulting in the growth of nasal, bowel or mixed flora. Immersion in dirty water, especially if the surface tension, has been reduced by soap, may lead to otorrhoea. In adults who have had a grommet inserted following radiotherapy to the neck, earornasopharynx, otorrhoea may be particularly troublesome and difficult to eradicate. Otorrhoea will usually settle with a course of antibiotic ear-drops. While many of these are theoretically ototoxic, evidence suggests that, in the human middle ear with inflamed mucosa, penetration to the inner ear causing sensory hearing loss is extremely unlikely, and most otolaryngologists would recommend ear-drops in this situation (Robb & Johnston, 1991). 3 Where discharge persists despite appropriatetreatment, it is postulated that the grommet may be acting as a foreign body and removal of the grommet is indicated. Granuloma formation, bleeding and polypoid mucosa which herniates through the grommet may complicate the reaction. 4 Sensorineural loss is uncommon following grommet surgery. However, excessive manipulation of the TM, excessive suction and noise from the suction tip may produce a measurable high-frequency loss above 8 kHz. 5 Premature extrusion of the grommet may be due to faulty placement, a blow to the head with dislodgement of the grommet from the TM, or a thin atrophic T M

failing to support the grommet. Usually, however, there is no apparentreason why a grommet extrudesearlier or laterthan average and this is assumed to be due to different individual rates of epithelial growth. 6 Atrophic areas of the TM and myringosclerosis are not uncommon. Myringosclerosis (tympanosclerosis restricted to the TM) is more common when the grommet insertion is traumatic and when bleeding into the T M hasoccurred. Reinsertion of grommets may also increase the incidence of this finding. Generally, myringosclerosis does not have an adverse affect on hearing thresholds. 7 Persistent perforation is unusual except where larger grommets or T-tubes have been used. The incidence can be reduced if the T M edges are freshened and the perforation patched with Gelfoam or fat at the time of tube removal.

Alternative p Serous otitis media may be managed in the short term withantibiotics or decongestants, although neither will produce long-term resolution of effusion in most cases. Nasal allergy should be addressed as part of the overall plan of management. If this coexists, symptoms may improve with antihistamines or nasal steroids or both. Autoinflation of the Eustachian tubes with balloons or other devices may produce short-term improvement. Many younger children find thisa difficult anduncomfortable technique to’master.Long-term compliance with treatment may be poor. Considerationshould be given to other procedures that may improve the long-termbenefits of surgery and, in particular,adenoidectomy (Maw & Herod, 1986). Diathermy to the nasal turbinates, sinus washouts and tonsillectomy may be indicated in a small proportion of children requiring grommets. Long=term ventilation tubes

The indications for the insertion of long-term VTs are even morecontentious than thoseforthestandard grommet. Where standard ventilation tubeshave repeatedly extruded prematurely, or where the otorrhoea of the middle ear (OME) is persistent over many years, the choice of a long-term VT may be justified. In children with craniofacial abnormalities, cleft palate or Down’s syndrome, when the need for longer-term middle ear ventilation can be predicted, then the insertionof a long-term VT as the initial procedure may be appropriate. Inser-

Tympanostomy Tube tion of a long-term VT as a first procedure for uncomplicated cases of OME is not recommended (Mangat et al., 1993). The surgical technique is similar, inserting first one arm of a T-tube andthen the second into the larger than normalmyringotomy incision: there are speciallydesigned T-tube insertors available. The technique of insertion of the Permavent tube is the same as thatfor the standard grommet. Thecomplications include recurrent otorrhoea in over 20% of cases, impacted wax in about 10% and persistent perforation in 20-30% (Hern et al., 1995). The most serious of these is the high persistent perforation rate, which contrasts to a rate of approximately 3% with a standard grommet. The complications of infection and occlusion of the lumen o f the VT may be reduced by using antibioticsteroid drops once a week. The advice regarding water avoidance applies as for standard grommets. There is some disagreement as to whether removing the tubes electively increases or abolishes the persistent perforation rate (Prichard et al., 1992; Hern et al., 1995) and this may relate to the type of tube used. If the tube is still in situ when the child has reached 12 years of age, the likelihood of further middle ear disease (excluding special indications above) is low and the tube should be removed. When removing a long-term tube, the procedure is carried out as a day-case general anaesthetic procedure as for grommet insertion. The edges of the healed myringotomy incision are freshened and the areais filled with sterile cellulose sponge fragments. An overlay technique using fine silastic sheeting may also promote healing of the area (Courteney-Harris et al., 1992). If the perforation persists despite this technique, daycase fat graft myringoplasty (4.v.) should be considered

Insertion

37

as the next procedure and, failing this, formal type 1 tympanoplasty (4.v.).

Acknowledgement The assistance of Dr M.S. Inglis, Consultant Anaesthetist and Director of theDay Surgery Unit, Epsom Healthcare N H S Trust, is acknowledged in the preparation of the anaesthetic protocols in this chapter.

References Courteney-Harris RG, Ford GR, Ganiwalla TMJ & Mangat KS (1992) Closure of tympanicmembraneperforationafterthe removal of Goode-typetympanostomy tubes: the use of silastic sheeting. J . Laryngol. Otol. 106, 960-2. Hern JD, Hasnie A & Shah NS (1995)A long-termreview of the Shah Permavent tube. J . Laryngol. Otol. 109, 277-80. Johnston DF, Wrigley S, Robb PJ & Jones H (1990)The Brain laryngeal mask in paediatric day case anaesthesia. Anaesthesia 45, 924-7. Leeds University (1992)The treatment of persistent glue ear in children. Effective Health Care 4. Mangat KS, Morrison GAJ & Ganniwalla TMJ (1993) T-tubes: a retrospective review of 1274 insertions over a 4-year period. Int. J . Paed. Otorhinolaryngol. 25, 119-25. Maw AR & Herod F (1986) Otoscopic, impedance and audiometric findings in glue ear treated by adenoidectomy and tonsillectomy: a prospective randomised study. Lancet i, 1399-402. Mawson SR & Ludrnan H (1979) Diseases of theEar, 4th edn. London, Edward Arnold, p. 525. Prichard AJN, Marshall J, Skinner DW & Narula AA (1992) Longterm results of Goode’s tympanostomy tubes in children. Int. J , Paed. Otorhinolaryngol. 24, 227-33. Pringle MB (1992) Swimming and grommets. Br. Med. J . 304, 198. Robb PJ (1993) Glue ear: putting the case for surgery. Med. Mon. 6, 67-9. Robb PJ &Johnston DF (1991) Theclinical management of otorrhoea following grommet insertion. Clin. Otolaryngol. 16, 367-70. Shah N (1991) Otitis media and its sequelae. J. Roy. Soc. Med. 84, 581-5.

1 Myringotomy with or without ventilation-tube (VT) insertion. 2 Myringoplasty. 3 Ossiculoplasty including stapes surgery. 4 Excision of small glomus tympanicum tumours. 5 Tympanic neurectomy. 6 Access to theovalandroundwindows in cases of suspected perilymph fistula.

1 Corticalmastoidectomyforacutemastoiditis and drainage of subperiosteal abscess. 2 Cortical mastoidectomy in the treatment of a chronically dischargingtympanicmembrane (TM) perforaa ‘mastoid reservoir’ o f infection is tion, where suspected. 3 Surgical treatment of cholesteatoma. 4 Radical surgery for malignant temporal bone neoplasms. 5 Access to the facial nerve in the temporal bone.

1 Membranous and osseous labyrinthectomy. 2 Endolymphatic sac surgery for Meni6re’s disease, 3 Singular neurectomy and posterior semicircular canal plugging for benign paroxysmal positional vertigo. 4 Cochlear implantation.

1 Removal of acoustic neuromas. 2 Vestibular nerve section for intractable vertigo.

A recent pure-tone audiogram (PTA) must be available priorto anysurgical approach to the middleear or mastoid. This is to enable postoperative changes in the hearing level to be quantified, and to accurately assess cochlear function prior to surgery. For elective surgery any active infection in the earcanalskin, middle ear or mastoidmust receive prior medical treatment. Informedconsentmust be obtained. The nature of any discussions with patients or relatives will depend on the exact surgical procedure undertaken. Itis important when discussing success rates and complications of operations to relateto one’s own surgical experience rather than that cited in the medical literature. The requirements for preoperative imaging will depend on the procedure undertaken. CT is the investigation of choice in delineating middle ear and mastoid pathology. For the majority of cases, however, preoperative imaging is not required.

The pinna is based on a framework o f elastic cartilage thrown intofolds. Medially the cartilage is prolonged as a tube forming the cartilaginous portion of the external auditory canal (EAC). Attachment of this cartilage to the underlying bone stabilises the pinna in position.

Approaches to the ~ i d d l Ear e and The underlying temporal bone iscornposed of four parts:squamous,petromastoid,tympanicand styloid (Fig. 8.1). Onthe lateral surfaceof the temporal boneat the posterosuperior limit of the bony external canalis a depression known as the suprameatal triangle (of MacEwen),which lies 1Smm lateral to themastoid antrum in the adult. The anterior borderof this triangle is usually marked by a projection (Henle's spine). The EAC in the adult is 24mm long and is composed of a lateral cartilaginous part and a medial bony part. The meatal cartilage forms a gutter with its roof formed by fibrous tissue. Likewise thetympanicbone is Cshaped in cross-section with a gap superiorly formed by the squamous and petrousbones. The canal is S-shaped, withthecartilaginous part directed posterosuperiorly and thebony part directed anteroinferiorly,The T M lies at the medial limit of the external canal and lies obliquely at 55" to the anterior canal wall, whichasa result islonger than theposterior wall. A prominent bony anterior canal wall can often obscure the anterior portion of the TM. Theskin of the cartilaginous canalis hair-bearing and contains ceruminous glands. The skin covering thebonycanal is thin andadherent to the underlying bone. The T M is composed of two parts: the pars tensaand the pars flaccida. The pars tensa forms the inferior part of the membrane and is composed of a thin outer layer of squamousepitheliumand an innermucosal layer. Sandwichedbetween these layers is a layer of fibrous tissue. The medial surface of the pars tensa is adherent to thehandle of the malleus. The pars tensais thickened

ast to id

39

at its circumference as the annulus tympanicum, which inserts into a groove in the tympanic plate. The pars flaccida is thicker and is morphologically identical to deep ear-canal skin. The physiological process of lateral epithelialmigrationacts to keep thecanal free of squamous epithelial debris. The sensory nerve supply to the pinna, external canal and T M is derived from the Vth, VIIth, IXth and Xth cranial nerves, and from the cervical plexus (C2 and C3). The exact distribution of these nerves is variable.

nae§the§ia

Local or general anaesthesia maybe used; the method o f choice will depend on the suitability of the patient, the preference of the surgeon and the availability of hypotensive general anaesthesia, For procedures under local anaesthetic (LA) use a combination of infiltration and topical application ofLA. The soft tissues around the pinna (depending on the site of any incision) and the ear-canalskinare infiltrated witha 2% lignocaine/ 1:80 000 adrenaline mixture. To anaesthetise the middle ea: mucosa,cotton-wool balls soaked in 4% lignocaine solution are applieddirectly. An. intramuscular injection of Omnopon can be given 20min prior to surgery to provide additional analgesia. atient ~o§itionin

The patient is positioned supine on the operating table, with reverse Trendelenburgtilt and extension o f the neck. The head is turned away from the surgeon, with the operated ear uppermost. It is o f prime importance that thesurgeon adopts a comfortable sitting positionin relation to the patient. Skin ~ r e ~ a r a t i o n

Mastoid process

/

""t.2,

Fig. 8.1 Lateral surface of the right temporal bone.

Shaving of the skin around the ear may be necessary. Theamount shaved will depend onthe site of the incision and should be the responsibility o f the surgeon. Theearcanaland middle earare physiologically contaminated sites and eradication of all microorganisms is neither possible nor desirable. Skin preparationshould be with anaqueous solution,suchas povidone-iodine,

qa

Chapter 8

The approachchosen by the otologist is governed by the procedure being undertaken and personal preference. Surgical procedures on the middle ear cavity, where theearcanal is sufficiently wide, can be undertaken permeatally. Wheretheearcanal is narrow,both endaural and postaural approaches can be adapted to provide access to the middle ear. Most otologists use a postaural approach for procedures involving the mastoid air-cell system. An endaural approach can, however, be used to provide access to this area. Permeatal approach. -posterior tympanomeatal flap

1 The EAC and TM are inspected with the operating microscope and the largest aural speculum which the canal will accommodate is inserted. Shea speculae are suitable and the canal should accommodate aminimum 6mm speculum size. A speculum holder can be used to facilitate working with both hands simultaneously. The canal is cleared o f epithelial debris. 2 The canal skin is infiltrated with LA to reduce bleeding and facilitate dissection. A single injection of approximately 1m1 of solution isgiven slowly into the posteriorcanal wall at thejunction of the bony and cartilaginous canal (this corresponds to the medial extent of the canal-skin hairs). 3 An incision is madeintothecanal skin downto the bone. A two-limbed incision is preferred (Fig. 8.2).

Fig. 8.2 Endorneatal skin incision for a right posterior tyrnpanorneatal flap.

Fig. 8.3 Middle ear structures revealed through a right posterior tympanorneatal flap.

The transverse component is madewitha Lumsden knife and passes from superior to inferior. The incision remains parallel to the annulus, having to pass more medially in the inferior part of the canal. The longitudinalcomponent is madewitha Plester knife and microscissors, and passes from the superior extentof the transverse incision medially along the posterosuperior canal wall towards the pars flaccida. 4 The canal-skin flap is elevated using an elevator and narrow suction tip if necessary (the canal skin must be protected from the sucker). The dissection may be facilitated by the use of a cotton-wool ball impregnated with 1:1000 adrenaline, placed against the skin flap. The skin of the superior bony canal is relatively thick and dissection should commence here and subsequently progress medially and inferiorly. There may be some tethering of skin to the underlying tympanomastoid suture, and care must be taken to avoid tearing the skin flap in this location. Likewise, the skin over the inferior bony canal is extremely thin and easily torn. 5 The dissection continues medially until the annulus tympanicum is identified. The annulusis then dislocated from its groove superiorly, using a dissector such as a Hough elevator, and the middle ear is entered, by dividing the middle ear mucosa with a sharp needle. Using a drum elevator (e.g. Rosen’s) the annulus is dislocated inferiorly and anteriorly, allowing the tympanomeatal flap to be reflected anteriorly and giving access to the middle ear (Fig. 8.3).

Approaches to theMiddleEarandMastoid

41

6 When access to the posterior mesotympanum is required,thechordatympani nerve can be reflected inferiorly. This canbe facilitated by identifying the canal for the chorda tympani,and with a sharp pick removing bone, allowing the nerve to exit the bony canal at a more inferior position. Endaural approach

1 The endaural incision utilises the notch between the cartilages of the tragus and helix. The EAC is infiltrated with LA and adrenaline, as in the permeatal approach to the middle ear.Additionalinfiltration is inserted between the tragus and helix, and also superiorly anterior to the helix. 2 The size of theendaural incision depends onthe procedure being undertaken (Fig. 8.4). If the incision is being used to facilitate access to the middle ear,for example during stapedectomy, asmall endaural incision is required. If a portion of temporalis fascia is required for T M reconstruction, the endaural incision may be extended superiorly. Finally, some surgeons who use the endaural approach formastoidectomy surgery will carry the incision around the top of the pinna, allowing the pinna to be reflected inferiorly to allow access to the mastoid cortex. 3 The incision is facilitated by the use of a Lempert’s endaural speculum, and is made using a scalpel with a size 15 blade. The incision commences in the superior

Fig. 8.5 Endaural incision deepened to expose the temporalis fascia and external bony canal.

part of “thebony external canal, incising the skin down to bone. The incision then passes superiorly and laterally between the tragus and helix. Deepening the incision anterior tothe helix gives excellent exposure of the temporalis fascia, which may be harvested. The tragal cartilage and perichondrium may also be exposed and segments removed forsubsequent middle ear reconstruction. 4 The incised skin in the superolateral part of the bony external canal may now be elevated with a Lempert’s periosteal elevator to improve visualisation of the deep canal and TM (Fig. 8.5).At this stage, self-retaining retractors are inserted and, using microsurgical instruments,meatal skin incisions aremade,as in the permeatal approach to the middle ear. Postaural approach

Fig. 8.4 Endaural skin incision.

1 A ‘hockey-stick’-shaped postaural incision (Fig. 8.6) is made, with the inferior extension passing approximately 5mm behind thepostauricular crease. The superior part of the incision passes over the top of the pinna, facilitating access to the anterior epitympanum and zygomatic cells during mastoid surgery. In infants the mastoid process is relatively undeveloped, leaving the facial nerve at the stylomastoid foramen unprotected by bone. As a result the postaural incision in infants

Fig. 8.6 ‘Hockey-stick’ postaural incision.

bloodless plane, the dissection proceeds inferiorly to expose the periosteum over themastoid process and anteriorly towards the cartilaginous EAC. 3 The next stage of the approach is dependent on the surgical procedure being undertaken.Optionsareas follows: (a) A portion of temporalis fascia can be taken to use as a graft during subsequent T M reconstruction. (b) The periosteum over the mastoid cortex may be incised and elevated to allow access for mastoidectomy surgery. A T-shaped periosteal incision provides excellent access for this purpose (Fig. 8.8). (c) The approach may proceed anteriorly, elevating of the EAC. The canal the skin from the posterior part skin may be incised posteriorly to enter the lumen of the canal. The remainder of the canal skin may be elevated medially asatympanomeatal flap to gain access to the middle ear. (d) A skin flap from the external canal may be dissected to facilitate meatoplastyduring open-cavity mastoidectomy surgery.

Surgical packing of the external ear canal is a routine part of most approaches to the middle ear and mastoid.

Fig. 8.7 High postaural incision in infants.

must be situated high and posteriorly, approaching the mastoid cortex away from the facial nerve (Fig. 8.7). 2 The incision is deepened superiorly until the temporalis fascia is identified. Staying in this relatively

Fig. 8.8 Postaural approach exposing temporalis fascia and mastoid cortex with T-shaped periosteal incision.

Approaches to theMiddle EarandMastoid The purpose of packing is to retain a tympanomeatal flap in position, to secure haemostasis and to act as an antiseptic. The packing used will depend on personal preference. The author uses nylon strips, cotton-wool balls and ribbon gauze impregnatedwithbismuth, iodoform and paraffin paste (BIPP). This packing remains in situ for 1-2 weeks. Incisions for otosurgery are closed in two layers with interrupted sutures. The use of a wound drain is not necessary. A pressure bandage is applied for 24 h where an external incision has been made.

Following any surgical procedure on the middle ear or mastoid the integrity of the facial nerve and cochlear function must be ascertained. The presence of a cochlear reserve in the operated ear can be crudely assessed by the Weber test; if there is doubt, however, a masked bone-conduction audiogram should be obtained.

The complications of specific procedures will be dealt

43

with elsewhere. The following complications can occur after any surgical procedure on the middle ear or mastoid. 1 Haemorrhage from an incision. 2 Wound haematoma. 3 Wound infection with possible perichondritis of the pinna. 4 Sensitivity to aural packing. 5 Loss of cutaneous sensation around the ear following external incisions, due to interruption of sensory nerve supply. This is usually temporary, with sensation recovering after a period of weeks.

Further rea Ludrnan H (1988) Mawson’s Diseases of the Ear, 5th edn. London, Edward Arnold. Tos M (1993) Manual of Middle Ear Surgery, Vols 1 and 2, 1st edn. Stuttgart, Thierne.

ri PETER-JOHN WORMAL

4 What is the state of the other ear? Usually the worst ear is operated on first. Is it possible to bring the operated ear to within 1.5dB of the other ear, or better than the other ear? If, after surgery, the air-conduction gap between the ears is greater than 1.5dB, the patient will not notice any air-bone gap closure that may have been achieved (Browning et al., 1991). 5 Has there been previous ear surgery? Repeat surgery is more difficult and requires an experienced surgeon. 6 Are there any associated ENT complaints, e.g. nasal stuffinesddischarge?Postnasal space pathologymay contribute to Eustachian tube dysfunction.

Surgical closure of the tympanic membrane (TM) without ossicular reconstruction.

1 Closure of the air-bone gap in perforated eardrum to within 1.5dB of the other ear. 2 Prevention of recurrent otorrhoea.

1 Age 8 years if other ear has normal hearing threshold (Koch et al., 1990). For children with bilateral conductive hearing loss and inactive ears, surgery may be considered fromschool-going age if the compliance with wearing a hearing-aid is low. 2 Active otorrhoea at the time of surgerylowersthe success rate. 3 It is inadvisable to put an only hearing ear at risk. 4 The presence of skin in the middle earoronthe underside of the T M which is not accessible or is impossible to remove.

Examinatio

1 Position and sizeof the perforation as a percentage of the TM. Anteriorperforationsmay be better approached via a postauricular incision to enable the anterior rim of the perforation to be visualised. Large and subtotal perforations are technically more difficult. Can the rim of the perforation be fully visualised or will a bony canal wall prominence need to be removed for visualisation at the time of surgery? If so, a drill will need to be requested for the operating tray. 2 Ensure there is no associated disease in theear, such as cholesteatoma, so that appropriate surgery is performed. 3 Is the ear active and does the patient need treatment (aural toilet,ear-dropsand systemic antibiotics) to render the ear inactive before surgery? 4 Eustachiantubepatency is no longer considered to influence the success rate of myringoplasty (Reimer et al., 1988; Sloth & Lildholdt, 1989; Jonathan, 1990). 5 What is the state of the other ear? Is the worst ear

1 Is otorrhoea present and for how long has the ear been discharging? 2 Is the patient deaf and for how long has this been noticed? 3 Is there associated vertigo or tinnitus? If present, one should look for other pathology such as cholesteatoma. 44

~ y ~ i n g o ~ l ~ s4t5y being operated on? Is the other ear infected and does it need appropriate treatment? 6 Do tuning-fork tests confirm the presence of conductive deafness? A sensorineural deafness cannot be improved by myringoplasty. 7 The rest of the ENT system needs a thorough examination to exclude associated nasal or postnasal space disease and potential causes for referred otological symptoms.

Pure-tone audiogram

The pure-tone audiogram (PTA) is needed to confirm the presence and degree of the conductive deafness and to allow comparison with the other ear. The PTA also documents, for medicolegal reasons, the state of the ear preoperatively andthus should have been performed within 3 months of the operation.

canal is usually prominent and can often obscure the anterior edge of a perforation.

The T M consists of two parts: a pars tensa and a pars flaccida. 1 The pars tensa consists of three layers: an outer layer of squamous epithelium (skin), a middle fibrous layer withboth circular and radial fibres andan inner mucosal layer (cuboidal epithelium). 2 The pars flaccida consists of the squamous .epithelial layer and mucosal membrane,but lacks the intrinsic strength of the pars tensa as the fibres of the fibrous layer are randomly orientated. 3 The relevant surgical landmarks are presented in Fig. 9.1.

Operative technique Preparation Anaesthesia

The external canalconsists of a cartilaginous outer third and bony two-thirds. 1 Thecartilaginouscanal.The cartilage of theouter canal does not form a complete ring, with a defect at 1 o'clock, just anterior to the base of the helix of the ear where the endaural incision can be made. 2 The bony canal.Theanteriorportion of the bony

General anaesthetic This is the most commonly used method. A controlled induction and relatively slow pulse will give agood operative field. To improve the field, infiltration with a combination. of local anaesthetic (LA) and adrenaline/ vasopressin into the incision area and the bony external canal should be performed. The syringes drawn in solid lines in Fig. 9.2 indicate these infiltration points.

Local anaesthetic

Fig. 9.1 Diagram of the tympanic membrane and its surgical landmarks.

This operation is eminently suitable for LA and mild sedation. This is especially true when general anaesthesia carries a risk due to underlying systemic disease. The nature of the LA and operation needs to be carefully explained to the patient as some patients may not tolerate LA. The following LAs are used: 1 0.5% Bupivicaine (toxic dose 3mglkg) with 1:200 000 adrenaline; 2 1 or 2% Lignocaine (toxic dose 3-5 mglkg) with either 1:80 000 or 1:200 000 adrenaline; 3 synthetic vasopressin may be substituted for adrenaline in a concentration of l :20000 or l :50000 where anaesthetic risks preclude the use of adrenaline. Sedation withashort-acting benzodiazepines, such as midazolam, is necessary. An initial dose of 5mg is

46

Chapter 9 ring should be placed underthehead.Theshoulder support creates thecorrect angle between head and neck, allowing rotation of the head away from the surgeon, for the TM to lie at right angles to the surgeon. This prevents the surgeon from leaning on the patient's chest when working on the superior part of the eardrum. Thepatientshould also be placed in theantiTrendelenberg position as this improves venous drainage and creates a better operating field.

Postauricular incision (Fig. 9.3)

This is the incision of choice when there is a large or anterior perforation of the TM. It also gives easy access to autologous temporalis fascia. Endaural incision (Fig. 9.3) Fig. 9.2 Diagram o f the local anaesthetic and vasoconstrictor infiltration needed for general (solid lines) and local anaesthetic (solid and dotted lines).

given, which can be topped up by three 2mg doses as required to a maximum of 11mg for a 70 kg adult. The syringe drawn in dotted lines in Fig. 9.2 represents theadditionalinfiltration needed for complete anaesthesia of the ear for myringoplasty by either the endaural or the postauricular approach.

A smaller incision appropriate to central or posterior perforations.

1 Infiltration of vasoconstrictor and LA (Fig. 9.2). 2 Inspection of the external canal and T M of the ear with microsuction. This allows appreciation of the per-

Prophylactic antibiotics

Inthe inactive uninfected ear, systemic prophylactic antibiotics do not influence the success rate of myringoplasty or the audiometric outcome (John et al., 1988). If the ear is active, the surgery should be postponed until the activity is controlled. If this cannot be achieved, a corticalmastoidectomy should be performed and adequate drainage established between the middle ear and the mastoid via either a superior or a posterior tympanotomy prior to the myringoplasty being done. The ear should be prepared for surgery by wiping the ear and surrounding area with a solution of iodine and water. Alcohol and chlorhexidine should be avoided as they may be toxic to the inner ear. Patient positioning

The patient should be positioned on hidherback with a shoulder support elevating the shoulders 5cm. A head

Fig. 9.3 Diagram demonstrating the postauricular and endaural incisions.

~yr~ngopl#sty 47 foration position and canal protuberances, which may influence choice of incision. 3 If a postauricular approachis chosen, a Rosen’s elevator is used to incise theposteriorcanal wall 10mm abovetheannulus.Thismarksthe place wherethe externalcanal-wall skin will be incised duringthe postauricular approach. 4 The chosen incision is performed. The postauricular approach

1 The incision as shown in Fig. 9.3 is performed, the posterior auricular muscles are cut andthe loose areolar layer above the temporalis muscle is identified. With a scalpel, the softtissues are cut up to the posterior border of the external ear canal, without the canal being entered (Fig. 9.4). A blunt double hook is used to elevate the skin, allowing the dissection to be continued superiorly, keeping in the plane superficial to the temporalis muscle. A 4 X 5 cm area of the temporalis muscle is exposed (Fig. 9.4). Using an 11 blade, a 3 X 4 cm area of fascia is incised. The edge of the fascia is elevated with forceps and, with blunt dissecting scissors, the fascia is removed. 2 A scalpel is used to create a soft-tissue flap by incising throughtheperiosteumontothe skull (Fig. 9.4). When sutured, this flap will pull the attached postauricular external canal skin against the bony posterior canal wall. This soft-tissue flap is elevated forward with a periosteal elevator until the spine of Henle is visualised. The soft tissues are dissected free from the

Fig. 9.5 Diagram of postauricular approach with visualisation of the entire tympanic membrane.

spine and, using a canal-wall elevator, the skin of the posterior canal wall is pushed anteriorly until the incision made earlier with the Rosen’s elevator is seen. 3 An 11 scalpel blade is used to continue the incision in the posterior canal-wall skin in a U shape both superiorly and inferiorly, transecting two-thirds of the circumference of the external canal. 4 A self-retaining two-pronged retractor is positioned to hold the outer part of the ear canal and the pinna forward. A second self-retaining retractor is positioned at right angles to holdthesuperiorand inferior soft tissue awayfromtheearcanal. If the microscope is positioned above the partially severed external canal, the bony external canal and entire T M should be seen (Fig. 9.5). Adequate exposure is essential. Without full visualisation of the TM,the chances of success diminish and the incidence of complications rises. If the bony canal wall obstructs part of the T M perforation and visualisation cannot be obtained by rotatingthepatient’s head, then this prominence needs to be removed with a drill or curette until full visualisation is achieved. The endaural approach

Fig. 9.4 Diagram of the postauricular approach and periosteally based soft-tissue flap.

Theendaural incision isbest performed with an 11 blade, as shown in Fig. 9.3, ensuring that the periosteum is incised. A self-retaining two-pronged retractor is inserted and theexternalcanalopenedas widely as possible. The loose areolar layer lying superfi-

48

Chapter 9

cia1 to the temporalis muscle is identified. A blunt double hook is used to elevate theskin, allowing easier access to this layer. A 4 X 5 cm area of temporalis muscle is exposed. Using an 11 blade, a 3 X 4 cm area of fascia is incised. The edge of the fascia is elevated with forceps and blunt dissecting scissors and the fascia is removed. The self-retaining retractorsare repositioned andadequate visualisation of the T M is ensured. If the anterior edge of the perforation is not visible, the endaural incision should be extended to allow the self-retaining retractor to pull thepinnamore posteriorly. If further exposure is needed, the posterior canal-wall skin lying lateral to the incision is mobilised subperiosteally in the posteroinferior direction. This allows a better angle of vision and more of the anterior T M can be visualised (Fig. 9.6). Preparation of the temporalis fascia autologous graft

at ‘6 o‘clock’ ~~

The temporalis fascia graft is placed on a glass slide and compressed withaswab to remove excess moisture from the graft. One end of the graft is held with the swab while the graft is spread and fat and muscle removed with a scalpel (11 blade). This procedure is repeated until the entire graft is cleaned of excess tissue. The graft is allowed to air-dry on the slide. Tympanic membrane and middle ear preparation.

The edge of the perforation is excised with a curved

Fig. 9.7 Diagram of the incisions for the posterior canal-wall flap.

needle until the fibrous middle layer of the TIM is seen. The mucocutaneous junction needs to be broken along theentire circumference of theperforation. A sickle knife is used to denude the undersurface of the TM, creating a raw bed for the graft. Care needs to be taken to ensure that the incudostapedial joint is not touched and that excessive movement of the malleus does not occur. The edges of the perforation should be everted to exclude and remove, if present, ingrowth of squamous epithelium. The posterior canal-wall flap

Fig. 9.6 Diagram of endaural approach with extended incision and posterior flap mobilisation to improve anterior tympanic membrane exposure.

The superior incision is started at 2 o’clock and angled on tothe posterior canalwall to join the horizontal limb of the posterior incision. The inferior limb is started at 6 o’clock and angled on to the posterior canal wall (Fig. 9.7). Theflap is raised along as wide an area as possible with a Rosen’s elevator. Care should be taken not to apply suction to the flap as this could cause tearing of the flap. The suction tip can be placed either on the flat portion of the elevator or on a cotton-wool ball placed on the elevated portion of the flap. The annulus of the T M is identified and elevated out of its bony groove. This is best done at 8 o’clock, as this is below the incudostapedial joint and the chorda tympani. The annulus is gently pushed forward and the chorda tympani identified and preserved. A canal-wall elevator is used to elevate the annulus to 6 o’clock inferiorly and

~ y ~ i n ~ o p l a s t y49 asfarasthe neck of the malleus superiorly. The incudostapedial jointis identified and the mobilityof the ossicular chain is checked by carefulmovement of the handle of the malleus. A wide exposure of the middle ear is mandatory to ensure easy and precise placement of thegraft. Most technical difficulties and resultant graft failures occur due to inadequate exposure at this step. Placing of the graft

Placing continuous traction on the graft, an 11 blade isused to elevate the graft from the glass slide. The graft is trimmed to the correct size with a pair of fine scissors. The graft shouldbe larger than the perforation by 3mm on all sides. It is better to use a slightly larger than a smaller graft to ensure complete closure of the perforation. Small pieces of Spongistan areplaced under the perforation edges to support the graft. The posterior flap is elevated forward and the graftis placed underthe TM. The graft isplaced underthe handle of the malleus but,wherethere is a large anterosuperior perforation, it may be placed lateral to the malleus if the drum remnants have been removed fromthehandle(Stage & Bak-Pedersen, 1992). If epithelial remnants remain, a cholesteatoma pearl may result. The posterior flap is replaced and the position of the graftchecked. A canal-wall elevatoror similar bluntended instrumentis used to ensure that the graft is under all edges of the perforation. The instrument should be placed underthe TM edge andsweptsuperiorly or inferiorly rather than poked in and out as this action may pull the graft out as the instrumentis removed. Overcoming the anterior-based perforation

An anterior perforation which abuts the anterior canal wall or has a narrow rim can be overcome by using the tuck-through-tail methodof additional support.Using a Rosen’s elevator, an incision is made in theanterior canal-wallskinabovetheannulus and abovethe Eustachian tube orifice. The annulus is elevated and the middle ear mucosa in the entrance to the Eustachian tube perforated. The pocket is widened sufficiently to allow passage of a thin suction tip into the Eustachian tube. Before the graftis placed, the anteriormillimetre is partially removed and formed into a tail attached to the anterior edge of the graft. This is moistened and rolled between the fingers to formatail (Fig. 9.8).Using crocodile forceps, the graftis placed with this tail down theEustachiantube. The thin sucker tip is placed

Fig. 9.8 Diagram for the creation of a tail on the graft and the incision for the anterior canal-wall pocket for sucker tip and graft tail.

through the anterior canal-wall pocket down the Eustachian tube and the tail is sucked into the sucker tip. The tip is withdrawn with the tail until the graft is firmly seatedundertheanteriorannulus.Additional support maybe requiredwithSpongistanalongthe superior and inferior borders of the perforation. Once the remainder of the graft is correctly positioned, the excess tail is removed with microscissors lateral to the annulus. This method overcomes anterior graft failure due to lack of support of the anterior graft edge. Inadequate technique when dealing with anterior-based perforations is the most common cause of immediate graft failure(Jurovitzki tic Sade, 1988; Sharp et al., 1992; Vartiainen, 1993). External canal packing

A thin sheet of Silastic with a circular end, 8-10 mm wide and 3 cm long, is inserted on to the T M graft without disturbing its position. The Silastic should rest on theT M remnant rather than on the graft alone. Two 1cm pieces of gauzeimpregnatedwithbismuth, iodoform andparaffin paste (BIPP)are rolled and placed withacrocodileforceps ontothe Silastic sheeting, ensuring even, moderatepressure on theentiregraft. These small pieces of BIPP allow better visualisation of the graft during placement of the packing, which decreases the chanceof disturbing the positionof the graft. The incision is closed before a final 3cm strip ofBIPP

gauze is placed in the remaining external canal. Alternate formsof packing arepieces of Spongistan soakedin gentamycin and hydrocortisone solution or gentamycin and hydrocortisone ointment appliedon tothe graft and filling the external canal. Wound closure

Postauricular wound The soft-tissueflap is suturedwith3/0 vicryl or 210 chromic. By replacing this flap, the posterior canal-wall skin attachedto the flap is pulled firmly against the bony posterior canal wall. An interrupted subcutaneous layer of sutures is added, followed by continuous a subcuticularsuture, using thesamesuturematerial throughout.

reperforations maybe without infection.

due to graftatrophy with or

The incidence of deadearsaftertympanoplastyhas decreased since surgeons have avoided using alcohol and chlorhexidine as an antiseptic. However, sensorineuralhearing loss, especially in the high frequencies, can occur as result a of excessive manipulation of the ossicular chain. SS

A conductive hearing loss may persist despite closure of the perforation if ossicular adhesions or discontinuity was present at surgery or occurred after surgery.

Endaural wound Depending on the length of the incision, either one or two deep mattress sutures with 210 nylon are sufficient for closure.

These arecaused by buryingkeratinisingepithelium under the graft. They are usually visible through theT M or graft and may need excision.

A mastoid dressing is appliedfor 24 h. Thisshould include support of the ear posteriorly with cotton wool as this is more comfortable for the patient. The Weber tuning-fork test is performed prior to discharge to exclude a dead ear. The patient is instructed to wash his/ her hair after 3 days without allowing water into the ear. This can be prevented by placing cotton wool covered with Vaseline in the conchal bowl. Endaural sutures are removed after 5 days. Postauricular sutures do not require removal as they are subcuticular. The patient is seen in the out-patients 3 weeks after the operation when theBIPP gauze and silastic are removed under the microscope. If complete healing has not occurred, a 5-day course of gentamycin and steroid drops is prescribed. The patient is reviewed 3 months later and a repeat PTA performed.

Canalstenosis may occurfromcontracture of the wound when an endauralincision has been used. This is rarely seen with a postauricular incision.

Complicati Graft failure

A complete graft take rate of 80% or better should be expected.Immediategraftfailuresare usually due to technical faults, with the most common area of failure been the anterior edge of the perforation. Late

Total replacement of the T M by a harvested homograft cadaver TM has been successfully used in Europe. Legislation regarding the useof homograft tissues differs widely from countryto country. The risk of transferring diseases such as Jakob-Creutzfeld slow virus and HIV appears small but is none the less present. An alternative to homograft replacementof the T M in total perforationsis utilisation of formalised autologous temporalis fascia. The fascia is draped over a mould of the T M and external canal. The fascia is placed in 4 % formalin for 3min and washed in saline for a further 9 min before beingallowed to dry. After removal of deep canal-wall skinand TM, the graft is placed on the handle of the malleus and pressed into the bony annulus. It is supported by Spongistan in the middle ear and packing in the external ear (Pfleiderer & Moffat, 1988).

Transcanal myringo

This procedure may be used for small central perforations with minimal air-bone gap. The temporalis fascia is taken through a separate incision behind the ear and prepared as described. The middle ear is prepared as described. Spongistan is placed in the middle ear and the graft is pushed through the perforation onto the bed of Spongistan. Apposition of the graft to the perforation edges is ensured and the canal is packed as described. The ossicular chaincannot be examined whenusing this approach.

References Browning G, Gatehouse S & Swan I (1991) TheGlasgow Benefit Plot: a new methodforreporting benefits from middle ear surgery. Laryngoscope 101, 180-5. John D, Carlin W, Lesser T, Carrick D & Fielder C (1988) Tympanoplasty surgery and prophylactic antibiotics: surgical results. Clin. Otolaryngol. 13, 205-7.

Jonathan D (1990) The predictive value of Eustachian tube function (measured with sonotubometry) in the successful outcome of myringoplasty. Clin. Otolaryngol. 15, 431-4. Jurovitzki I& Sade J (1988) Myringoplasty: long-term follow-up. Am. J . Otol. 9, 52-5. Koch ‘W,Friedman E & McGill T (1990) Tympanoplasty in children: the Boston Children’s Hospital experience. Arch.Otolaryngol. Head Neck Surg. 116, 35-40. Pfleiderer A & Moffat D (1988) Thefasciaform graft: a technique for repair of large perforations of thetympanicmembrane. Clin. Otolaryngol. 13, 427-34. Reimer A, Andreasson L, Harris S & Ivarsson A (1988) Predictive value of tubal function, Valsalva’s manoeuvre and volume of ear spaces. Acta Otolaryngol. (Stockholm) 499 (Suppl.), 127-30. Sharp J, Terzis T & Robinson J (1992)Myringoplasty for the anterior perforation: experience with the Kerr flap. J . Laryngol. Otol. 106, 14-16. Sloth H & Lildholdt T (1989) Tests of Eustachian tube function and ear surgery. Clin. Otolaryngol. 14, 227-30. Stage J & Bak-Pedersen K (1992) Underlay tympanoplasty with the graft lateral to the malleus handle. Clin. Otolaryngol. 17, 6-9. VartiainenE (1993) Findings in revision myringoplasty. Ear Nose Throat J . 72, 201-4.

S ANTONY A. NARULA

Reconstructive surgery of the middle ear toimprove the conduction mechanisms.

1 This should never be performed in an only hearing ear and rarely in an ear which is the better hearing ear. 2, Ossiculoplasty should not usually be performed at the same time as conservative cholesteatoma surgery, but at a later stage. 3 Reconstruction in the presence of active infection is generally not advised.

only a small percentage of the sound energy in normal speech is above 2 kHz, a significant proportion of comprehension resides inthe higher frequencies. This is especially important as inexpert or clumsy intervention can lead to a high-frequency sensorineural deafness even if the air-bone gaphas beenclosed forthe 'classic' speech frequencies of 500, 1000 and 2000 Hz. Occasionally it may be appropriate to offer reconstruction in a patient whose hearing thresholds are so low that the surgery isreally an attempt to provide better thresholds precisely forthepurpose of better hearing-aid fitment.

perative tec Preparation

Audiological evaluation is the most important element of assessment. Inany case, with bilateral conductive deafness great care needs to be taken in performing the pure-tone audiogram (PTA), as accurate masking may bedifficult to achieve. A masked speech audiogram should also be available, and tympanometry (otoimittance) can help to avoid occasional errorsabout middle-ear effusion and toconfirm ossicular discontinuity. The surgeon also needs to be familiar withthe psychoacoustics of binaural hearing and help the patient to realise that, if the operated ear is to provide useful binaural hearing, it must come up to within no less than 1.5-20 dB of the unoperated (i.e. better) ear. In anycase, wherethepatient is unsure about proceeding there should be an opportunity to try a hearing-aid. The problem of which frequencies of the PTA should be evaluated- both before and after surgery-remains controversial. Itmust be remembered that, although

In the IJK most procedures are performed under general anaesthetic (GA)with hypotension. Local infiltration of theearcanalwith a combination of lignocaine/l in 80000 adrenaline and IV sedation are a perfectly feasible alternative but require experience. The patient is supine with the head turned away from the surgeon. A head-up tilt of 15-20" is helpful and the patient should be secured to the operating table in case tilting is required. Antibiotics and otherprophylactic drugs are not needed. incision

Endaural, permeatal or postaural approach according to preference (see Chapter 8).

Ossiculoplasty

53

ossicular replacements. It has goodbiocompatibility but long-term results are not yet available. At present the author considers preformedhydroxylapatite devices (for example, Fig. 10.1)to be the easiest to use and stable over long periods. There are many different designs, according to the individual’s preferences, and they are also available now in combination with wire and plastipore to provide more malleability. These newer ones are easy to adjust, as they can be cut instead of drilled, but their long-term stability is not yet well established. Fig. 10.1 Ceramic preformed prosthesis (Applebaum type). (With permission from Smith & Nephew Surgical Limited.)

Clinical problems

Eroded long process of incus Special considerations

The surgeon needs to be familiar withthe range of available biomaterials. 1 Autograft bone. This may be the remains of ossicle (usually an erodedincus) or a piece of cortical bone from the squamosa. Ithas the advantages of being available, reliable and biocompatible. The use of homograft bone from another donor is to be discouraged because of the theoretical risk of transmission of slow viruses, such as Creutzfeld-Jakob disease. 2 Cartilage. This is also available locally and biocompatible. However, it has a tendency to lose its rigidity over time and is difficult to shape. 3 Plastics. Teflon and polythene tubing were introduced originally in the 1960s but have been superseded because of their high rejection rate. 4 Biocompatible synthetics. Plastipore is a high-density porous ethylene, available in a variety of preformed shapes. It also has a tendency to extrude, although this can be delayed by interposingcartilage between the device and the tympanic membrane (TM). 5 Bioactive glass (e.g. Ceravital and Bioglass) was introduced in the mid-1980s. It promotes soft-tissue attachment, does not need to be covered with cartilage and promotes an osteogenic reaction. However, it is quite brittle and therefore difficult to trim to size. 6 Bioceramics are currently popular, especially hydroxylapatite and its derivatives. This is designed to resemble the mineral matrix of human bone and the dense form can become mineralised by calcium to become incorporatedas vascular bone. Extrusion may occur if it is incontactwiththeTM,andcartilage reinforcement is wise in such cases. ’7 Glass ionomer cement. This has recently been introduced ina variety of forms, including preformed

This is one of the commonest discontinuities. The appropriate and time-proved technique is incus transposition (Fig. 10.2). The only disadvantageof removing the body of the patient’s own incus is the slight loss of support to the posterior part of the attic region. This is not usually a significant factor unless repairing a defect of the posterior part of the pars tensa. The alternative is a hydroxylapatite partialossicular replacement prosthesis (PORP).The author finds the notched Wehr’s device easiest to insert (Fig. 10.3). The GrotePORP is designed to lie in a pocket between the handle of the malleus and the TM, but it can be difficult to achieve the necessary pocket and insert the straight limb of the prosthesis. Absent suprastructure of stapes

Selection of a device depends on whetherthere

is

Groove here for malleus handle

j

stapes head

I

Fig. 10.2 Modification of eroded incus for transposition. Use a fine diamond-paste burr.

54

Chapter 10

Fig. 10.3 Hydroxylapatite partial ossicular

I L

a malleus handle to actas an anchor; in this case use anotched TORP such astheWehrs (Fig. 10.4). When there is no malleus handle, direct contact with the membrane calls for a reasonable surface area of TORPto collect thesound energy. In addition, a degree of tension is required to promote the equivalent of thecatenary(chain-like) effect of the middle ear transformer mechanism. Unfortunately, the cases where thereareno useful ossicles to build onare oftenpost-canal-wall-down mastoidectomies; when the bridge has been taken down and the facial recess opened at the original surgery, the distance of the tympanic segment to the footplate is reduced. This loss of height makes adequate TORP placement more difficult. Lenticular process only absent

This is a minor variant of eroded long process of incus. It is often the most satisfying to reconstruct in a variety of ways.

I replacement prosthesis.

Procedure

1 Perform tympanotomy.

2 Evaluate the problem and measure the distances. A stapedectomy-type measuring rod is useful; crocodile forceps can be used to estimate horizontal gaps against a sterile ruler. Successful reconstruction requires tension in the middle ear.A distance of more than2.5mm between the stapes and malleus is associated with poor results. 3 Check the mobility of the stapes. It is easy to overlook a small degree of tympanosclerosis. NB If the stapes suprastructure is damaged or absent, the results are significantly worse. 4 Decide on the material to be used (see section above on biomaterials).A familiarity withthe designs and availability of a large number of devices is essential in the operating room. 5 DrilUtrim prosthesis to size. Always trim less than you think is necessary and then ‘try’ it in place before making final adjustments.

Ossiculoplasty 6 Place in position. NB Do not push on to the head of the stapes or on to thefootplate directly while trying to place a device under the malleus. Instead, always lift the malleus with a needle or hook. At this stage, two-pronged a micromanipulator (e.g. Cawthorne, Austin)is very helpful to move the bonelimplant and to hold it in position with one hand while lifting the malleus with an angled pick. A selection of alligator forceps pointing sideways and upwards can be helpful to position the device initially without obscuring the surgeon’s view. In the case of a narrow oval window niche, the bony overhangs make ankylosis more likely.

Theear is closed in the usual way withsubcuticular absorbable skin sutures.

The patient may experience dizziness for 1-2 days but is usually well enough to go home within 24 h.

55

1 Injudicious manipulation of theovalwindowarea may lead to sensorineural deafness. 2 Facial palsy is a rare complication. 3 The prosthesis may extrude between 6 and 24 months postoperatively. 4 Persistent conductive deafness should be re-explored.

Briggs RJS & Luxford WM (1994) Chronic ear surgery: a historical review. Am J . Otol. 15 (4), 558-67. Browning G (1993)Reporting the benefits of middle ear surgery. Am. J. Otol. 14, 135-40. Monsell EM (1994) Ossiculoplasty. Otolaryngol. Clin. North Am. 27 (4). Toner JG, Smyth CD & Kerr AG (1991) Realities in ossiculoplasty. J . Laryngol. Otol. 105, 529-33.

Stapedectomy TONY WRIGHT

lndications

Reduced bone-conduction levels

Absolute

The worse the bone-conduction level, the less likely a good result as far as the patientis concerned. If the airbone gap is closed, butthere is still the need fora hearing-aid, then very little has been achieved at some risk. The patient’s aim is to throwaway the hearing-aid, not to swap it for a less powerful model.

There are no absolute indications since otosclerosis can always be managed by some form of hearing-aid. Relative indications

1 A bilateral conductive loss caused by otosclerosis, ratherthan tympanosclerosis, withnormaltympanic membranes (TMs)and withnormal or near-normal bone conduction (after making allowance for the Carhart effect) is the best indication. 2 Unilateral otosclerosis. The author is not certain that this is the same pathology as bilateral otosclerosis although he has no evidence to support this statement. However,the author will operate following a 3-6month period of regular use of a hearing-aid on the affected side. This is because the sudden reintroduction of sound following a successful procedure can be extremely distressing withthesounds being unbearably loud for many months. One must be absolutely certain of the audiometry and be positive that one is not operating on a progressive unilateral sensorineural hearing loss.

Relative contraindications

Tympanosclerosis

A fixed footplate from previous middle ear disease is not, for the author,an indication for stapedectomysince the outcome is very much less certain, although he is not sure why.

Age

Age is no contraindication and the younger patient with Van der Hoeve’s syndrome need not delay operation. The wisdom of performing stapedectomies on the elderly is questionable since the slight loss of discrimination that inevitably comes from a stapedectomy may be enough to make an elderly person worse off despite an improved threshold. Contraindications

1 Active external or middle ear disease forbids surgery. Unless the ear canaland the T M are perfect or nearly so, the author will not offer the procedure. 2 Tinnitus is notan indicationfor surgery. Tinnitus may improve or even resolve following a successful stapedectomy, but this cannot be predicted and should be considered a bonus. Tinnituscan easily be made worse. The single, specific aim of the operation is to improve the hearing by closing the air-bone gap. Summary

Because theprocedurecan go disastrously wrong, individual patients almost have to ‘demand’ an opera-

Stapedectomy tion, rather than have it forced upon them by an eager surgeon. The patient with a dead ear, tinnitus or vertigo after afailed stapedectomy is with you for ever. Remember the late Gordon Smyth’s words: ‘There may be many moredeadearsfrom surgery thanfrom middle ear disease’ (Smyth, 1980). Thus,stapedectomy surgery should be undertaken by individuals who regularly performtheprocedure and there is almost certainly no place for the ‘occasional stapedectomist’. The person who performs stapedectomies in the ‘centre’ should be actively involved in teaching those trainees who are at a senior level and who want to continue in otology. If a registrar were performingastapedectomyunderthe guidance of a senior registrar and somethingshould go wrong,the case would be difficult to defend. Thetechnique of small-fenestra stapedectomy has been essentially unaltered for 20 years. However, the technology has changed and microdrills and lasers are now available, but then so are better microscopes and video recordings of theprocedure. What should be available and what is a necessity? Legally the argument that ‘the available financial resources were insufficient’ is used to defend thenonavailability of services or items of equipment.In addition, a ‘responsible body of medical practitioners’ perform stapedectomies without microdrills or lasers with good results, and this argument, based on the socalled Bolam principle, is, at present, enough to justify the non-essential nature of their use. However,both microdrills and lasers are very useful additions to the surgical instrumentation and will in due course become something that no otologist can be without. The individual should, however, practise on temporal bones in theatreprior to surgical use. As to other items, it is absolutely essential to have the appropriate fine instruments for working in the region of the footplate and one should not consider startingstapes surgery without them.

Preoperative management History

It is important to establish what the individual patients hope to achieve from the procedure and why they want an operation so that their expectations and reality can be matched. Examination

The ear canal should be free of active otitis externa and

57

not narrowed by exostoses or osteomata. These need removal prior to considering a stapedectomy. The T M should be normal and,if the surgeonis certain that there is a positive Schwartz’s sign (a definite pinkish red glow from the promontory), then it is probably better not to operate until the progression of conductive loss has ceased, since the results seem to be less good with more sensorineural losses occurring. investigations

Really goodaudiometrywith reliable masked boneconduction levels is an absolute necessity. Do not even consider operating unless you are sure of the audiogram. The difficulty comes in a patient with a major conductive loss in one ear and, by chance, a predominantly sensorineural loss in the other. This is a most awkward combination to test because of masking difficulties. Tympanometrywith ipsi- andcontralateralstapedial reflexes might be helpful in earswitha recruiting cochlear-type loss. Retrocochlear losses may be detectable if stapedial reflex decay can be shown. Tuning-fork tests are sometimes very helpful and the author likes to have a preoperative Weber test result so that postoperative changes can be detected. If available, speech audiometry should be performed to assess theoptimumdiscrimination score. If this is low, say less than ’70% in the ear for surgery, then the chance of a good result as far as the patientis concerned is also low. Warning of risks As well as explaining theoperation

in the degree of detail that the patient wants, it is necessary to explain the risks in clear terms and to write in the notes and in the letter to the referring doctor thatyou have warned thepatient of them (Morrison, 1989). It is better to writedown what risks you have described since patients’ memories are fickle (Hutson & Blaha, 1991). Those risks are: 1 dead ear; 2 vertigo; 3 tinnitus; 4 alteration in taste to the side of the tongue; 5 that the operation might not work and that the conductive loss might persist; 6 a small risk of a facial palsy and therefore a facial weakness. Thereported incidence of sensorineural hearing loss varies from 0.5% to 4% in skilled hands (Beales, 1987), but the author can find no good figures for the other

58

Chapter 11

outcomes, although he continues to see patients with such complications. The author does warn patients of the small risk of a facial palsy, since it certainly has occurred and they need to be positive that they really do wantsurgery. If, having heard the risks, they do not want to go ahead, then nothing is lost because the conditionitself is not dangerous and is well managed by hearing-aids. If they do go ahead and a risk materialises, then the case is easier to defend, at least as far as consent is concerned.

The author has only occasionally performed stapedectomies under local anaesthesia because of the excellent hypotensive anaesthetic service providedfor him over the last 10 years. However, for a stapedectomy under local anaesthetic (LA), sedation with Omnopon and scopolamine is advised. Local anaesthetic technique

About 1h before the operation the author fills the ear canalwithaeutecticmixture of localanaesthetic (EMLA) cream, ensuring that the cream is lying on the TM.In the operating theatre xylocaine 2% with adrenaline l :80 000 is injected through multiple sites in the postauricular sulcus with the tipof the needle pointed to the meatus and with a separate injection in the groove between, the tragus and the superior rim of the helix. Then, using a Tumarkin slotted speculum and suction, the EMLA cream is aspirated andLA is injected into the skin of the meatus. The idea is to strip the skin and periosteum from the underlying bone in muchthe same way that an injection isused in submucous resection (SMR) of the nasal septum. The trick is to use a large speculum and inject at thejunction of thebony and cartilaginous canals in a slowish fashionso that skin in the deeper canal blanches but does not blister. Under general anaesthesia the author also injects the ear canal to make raising the tympanomeatal flap less bloody. General anaesthetic technique

Hypotensive anaesthetic with systolic pressures stablised at around 70-80mmHg and with a head-up position makes for a relatively bloodless field.

Theauthor doesnot give prophylacticantibiotics. If there is any suggestion of active infection, a stapedectomy must not be performed, siti

The patient lies on hislher back with the headon a head ring so that it can be turned away from the side of the operation.

Endaural incision

The author makes a small endaural incision in all cases and then takes two or three large pinhead-sized pieces of subcutaneous fat from this incision and saves them in saline. If general anaesthesia isbeing used, the tragal notch is not injected with local anaesthesia. The author then cuts down through this incision in order to open the meatus and two-tined Plester self-retaining retractors are used. Occasionally, and irritatingly, the inferior portion of the helix and ear lobe pivots into the line of view when the Plester retractors are opened and there may be a need for a stitch through the lobe or another Plester retractor, this time with a flat blade to improve the view. If the patient has a pierced ear lobe, then a thick silk suture can be passed through this and used to provide traction. The tyrnpanorneatal incision

The authoruses a round canal knife to make an incision parallel to the annulus and about 3-4mm from it, extending from 6 o’clock to 11 o’clock (Fig. 11.1).This cut is down to bone andshould barely bleed if the injection has been performed correctly. Then, with the help of a small cotton-wool ball soaked in adrenaline solution,the cuffof canalskin is elevated, using a Beale’s elevator. Do not suck on the canal skin for this is fragile, precious stuff. Small scissors often have to be used to cut the thicker skin over the outer attic wall. The middle ear is entered mosteasily inferiorly, using a small Beale’s elevatoror,better,aHugh’sraspatory to get between the sulcus and the annulus itself. Theannulus is then elevated andthe TM turned forwards, the chorda tympani being dissected from the TM in the process, until the flap is hinged on the handle of the malleus (Fig. 112 ) .

Stapedectorny

59

Check the diagnosis

Fig. 11.1 A tympanomeatal incision has been made with a round canal knife and a Beale’s elevator is being used to lift up a cuff of canal skin.

Using a slightly curved needle, the malleus handle is gently rocked by pushing against the medial aspect of it in a medial to lateral direction, to see that there is full and free movement of the tip of the long process of the incus. If there is fixation of the heads of the ossicles in the attic, then, afterchecking the mobility of the stapes, the author closes the ear, since to proceed with a nonconsented operation is not acceptable in non-lifethreatening conditions. To check the mobility of the stapes you must be able to see it and this is not always possible because of a prominentposterior bony canal wall. This needs removal and the author uses House curettes (large and small) asthese are particularly sharp butdo need replacing at regular intervals as they wear out. A curetteis not used like a lever, but rather like an ice-cream scoop with the sharp edge shaving away layers of bone. The difficulty arises around the entry of the chorda tympani into the bony canal wall and greatcare, using the small curette, is needed to release the nerve from its canal without damage. Enough bone should be removed so that the stapedius tendon and pyramid canbe seen. This fairly extensive removal of bone also allows in more light, which is a greathelp when looking at the footplate (Fig. 11.3). The stapes’ mobility is then checked by using a small Hugh’s raspatoryto try and rockthestapesin an anteroposteriordirection. If it is immobile, thenthe diagnosis is confirmed. Dividing the incudostapedial joint

Fig. 11.2 The tympanomeatal flap has been lifted and turned anteriorly until it is hinged on the handle of the malleus. The chorda tympani runs across the long process of the incus and partly obscures the view. The dotted lines on the posterior bony canal wall indicate the region of bone that should be curetted in order to improve access and lighting. The facial nerve (VII)lies just above the stapes and it is sensible to gently palpate this with a blunt instrument to ensure that the bony covering is intact.

Assuming that there are no major anatomical difficulties andthat thefootplate is not completely obliterated (these will be discussed briefly later), the incudostapedial joint is then divided. The neatest instrument is a small roundjoint knife and this is rotated throughthejointawayfromthestapediustendon, which is used as countertraction (Fig. 11.4). The author then cuts the stapedius tendon with small microscissors close to theneck of the stapes (Fig. 11.Sa). Itis no longer necessary to make a preliminary hole in the footplate, since the incidence of ‘perilymph gushers’ is so low and it is much easier to control any bleeding around the footplate region with it intact.

60

Chapter l 1 in saline, around the incudostapedial joint and tries to get the cutend of the stapedius tendonto stick to the fat. The ear is then closed. This operation is then equivalent to a Rosen’s stapes mobilisation, which often gives good hearing for some months or years until the fractured otosclerotic focus heals. If the patient then wants further surgery, theargon laser can be used to ‘fragilise’ the crura. Use of the laser

Fig. 11.3 After curetting the bony canal wall, the tip of the pyramid is visible and the chorda tympani can be gently elevated out of its canal and deflected inferiorly.

The author is increasingly using the argon laser during stapedectomy. The angled middle ear GheriniKaufmann endoprobe has an extremely fragile tip and must be used with great care. To ‘fragilise’ the posterior crus 0.2 S bursts are used at a power setting of 2W. The tip of the probe is placed lightly on the posterior crus and the laser fired. This is repeated, moving the tip a little sideways until the black carbon line is seen across the posterior crus. Unless there is a direct view of the anterior crus, the author does not use the laser blind because of the risk of damaging the facial nerve. With

Fig. 11.4 A small joint knife is being used to cut through the incudostapedial joint. It is gently inserted between the lenticular process of the incus and the head of the stapes and rotated from side to side. The angle of the blade on the shaft makes this a relatively simple manoeuvre.

Fracturing the crura

The author uses a slightly curved needle and, with this between the facial nerve and thearch of thestapes, gentle pressure is exerted against the arch of the stapes in an inferior direction (Fig. 11.Sb).While doing this, it is very important to keep the microscope focused on the footplate and to look at the footplate. If this starts to mobilise while trying to fracture the crura, the author stops the operation, wraps the fat, which has been kept

Fig. 11.5 (a)Some microscissors are used to cut the stapedius tendon close to the neck of the stapes. (b) With the tendon cut, a small curved needle or hook can be used to deflect the crura inferiorly away from the line of the facial nerve.

Stapedectomy

6I

felt and then it is time to move up to the larger 0.8 mm trephine (Fig. 11.7’). This is used untilthe increased torque is felt again and is then stopped. Theauthor does not use a microdrillto perforate the footplate, but this is an alternative way of creating a smooth 0.8 mm diameter stapedotomy. Once the stapedotomy has been created, suction must never be used near the oval window niche. If perilymph obscures the view, it may be absorbed using very small, dry, cotton-wool pledgets. Inserting the piston

Fig. 11.6 When using the trephine to penetrate the footplate it is important to have good control over the movement. This is achieved by having the shaft of the trephine resting on the index and middle figures of the left-hand (for a right-handed surgeon) and gently rotating the shaft using the index figure of the right-hand. Using the index figure of the left-hand is a good technique for stabilising the instruments down the ear canal and this technique can also be used during placing the piston and crimping the platinum band.

the posterior cruseffectively broken, then fracturing the anterior crus is ver 10mm diameter). All micro- and many macroadenomas are now considered to be treatable by trans-sphenoidal surgery, but those unsuitable will be discussed under Contraindications. Endocrine disor ers caused by function in^ pituitary adenomas

The functioning adenomas are as follows: Prolactinoma (prolactin-producing adenoma)

Thesearethecommonestadenomas.Theyoften respond well to treatment with dopamine agonists, such as bromocriptine. Surgery is reserved for: 1 those prolactinomas which do not respond to medication; 2 patients who are intolerant of the medication; 3 unresponsivemacroadenomascausingintracranial complications. Acromegaly (growth-hormone-producing adenoma)

This is the second most common adenoma, Octreotide

(Sandostatin) has become available to treat this condition medically, but this drug is still in the process of development. Surgery is effective-most tumoursare macroadenomas. Cushing’s disease (ACTH-producing adenoma)

The adenomas causing Cushing’s disease are almost always microadenomas, andmay even occurin an ‘emptysella’, with the disease being caused by a tiny adenoma in the pituitary remnant. Careful endocrine assessment is essential to ensure that the syndrome is being caused by an adenoma in the pituitary, not in the adrenal or from an ectopic source (e.g. oat-cell carcinoma of the lung). Nelson’s syndrome

If a patient has an ACTH-producing pituitary adenoma and is treated by an adrenalectomy, he/she may develop Nelson’s syndrome, with hyperpigmentation andan expandingpituitaryadenomacausing palsies of the extraocular muscles by invasion of the cavernous sinus. Surgery will debulk these tumours,butradiotherapy should be used as well because of the invasion of the cavernous sinus, which is unlikely to be cleared by surgery alone. Rare adenomas such as TSH-producing adenoma

These can be effectively treated by hypophysectomy.

~~ans-spheno~dal Hypophysectomy

243

Compression of intracranial structures

Optic chiasma

Local

Chiasma1 compression typically causes gradual loss of vision, initially inthesuperiortemporalquadrants. There can be a suddenloss of vision because of bleeding into a pre-existing adenoma. If treated promptly, the recovery is good.

l Acute infections of the nose or sinuses. 2 Malaeration of the sphenoid sinus. This is a stated contraindication, but the author has not encountered it in 120 cases. 3 Suprasellar spread or cavernous-sinus invasion. Suprasellar extension of an intrasellar tumour may well by amenable to trans-sphenoidal surgery, but such tumours need carefulconsideration. If thetumour is spherical, it often drops down into the fossa when the lower part is removed. If it is bilobed, the upper lobe will not be as accessible from below and such tumours are better managedby a transfrontal approach. Tumour extension laterallyinto thecavernous sinusis not readily accessible by anyapproach,butcan be partially removed trans-sphenoidally. 4 Carotidaneurysm. If this is suspected,itmust be excluded by angiography.

Normal pituitary gland

Hypotituitarism can be caused by compression or replacement of the normal gland. For this to occur, the tumour is usually large enoughto compress other structures as well. Third ventricle and hypothalamus

An expanding tumour can disturb the flow of cerebrospinal fluid (CSF) by compressing the third ventricle.

General

Nerves in the cavernous sinus

These are rarely damaged by an expanding adenoma, and, if a pituitarylesion is causing an oculomotor palsy, consider alternative pathology, such as an aneurysm. Notethatmacroadenomas,pituitary cysts, other tumours,suchascraniopharyngioma,chordomaor metastatic carcinoma, or aneurysms may present as expanding lesions in this site. Theymaypresentwith symptoms or as an incidental finding on ascanperformed for another reason. Cerebrospinal fluid leaks from the pituitary fossa

Thesecanoccurfromthisregion because of the following: 1 empty-sella syndrome; 2 after pituitary surgery -either early or late; 3 post-traumatic; 4 glioma. The trans-sphenoidal approach is excellent for closure of CSF leaks coming through the sphenoid sinuses.

1 Risk of haemorrhage. Bleeding duringsurgery is mainly venous but it can be profuse. Any tendency to bleed is a contraindication to this surgery. 2 Poorgeneralhealth.Themorbidityfromtranssphenoidal surgery is significantly less than for transfrontal surgery, but thisis major surgery, and the patient should be as fit as possible.

Preoperative management These patients are almost alwaysreferred to the surgeon by another hospital doctor, most frequently an endocrinologist or aneurologist.They have usually been fully investigated and the diagnosis made, but isitessential for the surgeon to be satisfied that the diagnosis is correct and that the indication for surgery is appropriate. Preoperative examination

This is important todetect any nasalsepsis or abnormality which will complicate the approach. Imaging

Management of hormonally dependent tumours and diabetic retinopathy

Thiswaspopular,buthypophysectomy used for this purpose.

is no longer

C T scans

Axial and coronal CT scans show the bone and sinus detail. Sagittal reformats in the midline show the anterior aspect of the pituitary fossa.

244

Chapter 34

MRI scans MRI is particularly valuable because it is best for softtissue contrast and more like:ly than CT todemonstrate a microadenoma. It alsodem.onstrates extrasellar extension and the optic chiasma well. Angiography This is indicated if an aneurysm is suspected. A plain lateral view of the sinuses This is more or less to scale, and is useful as a reference during surgery.

If there is any suprasellar spread on imaging or if there is any visual disturbance,the visual fields should be formally recorded pre- and postoperatively.

physectomy The anatomy for the approach to the pituitaryis as for an external ethmoidectomy. The surgeon needs to be thoroughly conversant with the anatomy of the nose, ethmoid sinuses, and the medial wall and apex of the orbit. Particular points to note are as follows: 1 The anterior ethmoidal artery enters the nose from the orbit through the frontoethmoidal suture line 2.5cm posterior to the nasion. This is in the angle between the medial wall and the roof of the orbit. The level of the artery is below the floor of the anterior cranial fossa in the ethmoidal cells, but it may be above the level of the cribriform plate, medial to the anterior attachment of the middle turbinate (Fig. 34.1). 2 Theoptic nerve may indentthemostposterior ethmoid and the sphenoid sinuses. It can be vulnerable here if the surgeon dissects too far laterally. 3 The sphenoid sinus ostium is located halfway up the anterior, nasalaspect of the sphenoid sinus wall, several millimetres lateral to the attachment with the vomer. 4 Thecarotidarteries may be visible withinthe sphenoid sinus, where they may indent the lateral walls below the pituitary fossa. 5 Anatomy of the pituitary. The gland lies within the bony pituitary fossa, with one cavernous sinus on each side of it and the dorsum 'sellae posterior to it. It is encased in dura onall sides except superiorly, where the stalk of the gland enters through the diaphragmasellae.

Fig. 34.1 Trace of a coronal CT scan 2.5cm posterior to the nasion. A, level at which the anterior ethmoidal arteries leave the orbits; B,level of the cribriform plate.

Within the fossa, the pia and arachnoid have fused with the dura and there is no subarachnoid space. The anterior lobe is cellular and vascular, and the smaller posterior lobe isless vascular and consists mainly of unmyelinated nerve fibres, which are attached to their cell bodies in the hypothalamus. The blood supply is from twigs of the internal carotid and anterior cerebral arteries, and the anterior lobe also receives blood from the hypothalamus, via a portal venous system. Venous drainage is into the cavernous sinuses.

Operative technique Preparation

1 Topicalvasoconstriction in the nose is essential. Xylometazoline or cocaine spray is satisfactory. 2 Anaesthesia: general anaesthesia is required, with oral endotracheal intubation. The patient should be ventilated and mildly hypotensive. 3 Prophylactic antibiotic cover is essential. Coamoxiclav(Augmentin) l.2 g is given intravenously on induction, and repeated S-hourly for 48 h. Hydocortisone cover is also given, according tothe regimen given in the postoperative managementsection. 4 Positioning of the patient: the headis slightly elevated and supported in a head ring, so that it can be moved during the operation but is stable. The operating table should be radiolucent so that the patient canbe screened on the table if necessary. incision

The skin is preparedwithaqueous chlorhexidine. The head is draped so that the nose, eyes and forehead are exposed, and the eyes are held shut with Steristrips.

Fig. 34.2 Skin incision for transethmoidal approach.

A curved incision is made from the medial end of the right eyebrow to the inferior margin of nasal bone. The incision mustrunanterior to themidpoint, between the medial canthus and the nasion (Fig. 34.2), because this prevents unsightly webbing of the scar. Incise right down to bone, using the full length of the incision, and obtain haemostasis. If the surgeon is right-handed, it is easier to maketheapproachthroughtheright side. However, if the patient has a lesion which requires an approach through the left, or if the patient is blind or has poorsight in the left eye and good vision in the right, it is perfectly possible to do the approach through the left ethmoids.

The periosteum is dissected off the bone. At the point of incision, this isfirmly adherent and a small, sharp, periosteal elevator is needed. Once the anterior lacrimal crest is exposed, the periosteum posterior to this strips readily off the medial wall of the orbit. A self-retaining retractor can be inserted to hold the orbital contents laterally, but it is important to avoid putting too much pressure on the eye. The author prefers the Talbot retractor to the more widely used Ferris Smith, because it has a good self-retaining ratchet and the handles can be rotated andclipped to the head towels to maintain good access.

The frontoethmoidal suture line is identified in the superomedial corner of the orbit. The anterior ethmoidalartery is found about2.5cm fromthe nasion, running from the orbit to the nose. It should be dissected sufficiently to be able to ligate and divide it safely with diathermy or clips (titanium is essential because thepatient may need MRI in the future). The artery is an important reference point, as it is the posteriorsuperior limit of the excision of the lamina papyracea (Fig. 34.3). A rectangle of bone is removed fromthe medial orbital wall, as illustrated in Fig. 34.3.Theanterior ethmoidal artery is the posterior superior limit of the resection. The anterior ethmoidal cells are opened and cleared in aposteromedialdirection until the nose is entered. It is essential not to go superiorly or through the attachment of the front half of the middle turbinate, because the cribriform plate is vulnerable (Fig. 34.1). It is important to work posteromedially until the nose is entered, and then to identify the sphenoethmoidal recess and thesphenoidostium. These arefound by using the rounded end of a Freer’s dissector passed through the right nostril, and working gently up the face of the sphenoid 2-3mm lateral to the midline. About 1cm above the inferior attachment of the vomer, the ostium can be gently probed and then seen. The ethmoids can then be cleared and, if necessary, the posterior part of the middle turbinate removed, to bring thefrontof the sphenoid into full view. At the superior limit of the ethmoidal cells, thewhiter bone of the floor of the anterior cranial fossa can be seen. Note that the optic nerve may lie in the superolateral part of the posterior ethmoid cells. The frontof the sphenoidis removed using a fine bone punch, such as the Hardy sella punch, working inferiorly first. The interior of the sphenoid sinus and

Fig. 34.3 Window into ethmoids.

Fig. 34.4 Axial view of access to pituitary via ethmoids.

the pituitary bulge are exposed. Careful review of the CT scans will demonstrate the position of the septum between the two sphenoid sinuses. The septum is removed if this will improve access. The posterior part of the nasal septum is removed by perforating it just anterior totherostrum of the vomer, thus allowing the surgeon to see the left sphenoidostium.The left sphenoid is then opened, allowing a good view of the whole pituitary fossa (Fig. 34.4). Ideally the surgeon should be able to see up to the point where the front wall of thepituitary fossa meets the roof of the sphenoid, and laterally to where it meets the lateralsides of thesphenoid sinuses. Thecarotidarteries may be visible in the lateral walls below the pituitary fossa. If thesinus mucosa is thick (a common finding in acromegaly), it canbe reflected inferiorly and held down with a small neurosurgical swab, and used to complete the closure at the end of the operation.

The surgeon needs to be sure of the midline. The rostrum of the vomer is a consistent midline feature. The microscope is used, and the surgeon can sit if the head is turned and 4.5" eyepieces are used. The bony anterior wall of the pituitary fossa is removed. If the bone is thin or eroded, it can be removed by pressing through it and picking it up with Hardy sella punches. If it is thick, a drill witha large burr isused untilenough dura is exposed to allow access for a punch. The bony defect is enlarged in the extradural plane to allow adequate access, but to a minimum of 1cm2. The dura covering the pituitary contains veins connecting the cavernoussinuses; these are oftenvisible and

should be avoided when incising intothe fossa. A cruciate or T-shaped incision may be made. The pattern is marked out with a coagulation diathermy on a low setting, and then incised withcuttingdiathermy or microdissection scissors. Once the dura is incised, a plane can be developed between the gland and the layers of the dura. The location and size of the tumour will then determine how the surgeon proceeds. If imaging hasdemonstratedthe location of amicroadenoma,this part of thegland is dissected. It is easiest to dissect along the floor until theposterior wall of the fossa is felt, thenalong theappropriate side and finally over thetop. If an obviousadenoma is identified at operation, remove this and a rim of normal gland for histology. Not all microadenomas are discrete, and imaging does not identify them all. The first operation is also much easier than any revision operations, and so the surgeon should aim to cure the disease rather than leave adenomatous tissue behind. If there is a macroadenoma, and particularly if there is significant suprasellarspread,thetumour may be opened and the fossa emptied. If the tumour is soft, the superior portion will drop down as the lower portion is removed, and in this way the tumour may be cleared. Raising the intracranial pressure at this point brings the superior extension down into view. When the superior surface of thegland is dissected, the very delicate diaphragma sellae can be seen as a blue pulsatile membrane, and the gland can be gently dissected off this, Gentle dissection will minimise CSF leakage. Closure

The author uses Lyostypt collagen foam to packthe pituitary fossa. Muscle was used but there is morbidity associated with the donor site, and collagen foam is just as effective. If there is venous bleeding during surgery, this stops rapidly withpacking, which does not need to be tight. A piece of bone from the septum or turbinate can be shaped and used to rebuild the front of the fossa. The sphenoid mucosa or turbinate mucosa can then be used to patch the area and covered with more Lyostypt; then a 1.25cm X 1m bismuth, iodoform and paraffin paste (BIPP) pack can be packed carefully intothe sphenoid, and into the right side of the nose. Seldom is a pack required in the left side if the sphenoid is adequately packed. The incision is closed in two layers, 4/0 Vicryl to the periosteum and interrupted 510 Ethilon to skin. The skin sutures should be put in to obtain exact apposition of the skin edges, and should be removed at 3 to 4 days to

~ ~ a n s - s p b e n o i~dy~pl o p b y s e ~ ~ o m247 y minimise scarring. If the incision is correctly located and is closed in this way, it will be virtually invisible in 6 months. Alight dressing rnay be needed to stopany ooze entering the eye, but nothing is achieved by putting on a head bandage or eye patch, which merely obscures a developing haematoma.

Postoperative management Neurological observations

Routine neurological observations should be carried out for the first 24h. On recovering from the anaesthetic, the patient is usually fully alert and orientated. There is little pain in the nose, but headache occurs if there was a significant loss of CSF on the table. Occasionally an orbital haematoma can develop, and so the eye must be watched for this. Fluid balance

An accurate fluid balance is important because the patient may develop a diuresis, particularly if the posterior pituitary has been injured or there was traction on the pituitary stalk. Itdoes not start until the first postoperative day. In the event of a diuresis (> 4 L urine output/ 24 h),if the urine output is >250 ml/h for 3h, give 1pg of DDAVP. The diuresis may not be due to diabetes insipidus, and so donot give DDAVP if theserum sodium is less than 145mmol/L or severe sodium depletion rnay result. Daily electrolyte measurement is required to monitor this. Steroid replacement

Steroid cover is used for all patients, and the regimen is as below. Day of surgery hydrocortisone 50mg IV/IM 6-hourly 1st day hydrocortisone 50 mg IV/IM 6-hourly 2nd day hydrocortisone 50 mg IV/IM 6-hourly 3rd day hydrocortisone 50 mg IVfiMlorally 8-hourly 4th day hydrocortisone 50mg IVlIMlorally 12-hourly 5th day hydrocortisone 50 mg mane, 20mg nocte 6th day hydrocortisone 30mg mane, 20mg nocte 7th day hydrocortisone 20 mg mane, 1Omg nocte Thereafter hydrocortisone 20 mg mane, 1Omg nocte The hydrocortisone must not be stopped until the pituitaryfunctionhas been formally assessed some weeks after surgery.

The haemoglobin is checked prior to discharge, and sooner if necessary. The nasal pack is removed at 5 days if there is no CSF leak. Postoperative visual-field testing can be arranged if the surgery was for chiasma1 compression. There is usually an early response to decompression. Patients go home 6-7 days postoperatively if all is well, on steroids and with a steroid warning card.

Complications Peroperative

1 Bleeding: this is venous, from the intercavernous connecting veins, and can be troublesome because it obscures the view of the surgeon. It is often possible to compress or pack the bleeding point with Lyostypt or a similar haemostatic material, or to clip it to the floor of the fossa withatitanium Ligaclip. Arterial bleeding from the carotid is possible, but must be avoided. Packing the fossa at theend of theprocedurestopsthe venous bleeding. 2 CSF leak from the cribriform plate area can occur if the surgeon is too high and medial anteriorly, and must be recognised and patched from below. 3 Optic-nerve injury is possible, but direct injury is avoided by remaining within the pituitary fossa. Early postoperative complications

1 Orbital haematoma can occur, and may need to be drained. 2 Diuresis: this is managed as described above and it usually settles within days, but, if it persists, nasal desmopressin is administered to control diabetes insipidus. 3 CSF leak rnay be troublesome, and indicates an inadequate seal inthe fossa. Antibiotic cover should be continued. It oftensettles within days, but, if it does not, lumbar puncture, lumbar drainage or repacking may be required. 4 Meningitis is unusual, because of prophylactic antibiotics. Patients can suffer from meningeal irritation several days postoperatively because of blood in the CSF. If meningitis is suspected, lumbarpuncture is done to make the diagnosis, and treatment started. 5 Crusting in the nose occurs intheethmoids and sphenoid, but settles with time. Late postoperative complications

1 Recurrence of the adenoma is the commonest complication,andlong-termfollow-up is important,with

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biochemical assessment and further imaging when indicated. 2 Hypopituitarism. 3 Diabetes insipidus. 4 Frontal sinusitis may arise if the frontonasal duct is damaged in the approach.

~ ~ t e r n a t i vtechniques e Trans-septal transllsphenoidal approach

This approach and variants of it arepopularamong neurosurgeons. An incision is made across the incisive fossae under the upper lip, and the septum is dissected in the subperichondrial and subperiosteal planes. The septum can be preserved and displaced laterally, and the sphenoid opened in the midline. A self-retaining retractor is inserted to maintain access during the procedure. Disadvantages 1 Longer route to the pituitary fossa. 2 Line of vision is the same as the route for instrumentation. In the transethmoidal approach, the instruments are used throughthe nose while thesurgeon views through the ethmoids.

3 Narrower access: the transethmoidal approach allows a wider angle of vision to thefront sphenoid.

of the

Advantages 1 No facial scar. However, if the technique described above is used in the transethmoidal technique, scarring is minimal. 2 A midline approach gives a symmetrical view of thegland. In thetransethmoidal technique, arightsided approach gives a better view of the left side of the gland. 3 The lower angle of approach gives a better view of the roof of the sphenoid sinus and makes suprasellar extensions more accessible by this route.

Further reading Hardy J (1982) Trans-sphenoidal hypophysectomy. In: Youmans JR (ed.) Neurological Surgery, Vol. 6. Philadelphia, W.B. Saunders, pp. 3959-72. Williams RA (1983) Trans-sphenoidal hypophysectomy. In: Ballantyne JC & Harrison DFN (eds) Rob & Smith’s Operative Surgery-Nose andThroat,4th edn.London,Butterworths,pp. 170-7.

Surgery for Cerebrospinal-fluid Rhinorrhoea CHRIS A. MILFORD

indications Leakage of cerebrospinal fluid (CSF)fromthe nose is symptom a of failed containment within the subarachnoidcompartment and its origin may be fromany of thecranial fossae. It may occur from the anterior cranial fossa through the frontal, sphenoidal or ethmoidal sinuses or directly through the cribriform plate. Escape of CSF from the middle and posterior fossae may occur directly via thesphenoid sinus or indirectly via themastoidair cellslmiddle ear through the Eustachian tube (CSF otorhinorrhoea). In this chapter,theproblem of CSF otorhinorrhoea will not be addressed and only the leakage of CSF into the nose directly or via theparanasal sinuses will be dealt with. Although the actualloss of CSF itself isof no particular consequence, a persistent dural fistula represents a persistent hazard for a potentially fatal purulent meningitis. Persistent CSF rhinorrhoea is therefore an absolute indication for the surgical repair of the leak.

Preoperative management The aetiology of CSF rhinorrhoea may be traumatic or non-traumatic (spontaneous). The evaluation of a patient suspected of having CSF rhinorrhoea should do the following: 1 Confirm the presence of the leak (confirm that the fluid is CSF). 2 Demonstrate the cause whenever possible. 3 Identify the site of the leak. Accurate definition of the leakage site is undoubtedly the most important factorin successful surgical treatment of this difficult problem. Contrast CT cisternography and intrathecal dye studies

(fluorescein) appear to be the most useful investigations for localisation.

Anatomy of the anterior skull base The bone of the anterior skull base is thin with densely adherent dura andhence trauma in this site often results in dural tears and CSF leaks. The most common location of anterior fistulae is the region of the fovea ethmoidalis and the posterior frontal sinus wall. In the region of the fovea ethmoidalis, the ‘weakest’ point is where the thick fovea ethmoidalis (that partof the frontal bone forming the roof of the ethmoid) joins the thin lateral lamella of the cribriform plate medially, and in particular where the anterior ethmoidal artery passes into the anterior cranial fossa (Fig. 35.1). The bone in the vicinity of the anterior ethmoidal artery is 10 times thinner than the neighbouring roof.

Operative technique Operative approaches are divided into intracranial and extracranial. Intracranial procedures will not be dealt with, although this may be the approach of choice in some leaks that cannot be localised (and especially if they cannot be lateralised). The particular extracranial technique adopted is dependent upon the site, size and nature of the leak and may be via a conventional external approach or, in some cases, may involve endoscopic techniques. Whichever technique is used, the principle used in repair is the same. Firstly, a free graft of tissue is used to mechanically stop the flow of CSF so that the rest of the repair can proceed and the overlying layers will not be disrupted. This initial free graft is best placed between the

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Fig. 35.1 Anatomy of the anterior skull base. 1, fovea ethmoidalis; 2, lateral lamella of cribriform plate; 3, ophthalmic artery; 4, anterior ethmoidal artery.

dura and bone, i.e. thegraft is ‘tucked in’ abovethe bony skull base on the intracranial side. Next, ideally, a vascularised graft is placed over the defect to bring in ablood supply, fibrin and the cellular elements of wound healing, e.g. a pedicled flap of nasal mucosa. Finally, atemporarysupportive dressing is required to keep the repair in place in the immediate postoperative period. The tviro traditional external approaches are as follows: 1 leakage of CSF throughthefrontalsinus may be approached via the anterior osteoplastic-flap procedure; 2 leakage of CSF through the cribriform platehoof of ethmoidhphenoid may be repaired via an external ethmoidectomy approach.

adrenaline, and both eyes are closed withtemporary tarsorrhaphysutures of 5/0 silk to avoid accidental damage to the cornea. The place of prophylactic antibiotics in the presence of CSF rhinorrhoea is still controversial and their use has been both condoned and condemned. The place of an indwelling subarachnoid lumbar drain in the postoperative period is not clear but would seem a reasonable option in the hopeof improving the success rate for this type of surgery. The drain canbe placed after induction and prior to the operation, and if used then prophylactic antibiotics are indicated until the drain is removed (510 days postoperatively). A Silastic cut-out (template) of the frontal sinuses is made preoperatively from the occipitomental view of the sinus X-rays. Thecut-out is placed in sterilising solution prior to surgery. The skin of the abdomen or thigh is prepared so that agraft of fatandlor fascia lata may be obtained if required. Incision

Although an eyebrow incision along the upper margin of the ipsilateral eyebrow can be used for a unilateral operation,the author believes abilateralosteoplastic flap is the procedure of choice, because of the better

Leakage of CSF through the frontal sinus

Preparation

The operation is performed under a general anaesthetic (GA) given via an oral endotracheal tube (ET) with a pharyngeal pack, with the patient supine and head elevated. The nose is packed with 1cm ribbon gauze soaked in a mixture of 1m1of 1:1000 adrenaline and 2ml of 5% cocaine solution, in an attempt toreduce the vascularity of the nasalmucosa. The skin is cleaned with aqueous chlorhexidine and thehead is draped with towels to exclude the hair, mouth and ear. Theincision line is infiltrated with 0.5% lignocaine and 1:200 000

Fig. 35.2 The eyebrow (spectacle) or coronal incision.

Surgery for ~erebrospinal-~uid Rhinorrhoea

Fig. 35.3 Procedure for osteoplastic flaps. After Rob 6 Smith’s Operative Surgery-Head and Neck (1983). IA McGregor and DJ Howard (eds).

qI

the supraorbital and supratrochlear vessels). This flap may be used forrepair of theanteriorcranial floor, following anterior craniofacial resection, and it can beused in this situation as avascularised flap to repaidline the posterior wall and floor of the frontal sinus in the presence of a CSF leak into this sinus (Fig. 35.3). 2 The X-ray template is taken from the sterilising soluti6n, rinsed with saline and placed over the frontalbone. A pencil is used to outline the template, 2mm a rosehead or fissure burr is used to follow the outline of the template (cuttingjust inside the line to ensure the incision is within the limits of the sinus) and the‘incision’ is gradually deepened until the frontal sinus is entered. Superiorly, the bone is bevelled obliquely as much as possible so as to ensure an accuratereapproximation of the osteoplastic flap and to prevent the bone falling in on replacement (Fig. 35.4). Holes can be made in the bone flap and corresponding margin of the frontal bone to facilitate replacement of the bone flap with heavy Vicryl ties (alternatively the miniplate fixation system can be used) at the end of the procedure. 3 The bone flap is then elevated at the superior aspect and, as the flap reflects downwards and forwards, there is a fracture across the floor of the frontal sinuses (the

access. For the bilateral osteoplastic frontalsinus procedure, the eyebrow (spectacle)or coronal incision can be used (Fig. 35.2). The eyebrowincision should be made along the entire length of the upper marginof the eyebrowand extended horizontally over the glabella. The coronal incision is made approximately 1 inch (2.5 cm)behind the anterior hairline. The bilateral eyebrow flap is elevated superiorly in a plane between thefrontalis muscle and the periosteum over the frontal bone, taking care not to incise the periosteum.The coronalflap is elevated in the same plane and reflected inferiorly over the face, exposing both supraorbital rims and the nasal process of the frontal bone (avoiding damage to the supraorbital and supratrochlear nerves). Since bleeding is much more of a problem with the coronal incision, neurosurgical haemostatic clips facilitate this approach. Procedure

1 Although the original description for the osteoplastic flap describes making an incision in theperiosteum (pericranium) andbone around the outlineof the frontal sinus, using the X-ray template, the author recommends adoptinga modification which involves first raising arectangularpericranial flap with its base at the supraorbital region (thus receiving its blood supply from

Fig. 35.4 Bone i s bevelled obliquely. After Rob 6 Smith’s Operative Surgery-Head and Neck (1983). IA McGregor and DJ Howard (eds).

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Chapter 35 Closure

1 In order to allow the pericranial flap to pass into the sinus easily, aslot may be created by trimmingthe inferior edge of the osteoplastic flap before returning it to its original position (the ‘letter-box technique’). The osteoplastic flap may be secured with heavy Vicryl sutures passed through holes made with a fissure burr. Thecoronal incision is suturedwitha deep layer of absorbable (310 catgut)sutures and interrupted skin sutures of 4 0 Prolene, with a small suction drain left in place. 2 The tarsorrhaphy sutures areremoved and a pressure dressing, to remain in place for 72 h, is placed over the forehead. Fig. 35.5 Free fat graft used to obliterate sinus on top of the pericranial flap.

interfrontal septum has to be divided with a chisel or curved osteotome to allow this). The supraorbital rims and glabella can be particularly thick in men, and a separate cut in the nasion may be helpful in achieving this fracture at the lower end.Whenthefracture is completed and the periosteum has been elevated from the frontal bone, the bone flap can be removed and kept in a betadine solution until the procedure is complete and it is time for the bone to be replaced (separation of the bone flap from its overlying periosteum and its removal does not appear tocompromise itsviability when it is replaced). 4 Once the osteoplasticflap has been removed, the interior of both frontalsinuses is inspected for thesite of the leak. A careful look for anything that pulsates is essential: CSF or anything else communicating with the cranial cavity, such as an arachnoid protrusion, transmits pulsations of the brain. The mucous membrane lining of the frontal sinus is removed, the bone being burred if necessary to remove all traces of mucosa. Posterior table bone can be removed at the site of the leak, and the dura can be repaired directly or a free pericranial graft placed over the site of the leak and tucked in behind the bony margins of the posterior wall. The use of tissue glue has been shown to improve results of repair of CSF fistulae. The inferiorly based pericranial flap may then be placed over the floor of the sinus/posteriorwall to seal the sinus from the nasal cavity. A free fat graft can then be used to obliterate the sinuson topof the pericranial flap (Fig. 35.5).

Postoperative management

Thepatient is nursed in bed forthe first 5 days postoperatively, with the lumbar drainon free drainage. He/she is advised to avoid coughing, sneezing and straining dueto physical activity. At the endof this time, the drain is clamped and, if there is no evidence of a recurrence of the CSF leak, the drain is removed. Following this, the patient is allowed to mobilise slowly and theantibioticsare discontinued afterafurther 5 days. Complications

l Failure to seal the CSF leak.

2 Bony depression of the osteoplastic flap, resulting in cosmetic deformity. 3 Haemorrhage, with haematoma formation under the flap. 4 Infection of the.primary site (osteomyelitis of the frontal bone flap) or fat donor site. Leakage of cerebrospinal fluid through cribriform plate/roof of ethmoid/sphenoid sinus

Preparation

See above. Incision

A 1 inch (2.5cm) curved incision is made halfway between the inner canthus and the anterior aspect of the nasal ridge. It may be extended under the eyebrow to facilitate access.

Surgery f o r Cerebrospinal-fluidRhinorrhoea

q3

be opened, thenasal septal flap described below needs to be elevated prior to removal of the anterior sphenoid wall). The middle turbinate is removed, which now allows access to theolfactory slit (region of thecribriform plate), andhence this area is now in continuity with the roof of the ethmoid air cells. 5 Oncetheexposure is complete, thedural defect is usually found with the aid of the operating microscope (200 mm lens). Again, a careful look for anything that

Fig. 35.6 Identifying posteriorly based septal mucosal flaps.

Procedure

1 The incision is extended through the skin, subcutaneous tissue and periosteum. Troublesome bleeding from the angular vessels can be dealt with using bipolar cautery. Two or three stay sutures, weighted with heavy haemostats, placed on each side of the incision act as effective retractors. 2 Periosteum is elevated, using a combination of sharp dissection, with the Freer’s elevator, and blunt dissection,withshortstrips of l c m ribbon gauze soaked intopicaladrenaline ( l:30000). The periosteum is mobilised to expose the nasal process of the maxilla, frontal bone and medial wall of the orbit. The lacrimal sac is displaced laterally without transecting the duct. 3 Dissection along the medial wall of the orbit continues to reveal theanteriorethmoidal vessels, which arecoagulatedwithbipolardiathermy and divided. The posterior ethmoidal vessels indicate the posterior limits of theethmoidair cells, and these aredealt with in a similar way. Lateral retraction of the orbital contentsduring this part of the dissection is best achieved by theassistant using acopper malleable retractor. 4 Theethmoidlabyrinth is entered by perforating the lamina papyracea just posterior to theposterior lacrimal crest, using a Tilley-Henkel forceps. The ethmoidal cells can be exenterated under direct vision via the incision and also with instruments inserted via the nose. The primary goal is to clean the mucosa away from the entire roof of the ethmoid sinus and to extend the explorationintothesphenoid sinus and region of the cribriform plateif necessary (if the sphenoidneeds to

Fig. 36.7 Posteriorly based septal mucosal flap-lateral view.

Fig. 35.8 Posteriorly based septal mucosal flap-coronal view.

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Chapter 35

pulsates is essential. Once identified, a posteriorly based septalmucosal flap is elevated (Figs 35.6-35.8). The superior incision extends along the anteroposterior dimension of the superior nasal septum at the junction of the septum and olfactory slit. This incision is carried as far anteriorly as possible (it is often necessary to remove most of the ascending process of the maxilla in this area to expose the anterosuperior nasal septum). The lower incision is approximately 2-2.5cm below, and parallel to, the superior incision (on elevating the flap, it invariably ‘shrinks’ and the author hasfoundthe classic description of a 1.5 cm-width flap inadequate). The anterior incision merely connects the anterior aspectof the superior and inferiormucosal incisions. A slightly longer flap can be obtained by extending the base of the flap on to the anterior face of the sphenoid (as is done when the leak is within the sphenoid). G A free piece of septalmucosaobtainedfromthe contralateral side is placed through the dural defect to stop the flow of CSF. It is best to push the plug through the fistula so that it acts as a one-way valve and is not simply flushed away by the flow ofCSF. Theseptal mucosal flap is then rotated into position over the defect and secured in place with the use of tissue glue. Over the flap is placed Lyostypt soaked in Sofradex topical antibiotic solutionandthe noseis packedwith l-inch (2.5cm) bismuth,iodoform and paraffinpaste (BIPP) impregnated ribbon gauze. Closure

The periosteal incision is closed with 4/0 catgut and 5/0 Prolene to skin. Chloramphenicol ointmentis applied to the incision. Postoperative management

Management of the lumbar drain in the postoperative period is asabove.Oncethedrain is clamped,the BIPP pack is removed if there is no recurrence of the CSF rhinorrhoea. The drain isremoved 24h after the removal of the nasal pack if no problems are encountered. Antibiotics are discontinued after removal of the lumbar drain and the patient is slowly mobilised. Complications

1 Incision-infection, paraesthesia and webbing of the wound may all result. 2 Haemorrhage-usually due to retraction of the ethmoidal vessels before adequate haemostasis is achieved.

3 Periorbital damage-epiphora and diplopia are usually transient. 4 Visual loss-unusualbutcan result if the globe is injured.

Endoscopic repair of CSF leak is a significant potentialcomplication of endoscopic ethmoidectomy, and immediate endoscopic repair of such leaks should be considered by any surgeon performing endoscopic nasal surgery if CSF rhinorrhoea isdiscovered intraoperatively. Other CSF leaks which are visible endoscopically are also amenable to endoscopic repair. Different techniques are described but all stress the importance of identifying the defect accurately. The mucosa is elevated from the surrounding bone and the free abdominal fat ormusculofascial graft is ‘tucked in’ above the bony skull base where possible, i.e. the intracranial side is supported.Mucoperiosteum (as a free graftfromthecontralateralnasalseptumor pedicled from the ipsilateral septum)is then placed over the defect and the edges are placed under the mucosal edges around the defect. Again, the use of tissue glue helps secure it, andfurthersupport is provided by the useof Gelfoam packing. Theapplication of endoscopictechniques to intranasalclosure ofCSF leakshasanumber of advantages over conventional methods. 1 Excellent field of vision, allowing exact localisationof the leak. 2 The ability to precisely clean mucosa from the bony defect without significantly increasing the sizeof the defect. 3 Accurate position of thegraftmaterial over the defect.

Alternatiwe procedures The nasal septal flap described above was popularised by Montgomery (197’3). However,other flaps have beendescribed for the repair ofCSF leaks, including theosteomucoperiosteal flap (Yessenow & McCabe, 1989), amiddleturbinate flap (Vrabec & Hallberg, 1964)and, where no septum or middle turbinate is available, a frontal pericranial flap introduced through a window createdby partial resection of the nasal bone (Pearson, 1991).

References Montgomery

WV

(19’73) Cerebrospinal

fluid

rhinorrhea.

Surgery for ~erebros~inal-~uid Rhinorrhoea Otolaryngol. Clin. North Am. 6, 757-71. Pearson BW (1991) Cerebrospinal fluid rhinorrhea. In: Paparella, Schumrick, Cluckman, Meyerhoff (eds) Otolaryngology, Vol. 111, Head and Neck. Philadelphia, WB Saunders, pp 1899-909. Vrabec DP & Hallberg OE (1964) Cerebrospinal fluid rhinorrhea.

255

Otolaryngol. Arch. 80, 218-29. Yessenow RS & McCabe BF (1989) The osteomucoperiosteal flap repair of cerebrospinal fluid rhinorrhea:a 20 year experience. Otolaryngol. Head Neck Surg. 101, 555-9.

Surgery JOHN K.S. ~O~

Introduction Epistaxis is an extremely common condition as well as a frequent otolaryngological emergency. It is estimated that up to 60% of people will experience one episode in their lifetime with 6% requiring medical attention (Shaw et al., 1993). In themajority of the cases the bleeding is idiopathic (Shaheen, 1987’). When a cause can be identified, epistaxis is usually secondary to nasal trauma, a local nasal pathology, a blood-vessel abnormality or a blood dyscrasia. Most epistaxes are mild and self-limiting; hospitalisation is only indicated for the severe cases. Even in these unusual cases, epistaxis can usually be controlled with anterior nasal packing. Posterior nasal packing is only occasionally required. Surgery is rarely necessary for epistaxis. Surgical treatment for epistaxis is controversial, with many options being available. The controversy relates more to the timing and nature of the surgical intervention than how to perform a particular operation. With the availability of modern endoscopes and accessory equipment, endoscopic techniques play animportant role in the managementof epistaxis (Bingham & Dingle, 1991; McGarry, 1991; Premachandra, 1991; O’LearyStickney et al., 1992).

Preoperative management Before surgery iseven considered, thepatientshould be adequately resuscitated. Attempts should be made to stop anteriornasal bleeding with an anterior nasal pack while, forposterior bleeding, balloontamponade is more effective. When balloon tamponade is used, the pressure should be adjusted to the minimum required to

arrest the bleeding. When nasal packs are used for more than 48h, it is advisable to give prophylactic antibiotics. Hypovolaemia should be prevented by adequate fluid replacement and, if necessary, with blood transfusion. Coagulopathy should be corrected and high blood pressure controlled. The majority of cases of, epistaxis will stop with adequate conservative treatment.

In general, surgical intervention is indicated in the following situations: 1 when there is continuous bleeding despite adequate conservative management; 2 whenthere is rebleeding whennasalpacksare removed; 3 when there is frequent and significant rebleeding.

The surgical management of epistaxis shouldbe tailored according to the cause whenever possible. Nowadays, using modern endoscopes and accessory equipment, the site of bleeding in most cases should be identifiable. Thus, when surgical intervention is considered necessary, surgical procedures can be logically considered in three steps. 1 Identification of the bleeding source. 2 Surgery for local control of bleeding. 3 Arterial ligation.

With modern endoscopes and the necessary accessories,

Surgery for Epistaxis the nose can be adequately examined even in the presence of active bleeding. Endoscopy for epistaxis differs slightly from diagnostic nasoendoscopy.

Endoscopy for epistaxis Preparation A full set of rigid endoscopes is required, including both 2.7mm and 4mm, with viewing angles of O", 30" and 70" for looking into narrow crevices and around corners. A flexible fibrescope with suction channel is a useful addition to bypass septal spurs and deflections. An efficient suction system is essential. A self-cleansing (irrigation andsuction) system withthe rigid endoscopes is useful accessory equipment. The procedure canbe performed under topical anaesthesia in most cases, using a long piece of ribbon gauze soaked in a solution of 4% xylocaine with 1:10 000 adrenaline. Small pledgets soaked in the same solution should also be available to pack narrow spaces as required. Torrential nasal bleeding is best managed under general anaesthesia.

Techniques The patient should be positioned supine, with the head raised, neck slightly extended, well supportedand turned towards the surgeon. Patients with epistaxis coming to surgery will almost always have a nasal pack inside their nose. Starting with the4mrn 0" endoscope, thenasal pack is slowly removed while taking care to note any sites of bleeding. Although the nasal mucosa is not topically prepared, there is usually enoughroomforthe passage of the endoscope immediately after the nasal pack is removed. Nasal secretions and blood clots are cleared with suction. No attempt should be ,made for a detailed endoscopic examination at this stage as thenasal mucosa will swell quickly and bleeding may recur at any time. The nasal mucosa should then be prepared using a single, long, narrow ribbon gauze. A singlepiece of ribbon gauze is preferred as it can be used to exert pressure on the bleeding pointsmore effectively than multiple smaller pieces. Layered nasal packing is applied, starting from the roof towards the floor. This will facilitate the subsequent endoscopy as the gauze is removed in the reverse order. Adequate time (10-15 min)should be allowed for mucosal anaesthesia and vasoconstriction to be achieved. As the nasal pack is removed great care should be taken to note any signs of bleeding, septal abnormality or varicose vessels at the posterior part of the nasal septum and the choana.

q7

If there is no bleeding after the nasal pack is removed, a gentle diagnostic nasoendoscopy shouldbe performed without reinsertion of a nasal pack. If epistaxis recurs at sites that can be localised, the pledgets should be accurately applied to these sites. The surgeon then prepares for local control of the bleeding. Surgery for local control of bleeding

In addition todiagnostic instrumentation, the following equipment should be available. 1 Bipolar diathermy (forceps and malleable pencils). 2 Monopolar suction diathermy. 3 A septoplasty set with a 2mm chisel.

Bleeding within the nasal fossa If bleeding continues after removal of the nasal pack and the source can be identified, this is controlled by simple means such asdiathermy. Whenever possible, bipolar diathermy should be used as it is more precise. The most useful instrument is the malleable bipolar diathermy pencil, which allows the surgeon to reach almostany bleeding pointwithinthenasal fossa. If the bleeding is profuse, monopolar suction diathermy provides suction and diathermy simultaneously. When bleeding is heavy, it may be stopped or slowed temporarily by injecting a small amount of xylocaine with adrenalinethroughadental syringe. Diathermy may then be applied.This technique works well on the septum.

Bleeding from behind a septal abnormality Any anatomicalabnormality identified on endoscopy preventing adequate control of the epistaxis should be dealt with immediately. These include septal deflections and spurs. Septal spurs can be corrected under local anaesthesia. The mucosa around the spur is injected subperichondrially/subperiosteally using 2% xylocaine with 1:80 000 adrenaline. Injection in the correct plane will result in immediate blanching of the overlying mucosa. A small incision is made using a Freer elevator parallel to the length of thespur.Mucosal flaps are raised on either side of the incision until the whole spur is laid open on either side by about 1mm. The spur is removed by means of a small chisel. The mucosal flaps are repositioned without suture at the endof the procedure (Fig. 36.1). If there is no oozing, no nasal pack is required. Otherwisea loose pack should be secured overnight.

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Chapter 36 3 there is recurrent severe epistaxis (especially when associated with hereditary telangiectasia). Contraindications

In general, surgical intervention is contraindicated in the following situations: 1 there is significant associated injury (especially head injury ); 2 there is a blood dyscrasia; 3 epistaxis recurs after previous arterial ligation (embolisation may be more useful). Principle of arterial ligation Fig. 36.1 Removal of a septal spur.

Bleeding from the back of the nasal septum or the nasopharynx

Posterior bleeding may be difficult to reach and in these cases the techniques described in ‘combined-approach nasopharyngoscopy’ may be employed. The endoscope is passed from the front, providing a visual guide, while the diathermy forceps or pencils are passed retrograde through the mouth. Nasal packing

If bleeding is profuse after removal of nasal packing prior to nasoendoscopy, then it is wise to place a loose nasal pack at the end of the definitive procedure. When bleeding is not controlled by the simple local measures described above,the nose should be repacked firmly witha bismuth, iodoformand paraffin paste (BIPP) pack. A plan should then be made for further appropriate intervention, including possible arterial ligation. If bleeding was secured with an anterior nasal pack alone, further intervention wouldbe planned at a later stage. If bleeding was not securely controlled or postnasal packing wasrequired, immediate arterialligation may be necessary. Arterial ligation Indications

Arterial ligation, although notcause-specific, is an effective means of epistaxis controland should be considered in the following circumstances: 1 rapid control of epistaxis is critical; 2 other methods to control the bleeding have failed;

The aim of arterial ligation for the controlof epistaxis is to lower the perfusionpressure so that bleeding will stop or may be stopped more easily by local measures. In general, themoredistalthe site of ligation themore effective theprocedure,asthe development of anastomotic channels will be less likely.

Relevant anatomy Blood supply of the nose

The nose is an extremely vascular structure, being supplied by branches from both the internal (ICA) and the external carotid arteries (ECA). The main blood supply is derived from the maxillary artery, which is the larger terminal branch of the external carotid. This is supplemented by the superior labial branchof the facial artery. The nose also derives some of its blood supply from the internal carotid system through the ethmoidal branches of the ophthalmic artery. Thebloodsupply of thelateralnasal wall can be described in quadrants made by vertical and horizontal lines passing through its centre(Last, 1978). The posterosuperior quadrant is supplied by ascending branches of thesphenopalatineartery.Theposteroinferior quadrant is supplied by branches fromthe greaterpalatineartery.Theanterosuperior quadrant is supplied by theanteriorandposteriorethmoidal arteries. Theanteroinferior quadrant is supplied by branches from thefacial artery and perforating branches of the greater palatine artery. Whereas the lateral nasal wall is supplied by quadrants, the septum is supplied in halves (Fig. 36.2) (Last, 1978). The anterosuperior half is supplied by the anterior ethmoidal artery assisted by branches from thefacial artery. The posteroinferior portion of theseptum is supplied by branches fromthe sphenopalatine artery.

Surgery for Epistaxis

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the bleeding is profuse and the source is poorly localised, a combination of arteries from both systems may need to be ligated (Hassard et al., 1986; Singh, 1992). The external carotid system

The external carotid system can be approached either by ligating the ECA in the neck close to its origin or by ligating the maxillary artery in thepterygopalatine fossa. The former approach has the advantage of being a simple procedure. The latter, although slightly more technically demanding, has the advantageof being more specific and achieves a better result (Spafford & Durham, 1992).

Ligation of the external carotid artery

Fig. 36.2 (a) Blood supply to the lateral wall of the nose. (b) Blood supply to the nasal septum.

The procedure can be performed under either general anaesthesia or local anaesthesia. The patient should be positioned supinewithshouldersupport and head raised. The neck should be slightly extended and turned to the opposite side. The incision is placed along a skin crease at the upper border of the thyroid lamina. Thisis continued through the platysma muscle and skin flaps are raised in the subplatysmal plane. The deep cervical fascia is then opened parallel to the anterior border of the sternomastoid muscle. The greater auricular nerve may be encountered and should be preserved. The carotidsheath is then identified by blunt dissection between the Sternomastoid muscle and theinfrahyoid muscles. The carotid pulsation is easily palpable. At its origin, the ECAis deep to theinternalcarotid.The external carotid is identified by demonstrating its branches. It is then doubly ligated, in continuity, with Osilk distal to its lingual branch (Fig. 36.3).In tracing the branches of the external carotid, the surgeon should be aware of the hypoglossal nerve, which may cross the surgical field. The deep cervical fascia is loosely approximated to the sternomastoid muscle. The wound is then closed in two layers.

Choice of arterial ligation

The decision to ligate an individual artery or a combination of arteries will depend on whether the site of bleeding is identified or not. A clear understanding of the principle of arterial ligation and the blood supply of the nose is necessary. When the bleeding is from the roof of the nose, theethmoidalarteries should be dealtwith first. On the other hand, when the bleeding is from the lower part of the nasal fossa or the lateral wall of the nose, the maxillary or the ECA should be ligated. When

Ligation of the maxillary artery The nose derives most of its blood supply from the ECA through its maxillary branch. Ligation of the maxillary artery is preferred to the external carotid in most instances of epistaxis, except in the critically ill patient, when the simplest procedure is indicated. The tributar-

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Chapter 36

Fig. 36.3 Ligation o f the external carotid artery.

iesof themaxillaryartery to the nose begin inthe pterygopalatine fossa. This is the ideal site to ligate the maxillary artery and its branches to the nose. The operation is preferably performed under hypotensive general anaesthesia. The patient is positioned supine with the head of the operating table raised. The patient’s neck is slightly extended and rotated towards the surgeon. The microscope, using a 300mm focallength lens, should stand at the top end of the table so that it is easily available even for bilateral ligation. The initial steps arethe same asfor Caldwell-Luc operation, except that theanteriorantralwindow should be enlarged until the whole of the posterior wall can be visualised through the microscope. The posterior wall of the antrum is palpated with a suitablebluntinstrument, such asa Freer’s elevator, to identify thethinportionfromthe thicker medial buttress. The mucosa is then removed over the posterior wall. The thickness of bone making up the posterior antral wall varies between individuals. When it is thin, theposteriorantral wall crackswith gentle pressure using a Freer’s elevator. Whenit is thick, alot of time can be saved by thinning the bone with a burr. The microscope should now be set into position. The cracked posterior bony wall is then removed piecemeal untilthe periosteal layer is exposed. Any prominent veins arecoagulated before the periosteal layer is opened to gain access into the pterygopalatine fossa. After the periosteum of the posterior antral wall has been opened, the main trunk of the maxillary artery is exposed by blunt dissection. This is achieved by the

repeated opening action of a pair of round-ended scissors into the glistening fat of the pterygopalatine fossa. The pulsation of the artery will be evident. After the main trunk of the maxillary artery is identified, it should be held taut withablunthook.This will facilitate cleaning of the rest of the artery and its main branches. No attempt should be made to clip the artery until all the branches of the maxillary trunk have been identified. The maxillary trunk and its branches have the configuration of an H inthepterygopalatine fossa (Fig. 36.4). The haemostatic clips should be applied firmly and doubly if possible, as shown. As the main trunk of the maxillary arterycomes from a deeper aspect than its branches, it canoccasionally be missed. The infraorbital branch may be mistaken forthe main trunk of the maxillary artery. Whenthehaemostatic clips are correctly applied, arterial ligation in continuity will suffice for most instances of acute bleeding. However, if the procedure is performed for hereditary telangiectasia, the maxillary artery should be divided and any aberrantvessels should be clipped or coagulated with bipolar diathermy. The buccal incision is closed loosely with interrupted catgut to lessen the postoperative facial oedema. There is no need for nasal antrostomy. Complicationsare similar to thosefrom CaldwellLuc operation. Isolated cases of total ophthalmoplegia have been reported in the literature (Beall et al., 1985).

>

The internal carotid system

The internal carotid system contributes much less to the nasal blood supply than the external carotid. The anterior and posterior ethmoidal arteries, both being derived from the ophthalmic artery, areconveniently reached in the orbit. The anterior ethmoidal artery is the larger of the two andcontributes more to the blood supplyof the nose. In many instances, only the anteriorethmoidal artery requires ligation.

Ligation of the ethmoidal arteries The operation is performed under general anaesthesia again, preferably using hypotensive techniques. The eye should be carefully protected by tapes or a temporary tarsorrhaphy.The skin preparationsolution must be non-irritant to the eye. A curved incision about 2cm in length is placed approximately midway between the dorsum of the nose and the medial canthus, as shown (Fig. 36.5).The incision should be marked accurately on the skin and the lacrimal apparatus shouldbe identified by palpation and avoided. The area should be injected with 1:200000 adrenaline 5-1Omin before the incision is made to minimise bleeding from the wound.

Fig. 36.5 Ligation of the ethmoidal arteries.

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261

The incision is continueduntilthe nasal bone is reached. The periosteum is raised in one layer with the skin. The periosteal flap is raised progressively into the orbit, displacing the orbital periosteum and the lacrimal sac laterally. Care should also be taken when raising the periosteum not to damage the trochlea, which would result in mechanical dysfunction of the superior oblique muscle (Couch et al., 1990). Theethmoidal vessels perforatethe medial orbital wall into the anterior and posterior ethmoidal canals respectively, at or close to the frontoethmoidal suture (Fig. 36.5). The anterior ethmoidal artery will be encountered at distance a about 1.5-2cm fromthe lacrimal fossa. It will appear as a cord-like structure. After it has been cleaned circumferentially, haemostatic clips should be firmly and doubly applied. If only the anterior ethmoidal artery is to be ligated, the clips are preferably left in coutinuity with the vessel. If the posterior ethmoidal artery is also to be ligated, the anterior ethmoidalartery requires dividing between the clips. Theorbitalperiosteum is similarly raised and the posterior ethmoidal artery will be encountered about 0.5-1cm further back. It is clipped similarly but it is not necessary that it is divided. Occasionally it may be difficult to clip the posterior ethmoidal artery because the field becomes either too narrow or too close

to theoptic nerve. In these instances theposterior ethmoidal artery can be simply coagulated with bipolar diathermy. Theanteriorethmoidalarterycan be absent in as manyas 14% of cadaver dissections unilaterally and 2.5% bilaterally (Shaheen, 1967). This is especially important to bear in mind if both the anterior and the posterior ethmoidal arteries areto be clipped. The optic nerve may then be mistaken as the posterior ethmoidal artery and clipped, resulting in blindness. Post-arterial ligation nasal endoscopy

At the end of any arterial ligation procedure for control of epistaxis, the nose should be examined for two reasons, The effect of ligation can be assessed immediately as successful ligation should leave thenasal mucosa blanched. If there is any residual bleeding, it should be significantly slowed. Thiscould be the ideal time for achieving local control. If the nasal mucosa appears blanched andwithout bleeding, onlya loose pack should be applied. If there is still significant bleeding, an arterial branch might have been missed or an additional artery may require ligation.

Epistaxis from haemorrhagic Epistaxis requiring surgery in most patients arises from arterial bleeding. However, in the case of hereditary haemorrhagic telangiectasia, epistaxis is due toboth arterial and capillary bleeding. Results of any form of therapy, including arterial ligation, are poor (Rebeiz et al., 1995).These patients usually require a combination of arterial ligation (or embolisation) and local control. It is important to cause as little mucosal damage as possible as there is always need for repeated local therapy. A number of lasers have proved useful in the management of thiscondition (Kluger et al., 1987; Illum & Bjerring, 1988; Haye & Austad, 1991).

Conclusion Epistaxis is acommon ENT emergency and may at times be life-threatening. Successful management depends upon an understanding of the condition and the ability to apply the techniques for epistaxis control in a logical manner.

Beall J, Scholl P & Jafek B (1985) Totalophthalmoplegia after internal maxillary artery ligation. Arch. Otolaryngol. 111 (lo), 696-8. Bingham B & Dingle AF (1991) Endoscopic management of severe epistaxis. J.Otolarngol. 20 (6), 442-3. Brucher J (1969) Origin of the ophthalmic artery from the middle meningeal artery. Radiology 93 (l), 51-2, Couch JM, Somers ME & Gonzalez C (1990)Superior oblique muscle dysfunction following anterior ethmoidal artery ligation for epistaxis. Arch. O p ~ t h a l ~ 108 o ~ .(8), 1110-13. Hassard AD, Kirkpatrick DA & Wong FS (1986) Ligation of the external carotid and anterior ethmoidal arteries for severe or unusual epistaxis resulting from facial fractures. Can. J.Surg. 29 (6), 447-9, Haye R & Austad J (1991) Hereditary hemorrhagic teleangiectasia-argon laser. Rhinology 9 (l), 5-9. Hiura A (1980) An anomalousophthalmicarteryarsingfromthe middle meningeal artery. Anat. Anx. 147 ( S ) , 473-6. Illum P & Bjerring P (1988) Hereditary hemorrhagic telangiectasia treated by laser surgery. Rhinology 26 ( I ),19-24. Kluger PB, Shapshay SM, Hybels RL & Bohigian RK (1987) Neodymium-YAG laser intranasal photocoagulation in hereditary hemorrhagic telangiectasia: an update report. Laryngoscope 97 (12), 1397-401. Last RJ (1978) TheNose. Section 6, Anatomy Regional and Applied, 6th edn. Edinburgh, Churchill Livingstone. McGarry GW (1991) Nasal endoscope in posterior epistaxis: a preliminary evaluation. J.Laryngol. Otol. 105 (6),428-31. NakagawaT,Tanabe S & Sato 0 (1982) Anomalous ophthalmic artery-case reports and review of literature. N o To Shinkei 34 (4), 40.5-13. O’Leary-Stickney K, Makielski K & Weymuller EA, Jr (1992) Rigid endoscopy for thecontrol of epistaxis. Arch. Otolaryngol. Head Neck Surg. 118 (9), 966-7. Premachandra DJ (1991) Management of posterior epistaxis with the use of the fibreoptic nasolaryngoscope. J. Laryngol. Otol. 105 (l), 17-19. Rebeiz EE, Bryan DJ, Ehrlichman RJ & Shapshay SM (1995) Surgical management of life-threatening epistaxis in Osler-Weber-Rendu disease. Anu. Plast. Surg. 35 (2), 208-13. Shaheen O H (1967) Thesis for the Master of Surgery, University of London. Shaheen O H (1987) Epistaxis. In: Kerr AG (ed.) Scott-B~own’s Otolaryngology, Vol. 4. Rhinology, 5th edn. Butterworth International Editions. Shaw CB, Wax MK & Wetrnore SJ (1993)Epistaxis: a comparison of treatment. Otolaryngol. Head Neck Surg. 109, 60-5. Singh B (1992) Combined internal maxillary and anterior ethmoidal arterial occlusion: the treatment of choice in intractable epistaxis. J.Laryngol. Otol. 106 (6), 507-10. Spafford P & Durham JS (1992) Epistaxis: efficacy of arterial ligation and long-term outcome. J.Otolaryngol. 21 (4), 252-6.

Endoscopy


Nasopharyn JOHN K.S. WOO

Introduction The nasopharynx is functionally part of the nose, although developmentally itis part of the pharynx. Notoriously difficult to visualise, the nasopharynx is frequently neglected when the nose and the throat are being examined. Pathology in the nasopharynx is central to many common ear, nose and throat disorders. Advances in modern endoscopic equipment allow this key anatomical region to be examined easily and thoroughly.

Surgical anatomy of the nasopharynx The nasopharynx is the part of the pharynx that lies behind the nose (Fig. 37.1).Its size isapproximately that of the terminalsegment of the thumbof its owner (Last, 1978). Anteriorly it opens into the nasal cavities while inferiorly continues it into the oropharynx. The Eustachian cushions project from its lateral walls, each in the shape of an inverted J. The long limb of the J extends posteromedially and continues inferiorly as the salpingopharyngealfold. The lateral recess (fossa of Rosenmuller) is the slit-like space, oneon each side, posterior and lateral to the long limb of the Eustachian tubal orifice. The internal carotid artery (ICA)is closely related to the fossa of Rosenmiiller; The skull base lies posterosuperiorly to the margin of the nasopharynx.

Indications for nasopharyngoscopy Thenasopharynxcannow be viewed withminimal discomfort to the patient and it shouldbe a routine part of every clinical examination of the ear,nose and throat.

Nasopharyngoscopy may also be a necessary part of another endoscopic procedure, such as flexible laryngoscopy and laryngobronchoscopy. It is also performed for therapeutic reasons, such as removal of a polyp or a foreign body, or laser therapy for a lesion in the nasopharynx.

Indirect The nasopharynx can also be examined with a postnasal mirror.Thisimportanttechniqueshouldnot be neglected as the nasopharynx can be clearly visualised in up to 70% of patients. The tongue is depressed slightly with a right-angled tongue depressor. The patientis then instructed to hold hislher breathtemporarily orto breathe through the nose. In this way, the soft palate will relax andthevelopharyngeal inlet will open for inspection. A postnasal mirror with an adjustable mirror head is requiredfor visualisation of the different parts of the nasopharynx.

Thenasopharynxcan be visualised eitherantegrade through the nose or retrograde via the oropharynx, and occasionally a combined approach is employed (Woo et al., 1990, 1991). Antegrade naso~hary

Antegrade nasopharyngoscopy can be performed using either a flexible fibrescope or a rigid Hopkins rod lens. There are advantages and disadvantages with either instrument. The flexibility of the fibrescope allows it to

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Anatomic boundaries

Fig. 37.1 Anatomy of the nasopharynx in relation to the lateral nasal wall.

bend around a septal spur and yet maintain an end-on view. The suction channel incorporated with some instruments allows aspiration during the procedure, thus maintaining a clear view. The flexible instrument has a longer working length so that a more comfortable distance exists between the doctor and the patient. The rigid Hopkin’s rod lens can be controlled with just onehand, freeing theotherhandforadditional instrumentation.Illumination is bright and it hasa wide-angled view and provides excellent optics. These characteristics offer a better-quality picture for still photography and video documentation. The transnasal view through a 0” endoscope is represented diagrammatically in Fig. 37.2. Theprocedure is best performedwiththepatient lying comfortably on a reclining chairwiththehead turned slightly towards the surgeon. The right-handed surgeon should sit on the patient’s right side with an adjustable stool. The examination position is adjusted so that the surgeon’s eyes are level’with the patient’s nose. It is necessary to anaesthetise and vasoconstrict the nasal mucosa for ease of the procedure and comfort of the patient. This can be achieved by applying ribbon gauze soaked with a5% cocaine solution. In institutions where cocaine is not easily available for medical use, a solution made up of four parts of 4% xylocaine with one part of 1:10000 adrenaline is suitable. Excess solution should be squeezed from the ribbon gauze before

Fig. 37.2 Endoscopic view of the nasopharynx through a 0” rigid endoscope.

insertion into the nose. The gauze should be carefully placed against the middle and inferior turbinates. For patients withvery swollen turbinates, the positionof the medicated gauze should be readjusted and pushed further inside the nose. After about 10min, the patient will be ready for the procedure.

~ ~ s o p ~ ~ ~ y n g o s 267 copy

Fig. 37.3 Endoscopic view of the nasopharynx through a 90" rigid endoscope.

The endoscope should be held in the surgeon's right hand. The other hand should adopt a position so that the fingers can steady the tip of the endoscope. This is particularly important when using the flexible endoscope. The tip of the endoscope shouldbe carefully introduced into the nostril under direct vision. The surgeon should immediately view throughthe eyepiece once the endoscope is inside the nose. The endoscope is advanced along the floor of the nose. Once the nasopharynx is reached, the patient is instructed to phonate 'ng' and 'ah' and asked to swallow. With these manoeuvres, the soft palate may be observed in a relaxed, tightened and dynamic state. Thismay expose an abnormality that might otherwise be overlooked. The flexible endoscope should be able to bypass most anatomical obstacles. When rigid endoscopes are being used, a brief inspection of the nasal fossae should be done first. The wider side of the nose should be used for the passage of the endoscope. The surgeon may, very rarely, find it difficult to advance the endoscope without causing some discomfort to thepatient. Under these circumstances, the other side of the nose should be tried or the flexible instrument be used instead. Retrograde nasopha

Here the nasopharynx is viewed from the oropharynx through a side-viewing rigid endoscope. This method is not suitable for patients with a narrow velopharyngeal inlet or patients with a long, redundant soft palate.

The patient should be seated and leaning slightly forward. In this way, gravity will tend to openthe velopharyngeal inlet. The back and neck should be well supported so that thepatientcannotretreatasthe endoscope advances. The surgeon should sit facing the patient with his eyes level with the patient's throat. No anaesthesia is necessary unless this is attempted in patients with a sensitive gag reflex. Under these circumstances, the throat can be anaesthetised using a 10% xylocaine spray. Suitable viewing angles range from 70" to 120", with the 90" lateral viewing endoscope being ideal as this angle is most versatile and suits the majorityof patients. Thepatient is asked to open hislher mouthwithout protruding the tongue. The endoscope is advanced under direct vision as the tongue is depressed lightly. The surgeon should only look through the endoscope after the tip of the endoscope has passed the uvula. A panoramic view of the nasopharynx is obtained by slightly rotating the endoscope along its axis (Fig. 3'7.3). The soft palate should be relaxed during the examination; this can be achieved by asking the patient to breathe through the nose or to temporarily hold hislher breath. haryngoscopy

In special situations the antegradeand retrograde routes are combined. This should be undertaken with general anaesthesia for the patient's comfort and safety. Nasopharyngoscopy under general anaesthesia is necessary when it is likely to cause a lot of bleeding andlor pain. The nasal mucosa should be prepared topically as described previously. The patient is placed in the supine position and intubatedtransorally with an endotracheal tube (ET).A Boyle-Davis or similar mouth gag is set in position. A suction catheter is passed through each nostril and brought out through the mouth. The soft palate is lifted forward by gently tightening the ends of the catheters (Fig. 3'7.4). Thenasopharynx is now easily viewed withthe endoscopes. Instrumentationcan be introduced simultaneously via the nose or mouth. In places wherenasopharyngealcarcinoma is endemic, it may be necessary to take deep biopsies from the fossa of Rosenmiiller under direct vision to confirm or exclude a submucosal tumour.In these circumstances a Yankauer speculum in combination with a headlight may be used to gain access. The Yankauer speculum is introducedthroughtheopenmouth, lifting the soft palateforward so that the beak of the speculum is placed behind the Eustachian cushion. In this way, the depth of the fossa of Rosenmiiller is opened while the Eustachian cushion is pushed laterally to avoid injury.

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Video-assisted nasopharyngoscopy During both antegrade and retrograde nasopharyngoscopy, the endoscope can be coupled with a video camera and theprocedure recorded and viewed on a television screen. This allows the endoscopic technique to be documented and taught simultaneously.

Complications of nasopharyngoscopy Complications associated with nasopharyngoscopy are rare. However, during passage of the endoscope, injury to the nose, throat or Eustachian tube may result if the procedure is not carefully performed. Even following deep biopsy, haemorrhage requiring transfusion is rare.

References

Fig. 37.4 Set-up for combined-approach nasopharyngoscopy.

Last RJ (1978) Tbe Nose. Section 6, Anatomy Regional and Applied, 6th edn. Edinburgh, Churchill Livingstone. Woo JKS & Sham CL (1990) Diagnosis of nasopharyngeal carcinoma. Ear Nose Throat J.69 (4), 241-52. Woo JKS & Waldron J (1991) Diagnosis. In: van Hasselt CA & Gibb AG (eds) Nasopbary~gealCarcinoma. Hong Kong, Chinese University Press, pp. 93-104.

Pharyngolaryngosco Rigid Oesophagosco (including Panendo SIMON A. HICKEY Pharyngolaryngoscopy Indications

Direct pharyngolaryngoscopy is indicated for the controlled and detailed examination of the pharynx and larynx and should be combined with palpation of the so-called ‘silent areas’ of the pharynx, i.e. the tongue base, postnasal space, tonsil fossae and, where accessible, pyriform fossae. It is indicated for: 1 The assessment and biopsy of lesions of the pharynx and larynx and the removal of foreign bodies therefrom. 2 Guidance during difficult intubations, the passage of a rigid bronchoscope, especially in children. 3 The identification of theoesophageal inlet forthe passage of a nasogastric feeding tube. A sliding or openbacked laryngoscope is used so that the endoscope can beremoved without removing thebronchoscope or feeding tube. 4 Direct pharyngolaryngoscopy is used to identify the opening of a pharyngeal pouch prior to packing or for placing a fibre light in order to facilitate the identification of the pouch in the neck. 5 It may also beused to directtheplacement of a stomach tube, for guidance during upper oesophageal myotomy and to provide access for the endoscopicdivision of the common wall of the pouch and pharynx in the Dohlmann’s procedure. Preoperative management

Instability of the cervical spine may occur with rheumatoidarthritis or spinaltrauma.Carefulpreoperative assessment, including flexionlextension X-rays of the cervical spine, is essential in such patients. Fibre-optic examination may be substituted where there is a risk of

cervical injuryfrommanipulationunderanaesthesia, although the examination will generally beless complete. Loose, capped or protuberant teeth are at risk duringpharyngolaryngoscopy and rigid oesophagoscopy. The patient shouldbe advised of this. The patient with an obstructingtumourshouldalso be advised that tracheostomy or prolongedintubation maybe necessary should postoperative swelling increase airway obstruction. Careful communication with the anaesthetistis essential in order that a decision can be made whether to intubate or not, the type of tube to be used, whether spontaneous, intermittent positive-pressure or jet ventilation is to be used and hence the type of muscle relaxant to be used. As directpharyngolaryngoscopyand rigid oesophagoscopycan result in profound vagal stimulation and dysrythmias, a careful cardiorespiratory history and examination are required preoperatively. Relevant anatomy As pharyngolaryngoscopyand

rigid oesophagoscopy require the passage of a straight instrument, it is essential that the operatorshould understand the movements of the cervical spine necessary to align the oral, pharyngeal and laryngeal inlets alongthesameaxisfor pharyngolaryngoscopy (extension of the atlantooccipitaljointcombinedwith neck flexion) and that these are different from those required to align the oral, pharyngeal and oesophageal inlets for rigid oesophagoscopy (extensionof both the atlanto-occipital joint and the neck). Careful preoperative examination may identify factors which may make it difficult to achieve such alignment, e.g. cervical lordosis, restricted neck movements,

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retrognathia, a bulky tongue base and protuberant upper dentition. These factors, especially in conjunction with poor relaxation or inadequate depth of anaesthesia, may make direct pharyngolaryngoscopy difficult or even impossible. The oesophagus runs from the cricopharyngeal sphincter to the oesophageal hiatus in the diaphragm and cardia of the stomach. Endoscopically the cricopharyngeal inlet lies, on average, 15cm from the anterior incisors. The indentation of the oesophagus by the aortic arch, as it crosses from anterior to lateral on the left side, lies at a distance of 25cm and the gastrooesophageal junction at approximately 40 cm from the anterior incisors. During its course, the axis of the oesophagus initially runs in the midline, but once the halfway point is reached it tends to curve anteriorly and slightly to the left. In order to pass a rigid oesophagoscope, it is therefore essential to align the oral and oesophageal inlet along the same axis (vide supra). Where access is made difficult by retrognathia, tongue bulk and protuberant upper dentition, it is possible to insert the oesophagoscope off-centre and compensate for this by some rotation of the head in order to realign the axis of the oral inlet with- the oesophagealinlet. Operative technique

Preparation

Anaesthesia Apreoperative drying agent, e.g. hyoscine, greatly facilitates the examination, by reducing secretions and preventing dangerous vagal bradycardia. Direct pharyngolaryngoscopy is possible under local anaesthesia and sedation,butmost prefer to use general anaesthesia. After induction, anaesthesia is maintained with a face mask. The pharynx and larynx are sprayed with local anaesthetic (LA) to reduce vagal stimulation and the risk of postoperative laryngospasm, and muscle relaxants are given to facilitate passage of the endoscopes. The examination may be carried out rapidly during a short apnoeic period, but preferably more slowly, while ventilatory support is achieved with intermittent positive-pressure ventilation or jet ventilation via a parallel endotrachealtube (ET)or cannula. In order to minimise the dose of anaesthetic gas inhaled by the operator, methods employing the spontaneous respiration of anaesthetic gases delivered to the pharynx should be avoided. Where a jet ventilator is used, care should be taken to ensure that an exit port for entrained gases is always

available, as there is a risk of pneumothorax.The Venturi injector should not be used for very small babies, for this reason.

Prophylactic antibioticslsteroid cover Prophylactic antibiotics are unnecessary in the absence of intercurrent valvular heart disease. The same is true of steroid cover, apart from exceptional circumstances, i.e. preceding steroid therapy or where there is likely to be instrumentation, lasering or intubation of an already critically narrowed airway.

Patient positioning The patient should be placed supine with theneck flexed and the head extended, so as to align the axis of the larynx with the mouth in the ‘sniffing the morning air’ position. Thismay be achieved by extending thehead on a flat table, with neck flexion occurring passively as a result (Kleinsasser, 1992) (Fig. 38.1). The position may be maintained by steadying the head with the left hand, placing the index finger in the mouth against the palatal surface of the front teeth and applying a gentle rotatory pressure to extend the head (some operators prefer to stabilise the head with a small neck roll or pillow to maintain the cervical lordosis). With theleft hand in this position,the left thumb can be used to support and control advancement of the scope and to protect the upper teeth from damage caused by inadvertent use of the teeth as a fulcrum to rotate the scope (Fig. 38.2). If an ET is passed, it should be positioned to lie to the left foraright-handed surgeon and vice versa for a lefthanded surgeon. Procedure

The operator is seated at the head of the table. A tooth guard is inserted to protect the upper teeth.If the patient has no upper front teeth, a gauze swab is used to protect the gingivae. Holding the scope in the right hand, the tip of the laryngoscope is passed between the teethand over the back of the tongue in the midline until the uvula is reached, progress being observed at all times by direct vision throughthe scope. The scope is then directed laterally to inspect the tonsillar fossae and faucial pillars. Aspiration of saliva may be necessary. The scope is then advanced, using the thumb of the left hand in conjunction with the right hand to control the movement. At this stage the tongue base protrudes into the axis of examination and needs to be elevated and compressed anteriorly, by lifting the scope towards

Pha~yngola~yngos~opyand RigidOesophagoscopy

271

Fig. 38.1 (a) ‘Sniffing the morning air’ position for pharyngolaryngoscopy, with alignment of the oral, pharyngeal and laryngeal axes. The dark arrow shows the correct direction of scope elevation for compression of the tongue base (redrawn after Kleinsasser, 1992). (b)Manoeuvre to achieve head extension with simultaneous neck flexion. This position may be maintained with the left hand (as in Fig. 38.2) or with a small ‘neck-roll’ pillow (redrawn after Kleinsasser, 1992).

Fig. 38.2 Positioning of left hand for pharyngolaryngoscopy and rigid oesophagoscopy.

the ceiling and by minor rotatory movements as the tip of the scope is advanced. The tongue base, valleculae and pyriform fossae are examined sequentially, distending these areas with the tip of the scope to allow adequate inspection. The examination of the hypopharynx and upperoesophageal lumen requires the use of a longer pharyngoscope or oesophagoscope. The laryngeal inlet is examined next. The tip of the

scope is passed behind the epiglottis and its laryngeal surface inspected. It may be necessary to displace the ET posteriorly at this stage in order to view the anterior larynx. Similarly thetube may need to be displaced anteriorly to view theposterior commissure. Despite careful patient positioning, it may not be possible to view the anterior commissure of the larynx. Use of the narrower-profiled ‘anterior commissure scope’ may improve the view, as may the application of pressure to the subglottictrachea.Theapplication of a suspending laryngostat often produces furtherelevation of the tipof the scope and improves the view. Examination may be impeded by retrognathia and protuberant upper dentition. Access may be improved by passing the scope through the teeth ‘off-centre’, i.e. between the molar teeth. This has the disadvantagethat usually only one side of the larynx and pharynx can be examined and the scope has to be reintroduced to examine the opposite side. Examination of the laryngeal ventricle is greatly assisted by the application of a laryngostat, in that the operatoris able to use two hands and can displace the false cord with a ”biopsyforcep or laryngeal hook and use a wide-angle 70’ Hopkin’s rod nasal endoscope to view the ventricle. Thesubglottis may be examined using a similar scope. Where a laryngeal lesion is identified, inspection ofxand surgery to the

larynx is greatly facilitated by the use of an operating microscope with a 400mm focal-length lens (see Microlaryngoscopy -Chapter 45). It is recommended that a full examination is performed as atraumatically as possible before taking a biopsy or making an incision, as the introduction of blood into the field greatly reduces observer accuracy. Excessive bleeding may be controlled by the application of a cotton pledget soaked in topical adrenalinesolution (1:1000) andsupported on a carrier. Alternatively a suction diathermy probe may be used. Postoperative management

Once the patient is awake and thus able to protect the airway, he/she is able to resume normal activities. The patient may experience some soreness and occasionally mild analgesics may be required. Complications

Occasionally laryngeal swelling will cause significant airwayobstruction.Thisshould be treatedwitha graded regimen according to severity, using humidification, nebulised racemic adrenaline, steroids, helium and oxygen. If worsening stridor, dyspnoea or desaturation occurs, thenreintubation or tracheostomy may be required. Careless technique may cause bruising or laceration of the lip. Suturing is rarely necessary. Occasionally a tooth will be chipped, broken or knocked out during introduction of the scope. A careful search for thetooth fragmentshould be made, including bronchoscopy if indicated. Laceration of the pharynx is uncommon and can usually be treated conservatively. Perforation is uncommon, except in cases of undiagnosed pharyngeal pouch or impingement on prominent a cervical osteophyte. Gentle technique should avoid such a disaster, but when it occurs the perforation should be explored and repaired. Alternative procedures

Although fibre-optic endoscopy has its advocates (Thomson & Batch, 1989), it is considered by many to be inferior to rigid endoscopic examination of the hypopharynx and upper oesophagus, as it does not allow easy distension of the area. This impedes anatomicalorientationduringtheexamination and hence impedes the assessment and staging of malignant disease. Direct observation makes obscuration by blood and saliva much less likely.The removal of large foreign

bodies is likely to be far less traumatic when the field is distended and theforeign body disimpacted under direct vision.

Rigid oesophagoscopy indications

Rigid oesophagoscopy is thetraditionalmethod of examination of the oesophageal lumen. Many of the functions traditionally fulfilled by such an examination have now been superseded by flexible fibre-optic oesophagoscopy (see Flexible OesophagoscopyChapter 39). Rigid oesophagoscopy remainsthe preferred method for removal of oesophageal foreign bodies and in some circumstances may still be used for the dilatation of oesophageal luminal stricture and the biopsy of endoluminal lesions. In expert hands, this is a safe procedure, but for theinexperienced operator there remains a relatively high risk of inadvertent oesophageal laceration and perforation. Perhaps the principal reason behind its finding continuedfavouramong otolaryngologists is deficient tuition of trainees in the use of the flexible endoscope. Preoperative management

A contrast examination of the oesophagus is mandatory priorto rigid oesophagoscopy in order to exclude pre-existing traumaticperforation by a foreign body and to delineate abnormalities which may significantly increase the rate of accidental perforation, e.g. cervical osteophytes, diverticulae, prestenotic dilatations and tumours. In thelatter case this may be the only way to define the lower limit of a lesion (Stell, 1979). A plain chest radiographshouldalso be taken to identify any gross cardiovascularabnormality which may compromise the examination, e.g. massive cardiomegaly. Operative technique and procedure

The patient is placed supine on the table with a pillow placed underneath the shoulders and neck to achieve minor neck extension and marked head extension (Fig. 38.3). The position is maintained by placing the forefinger of the left handon thehardpalateandpalatal surface of the incisor teeth, while the lower lip is retracted using the third finger. The oesophagoscope is inserted into the mouth and advanced until theuvula is visualised. Observation is maintainedthroughthelumen of the endoscope at all times. The oesophagoscope

Pharyngo~aryngoscop~and Rigid Oesophagoscopy

Fig. 38.3 Positioning for rigid oesophagoscopy. Breaking the table may assist with examination of the distal third of the oesophagus. The pillow supports the shoulders and neck in the correct position.

is then lowered such that it rests on the thumb of the left hand, thus protecting the upper dentition. If necessary, this thumb may be used as a fulcrum. At no time should the upper dentition be used as a fulcrum. The thumb is used to advance the scope and at the same time some minorrotatory movements withtherighthand will facilitate the passage of the tip of the scope. The aim of observation via the lumen of the scope is to maintain the centre of the lumen through which it is intended to pass the scope in direct alignmentwiththecentre of the observed field. The scope is then advanced intothe hypopharynx off-centre, such that it is possible to visualise theright aryepiglottic fold and theright pyriform sinus. The scope is thenadvancedintothe pyriform sinus and sweptintothe midline asit is advanced, so that it comes to lie behind the posterior lamina of the cricoid. At this point, the puckered inlet at the cricopharyngeus should become visible. Inadequate muscle relaxation and toniccontraction of thecricopharyngeus may impede passage of the oesophagoscope intotheupper oesophageal lumen. Gentle dilatatory pressure with the beak of the oesophagoscope at this point shouldbe maintained until cricopharyngealrelaxation is achieved and thetip of the oesophaguspasses with ease into the upper oesophagus. Attempts tohurry theprocedure at this stage may cause traumaand should be avoided. Oncethe endoscope is in the upper oesophageal lumen, its tip is

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advanced, using similar rotatory movements and left thumb pressure, untilthepulsatingindentation of theaorticarch is identified. At this point,the oesophagus will tend to curve anterolaterally to the left and this may cause some difficulty with the advancement of the scope. In kyphotic patients it may be necessary to extend the back and thus align the axes of the upper and lower oesophageal segments. This may be achieved by breakingtheoperating table. The distal segment of the oesophagus should then be examined in the same manner, but with great care, given that the directional stability of the tip of the oesophagoscope is somewhat reduced by thereduction in the lever arm between the proximal end of the oesophagoscope and the fulcrum on the left thumb. Care should be taken to assess not only the mucosal integrity of the oesophageal lumen, but also the presence of any reflux or indenting mass lesion. Examination should be continued during the removal of the endoscope. Particularattention should be paid to the cricopharyngeal inlet and postcricoid regions, where rotation of the beak of the scope to produce distension, andthusto display all segments of the oesophageal wall, will greatly facilitate the examination. Postoperative management

Where the examination has been uneventful and there has been no recognisable laceration or breach of the oesophageal mucosa, the patient shouldbe kept on clear fluids for 6 h postoperatively. Thereafter a normal diet may be reintroduced. Given the risk of silent perforation, close attention should be paid to the acute onsetof pain(particularlywhere it is pleuritic and radiating through to the interscapular region), fever, tachycardia and collapse, as all these may indicate oesophageal perforation. Where oesophageal perforation is recognised, initial treatment may be conservative, with the passage of a nasogastric tube and the immediate institution of a nil-by-mouth regimen and intravenous broad-spectrum antibiotics, e.g. acephalosporinwith metronidazole. Continuous close observation is essential duringthis period as further deteriorationindicates that open surgical closure of the perforation may be necessary. Healing may be assessed with contrast studies, and where recovery is protracted it may be necessary to institute parenteral feeding. Where there is gross thoracic contamination or associated pneumothorax, openclosure is indicated. Bleeding from traumatised oesophageal varices or endoluminal tumours may require endoluminal compression with balloons or open surgical management.

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Alternative procedures

It is possible to perform most of the procedures traditionally reserved for rigid endoscopy with thefibre-optic endoscope. One exception is atraumatic removal of impacted foreign bodies. The distension of the oesophagus achieved with the rigid oesophagoscope facilitates disimpaction and may allow lysis of the impacted foreign body and its subsequent atraumatic removal in the lumen of the oesophagoscope. To a large extent, balloon dilatation has now superseded the bougienage of oesophageal stricture.

Panendoscopy Panendoscopy is the systematic inspection of the upper aerodigestive tract to establish the site of aprimary tumour responsible for a malignant cervical node, or to exclude the presence of a synchronous or metachronous primary tumour. Itcomprises systematic examination of the mouth, pharynx, postnasal space, larynx, oesophagus, trachea and main bronchi, with palpation and with biopsies fromthepostnasal space and tongue base. Some alsoadvocate tonsillectomy on the side of the malignantnode. Close cooperation between surgeon and anaesthetist is essential, as they will be required to share the airway during the procedure. It will be necessary to change the position of the patient during the examination and hence the stability of the ET may be

endangered if it is not carefully maintained. It is wise to perform examinations of all areas to be inspected prior to taking biopsies as bleeding may compromise subsequent inspection and reduce the efficacy of the whole process in establishing a diagnosis. Examination of the mouth

Examination of the mouth canusually be achieved without anaesthesia unless there is marked trismus or pain resulting from a lesion in the mouth or pharynx. Care should be taken to inspect and palpate all regions of the mouth. Biopsies should be guided by the presence of obvious lesions on examination and palpation. Pharyngolaryngoscopy

This is performed as described previously. Examination of the nasopharynx (see also Nasopharyngoscopy-Chapter 37)

With the patient lying supine, a Boyle-Davis tonsillectomy gag is inserted and its positionmaintained by suspension (Fig. 38.4). Soft catheters are passed through the nostrils and brought outthrough themouth. By gentle traction on theends of thecatheters,thesoft palate is elevated off the posterior pharyngeal wall, allowing access to the nasopharynx from the oropharynx.

Fig. 38.4 Examination of the postnasal space with the operating microscope.

PharyngolaryngoscopyandRigidOesophagoscopy The postnasal space may then be examined, using either a 120" rigid endoscope or a laryngeal mirror (previously warmed to prevent misting). The use of an operating microscope improves the accuracy of mirror examination. The posterior end of the nasal septum and nasal choanae, Eustachian tube orifices and cushions, fossae of Rosenmuller, nasopharyngealroof and posterior wall are systematically examined. Guided biopsies are taken from the fossae of Rosenmuller and the posterior pharyngeal wall on the side of the involved node. This is the mostproximalanatomical segment examinedduring panendoscopy, and bleedingmay thuscontaminate all other areas of examination. The taking of nasopharyngeal biopsies should thus be the last part of the procedure. Biopsies are taken under mirror control, using Tilley-Henckel or similar forceps inserted through the ipsilateral nostriland keeping the shaftof the instrument against thefloor of the nose. Care shouldbe taken to avoid trauma during introduction of the instrument as this may cause bleeding and compromise visualisation during biopsy. Palpation of the postnasal space and soft palate forms an essential part of the examination, but should be delayed until all other areas havebeen examined, as it may cause bleeding. Oesophagoscopy

Oesophagoscopy should be performed as above, or alternatively flexible oesophagoscopy with vital staining may be substituted.

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Bronchoscopy

Traditionally bronchoscopy is performed using a rigid ventilating bronchoscope. The only advantage of rigid bronchoscopy over fibre-optic examination via the endotracheal tube is that the proximal trachea may be examined instead of being bypassed. Many feel that the inclusion of rigid bronchoscopy in panendoscopy is no longer indicated and that flexible bronchoscopy at the same or another sitting will suffice (Fulkerson, 1984). Proximal tracheoscopy can usually be achieved during laryngoscopy, particularly if a jet ventilator or Venturi injector is used to maintain ventilation during laryngoscopy.

References Fulkerson JW (1984) Medical intelligence: current concepts of fibreoptic bronchoscopy. N.Engl. J . Med. 311, 511-15. Kleinsasser 0 (1992) Microlaryngoscopy and Endolaryngeal Microsurgery:TechniqueandTypicalFindings (3rd edn). Hanley and Belfus. Stell PM (1979)Diseases of the hypopharynx. In: Maran AGD & Stell PM(eds) ClinicalOtolaryngology. Oxford, Blackwell Scientific Publications, p. 368-381. Thomson HG & Batch AJ (1989) Flexible oesophagogastroscopy in otolaryngology. J . Laryngo. Otol. 103, 399-1103.

Flexible Oesophagoscopy CHARLES S. R O B E R T S O N

Introduction Flexible oesophagoscopy is rarely performed in isolationbut is usually apart of aroutineupper gastrointestinal (GI) survey. This includes inspection of the oesophagus, stomach,pylorus and first and second parts of the duodenum. It is now usual to use a small-diameter, forward-viewing video-endoscope, which is easy to pass andmanoeuvreand gives a bright, high-definition view that can be seen by boththeendoscopist and assistants on a television monitor.

Indications for upper gastrointestinal endoscopy 1 For the investigation of: (a) theupper aerodigestive tractforsynchronous squamous cancers; (b) dysphagia; (c) chronic upper abdominal pain; (d) symptoms of gastro-oesophageal reflux; (e) upper GI bleeding; (f) iron-deficiency anaemia. 2 For the treatment of: (a) foreign bodies; (b) benign oesophageal strictures; (c) oesophageal cancer; (d) upper GI bleeding. 3 For theinsertion of apercutaneous endoscopic gastrostomy (PEG) feeding tube.

Contraindications These are all relative and related to the patient’s general

condition -especially severe cardiovascular or respiratory disease.

Patient preparation Patients are starved for 6 h prior to the examination. The endoscopist is responsible forensuring that the examination is indicated and that the patient is fit for and understands the nature of the procedure, following which written informed consent can be obtained. Dentures and glasses are removed.

Sedation Pharyngeal anaesthesia

Local anaesthetic spray to the pharynx may be helpful to suppress the gag reflex when no IV sedation is used. However, it is probably unnecessary if sedation is used, as it is bitter and unpleasant, may increase the risk of pulmonaryaspiration and prevents thepatientfrom drinking for 30 min postprocedure. Conscious sedation

Upper GI endoscopy can be performed without sedation but may be distressing for the patient. The major advantage is that no formal recovery is required and that the patient can resume normal activities immediately. However, most endoscopists prefer to sedate their patients, using IV drugs. This allowspassage and manipulation of the endoscope witha relaxed but responsive patient, able to maintain their vital functions. All drugs must be given slowly and titrated individually until ptosis of the eyelids and slurring of speech occur. Great care mustbe

Flexible Oesophagoscopy

takenwiththe elderly and thosewithknown liver, cardiac or respiratory disease. General anaesthesia is usually required for children and rarely for an otherwise uncontrollable patient. Drugs used in upper gastrointestinal endoscopy

Benzodiazepines

These drugsproducesedationwith amnesia and are, therefore, popular for IV use. The two most popular agents are Diazemuls (a lipid emulsion of diazepam which prevents thrombophlebitis) and midazolam (a water-soluble compound which does not cause thrombophlebitis).Midazolamhasafasteronset and shorterduration of action than Diazemuls. Smaller doses must be used to prevent hypoxia.

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Non-invasive blood-pressure and ECG monitoring are probably not indicated routinely. Oxygen should be administered via nasal cannulae to all patients.

The nurse’s role Ideally a minimum of two nurses assist at the examination. One nurse concentrates on the patient and stands behind the patient’s head giving reassurance, and ensuring an adequateairway, using suctionas necessary. From this position the nurse can also keep the mouthguard in position andcontrol thearms of a restless patient. Another nurse assists the endoscopist, concentratingonthe procedure,holding or moving the endoscopewhenasked and helping withtherapeutic manoeuvres (Fig. 39.1 ).

Procedure

Benzodiazepine reversal

Positioning

Benzodiazepines can be reversed using flumazenil 500 pg IV over 30 S . Its action is rapid but short-lived, so repeat doses may be necessary.

The patient is placed in the left lateral position with the head on a pillow covered with an absorbent towel. The neck is semiflexed. IV access is established in the right arm as flow in the dependent left arm may be variable. A mouth-guard is placed before thepatient becomes drowsy to protect the patient’s teeth and the endoscope.

Opiates

Pethidine 25-50mg is often used in combination with a smaller dose of benzodiazepine. As both agents cause respiratory depression, caution must be used if they are given together.

Opiate reversal Opiates can be reversed using naloxone 0.2-0.4mg IV. Its action is rapid but short-lived, so that repeat doses may be necessary. Hyoscine butylbromide

This may be given in doses from 20 to 40mg IV to paralyse the duodenum in order to aid inspection or to performtherapeutic manoeuvres. Its effects last less than 1Omin andit is therefore only given oncethe endoscope has passed the pylorus.

Patient monitoring This should be proportional to the perceived risk to the individualpatientundergoingthe specific procedure. Measurement of the pulse and tissue oxygen saturation using pulse oximetry is now usual and recommended.

Fig. 39.1 Patient and nurse positioning for flexible oesophagoscopy.

Passing the endoscope

The endoscopeis prechecked for proper functioningand thetiplubricatedwithaqueous gel. The endoscope should then be passed under direct vision, The tip of the scope is flexed, using the controls which are held in the left hand, and its alignment adjusted so that,when inserted through the mouth-guard, the tip naturally follows over the back of the tongue to pass into the posterior pharynx. The tipis then straightened, using the left hand thumb onthe up/down control. Thescope is gently advanced and the patient asked to swallow to relax the cricopharyngeus. In a routine survey, the oesophagus, stomach and first and second parts of the duodenum are examined. The endoscope is advanced under direct vision, using air insufflation and suction as required. If unsure o f the scope’s location due to loss of view or disorientation,thenthe scope must not be advanced ‘blind’ but should be withdrawn slightly. Any lesions seen should have theirpositionnoted,and biopsies and brushings are taken for histology and cytology if appropriate. Special care must be taken to examine the upperthird of theoesophagus on withdrawal as the endoscopeoften passes throughthisarea quickly on insertion, preventing an adequate view. The endoscopic landmark in theloweroesophagus is thesquamocolumnar mucosal junction, usually marking the oesophagogastric junction, which should lie at the level of the diaphragmatic hiatus (Fig. 39.2). This mucosal interface, where the pale pinkoesophageal mucosa meets the darker red gastric mucosa, is also known as the ‘Z-line’, and is normallylocatedapproximately 40cm from the incisors in adults. If the Z-line lies proximal to the diaphragmatic hiatus, then either a sliding hiatus hernia or a columnar-lined oesophagus (Barrett’s oesophagus) is present. The endoscope can then be advanced into the stomach through the pylorus and into the duodenum.

Recovery and discharge of day cases Following IV sedation most patients requirebetween 15 and 3Omin on a trolley before being able to be transferred to a chair to recover. By 1h postprocedure, patients are able to be discharged home with supervision. Prior to discharge they are given an information sheet. This includes details of the examination findings, follow-up arrangements and instructions emphasising that the patient must not drive or operate heavy machinery for 242.1.

Fig. 39.2 Endoscopic landmarks.

Complications Drug=induced respirato

As discussed, great care must be taken in using IV sedation, especially in elderly and infirm patients. Perforation of t

This occurs in less than 0.1% of cases and is more common when the endoscope is inserted blind, when a severely diseased organ or diverticulum is present, and duringtherapeutic manoeuvres. Typically thepatient complains of pain, and may be pyrexial. Surgical emphysema may be present. Free gas may be visible on abdominal X-ray or pneumomediastinum, a pneumothorax or pleuraleffusion on chest X-ray. Management will depend on the site of the perforation and the patient’s pathology, Puimonary aspiration

This is most likely in elderly patients, when the cough reflex has been suppressed and in the presence of excessive sedation. Minor degrees may be common but major problems are rare.

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Infection hazards

Infection of endoscopy personnel

Patient-to-patient infection

This should be avoided by adopting recommended procedures with blood and gastrointestinal secretions.

This shouldbeeliminated by following thecorrect recommendations for sterilising the endoscope and accessones. Bacteraemia

This is probably very rare but it is advised that patients with prosthetic heart valves are given amoxycillin and gentamicin to cover upper GI endoscopy.

Further reading Baiiiie J (1992) Gastrointestinal Endoscopy: BasicPrinciples and Practice. London, Butterworths. Cotton PB & Williams CB (1996) Practical Gastrointestinal Endoscopy, 4th edn. Oxford, Blackwell Science.

Rigid Bronchosc VICTOR ABDULLAH

Custav Killian of Freiburg, the father of bronchoscopy, modified theskeletonoesophagoscope to view the tracheobronchialtree in 1897 (Stevenson &C Guthrie, 1949). Today, a century later, many different types of rigid bronchoscopes are available. Most of these instrumentsareequippedwithfibreopticillumination and providequality magnifiedimages through specially adapted glass lenses. The typicalmodern universal bronchoscope has side-ports, which allow ventilation, suction and fibreoptically transmissible laser to be effectively and efficiently delivered. The modern universal rigid bronchoscope, apart from its diagnostic use, has provided for safer and more controlled performance of interventionalprocedures down thetracheobronchial tree for obstructive lesions. The rigid bronchoscope is particularly well suited for such procedures as isiteffectively an optically guided endotracheal ventilation tube (VT). A furthermerit is itswide-borelumen,which allows the ready removalof large blood clots and tissue debris,which, not infrequently,accompany interventional procedures. Whichever rigid bronchoscope is used and for whatever purpose, a safe method of insertion and advancement must be mastered.. Familiarity with the specific bronchoscope and a sound knowledge of the anatomy of the tracheobronchial tree and its important relations are essential prerequisites (Figs 40.1 and 40.2).

the heart, whichis its anteroinferior relation. Important relations of the cervical trachea include the isthmus of the thyroid lying over the second, third and fourth tracheal rings, the thyroid lobes laterally and the cervical oesophagusposteriorly.Inthe thorax,the trachea is flanked by the innominate arteries laterally. The thoracic oesophagus lies posteriorly and takes a gentle left turn to pass behind the left main bronchus. The distal trachea has the aortic arch lying on its left. Between the trachea and the alveolar sacs, the airway divides 23 times. The rigid bronchoscope, however,only allows examinationof the orifices of the third bronchial division. Thebronchopulmonarysegmentalopenings may be inspected just beyond thethirdbronchial divisions. The right main bronchus hastwo importantrelations. Passing over it from posteriorly to reach the superior vena cava is the azygos vein. The right pulmonary artery lies first below and then anterior to it (Fig. 40.2). The right upper-lobe bronchus takes off above the pulmonaryarteryand hence it is often described asthe ‘eparterial bronchus’, All other lobar bronchi, right and left, liebelow their respective pulmonary arteries and are termed ‘hyparterial bronchi’. The left main bronchus has the aortic arch above with the oesophagus and thedescending aorta as its posterior relations.

Anatomy

lndications

The adult trachea measures on average 12cm in length and is 2cm wide, with its patency maintained by 15 to 20 U-shaped cartilages. The right main bronchus, being 2.5cm long, is shorter, wider and morevertical than the left, which measures 5cm in length. The carina sits over

1 Diagnostic and routine examination

of

the

tracheobronchial tree. 2 Removal of a foreign body. 3 Interventional procedures such as laser widening or stent insertion for obstructive tracheobronchial lesions. 280

Rigid Bronchoscopy

28 I

4 The urgent establishment of an airway in upper airway obstruction if intubation fails.

Anaesthesia The author prefers the use of spontaneous assisted ventilation with gas induction or continuous IV propofol infusion anaesthesia. Oncethepatient is asleep, the larynx is sprayed twice or three times with 10% xylocaine spray using the Macintosh laryngoscope. Additional sprays can be delivered to the carina via the bronchoscope once it is inserted, using the long spray nozzle. Anaesthetic gas and/or oxygen is delivered via the bronchoscope’s ventilation channel throughout the procedure,withthepatientbreathingspontaneously. This can be assisted with bagging through the circuit if required.Mechanicalventilation and oxygen Venturi ventilation are alternatives to the above.

Procedure Position Right main bronchus

Fig. 40.1 Anatomical relationships of the trachea (posterior view).

The patient shouldbe supine with his head 2-3 cm from the edge of the bed. The insertion can be facilitated by the use of a shoulder support and gentle flexion of the cervical spine withthe head extended to rest on a head ring. This brings the trachea to a more horizontal position. Procedure

Oesophagus

Fig. 40.2 Structures crossing the right and left main bronchi.

The upper teeth should be protected with a tooth guard and the gums of an edentulous patient with a piece of saline-soaked gauze. The right-handed surgeon should use his left hand to open and steady the mouth. Theleft middle finger is used to support the hard palate while lifting it cranially. The left forefinger is used to displace the lower lip downwards to avoid it being rolled inwards and injured during insertion. The left thumb is used to support the scope while keeping it away from the upper teeth or gum. The best position for the insertion of the bronchoscope is from the side which allows an easier excursion and minimal leverage. The right side is preferred as thehead would be out of the way for the righthanded surgeon. Until the trachea has been entered, it is essential to keep the beak of the bronchoscope in sight. This applies in particular to bronchoscopes with adapted Hopkin’s rods. If the beak cannot be seen, the rod should be withdrawn during insertion orelse laryngeal injuries can easily be inflicted.

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Chapter 40

The scope should be lightly lubricated. Keeping the lobe segmental openings except with special-angled beak in the 12 o'clock position, it is used to displace the Hopkin's lenses. Figure 40.4 illustratesthe different tongue forward and away from the posterior pharyngealviews from different positions down theright main wall. The identification of the epiglottis is easy but its bronchus. elevation can be tricky. One should avoid flicking the Once the examination of the right main bronchus is epiglottis repeatedly but pass the scope straight on tothe completed, the scope can be retrieved to a position just arytenoids. The beak can then be elevated to reveal the above the carinawhile returning the head of the patient vocal cords (Fig. 40.3). The bronchoscope is then rotated 90" clockwise. With the bronchoscopic view centred on theleft vocal cord, the tip can be placed between the cords. The scope is then advanced while being rotated back 90" anticlockwise. This manoeuvre facilitates the passage through the glottis. The trachea now comes into view. Once in the trachea, the bronchoscope should be kept in the centre of the lumen at all times. The scope can be advanced while inspecting thetracheal wall until the distinct sharp edge of the carina is reached. It is more convenient to inspect therightmain bronchus first as it is more vertical and thus easier to enter. With the patient's head rotated to the left, the scope can be advanced down the right main bronchus. The first lumen to beviewedis therightupper-lobe Fig. 40.3 Bronchoscopic view showing advancement of bronchus. It is usually not possible to view the upperbronchoscope to the posterior arytenoids.

l

\Posterior basal

Fig. 40.4 Bronchoscopic views down the right main bronchus at positions (a) and (b). (Top, anterior; bottom, posterior.)

Rigid Bronchoscopy to the central position. The head can now be turned to the right side to facilitate the inspection of the left main bronchus. It is usually necessary to turn the head a little furtherasthe left main bronchustakes off more obliquely. The left main bronchus is narrower and twice as long as the right. Once inside, two openings separated by a ridge which looks just like the carina can be seen. This ridge is termed the subcarina or secondary carina. The upper opening contains the upperand lingular-lobe bronchi and the lower opening is the lower-lobe bronchus with its segmental openings (Fig. 40.5). The retrieval of foreign bodies fromthetracheobronchial tree is a not uncommon indication for rigid bronchoscopy, even in the adult population. During the procedure, the beak of the bronchoscope should be kept a short distance away from the foreign body to avoid displacing it further down the airway or createbleeding from surrounding granulationtissue. Bleeding around a foreign body can be minimised by a few drops of 1:20 000 adrenaline. The removal of the foreign body can be effectively performed using a Fogarty balloon, a wire basket or different types of grasping forceps. The choice of instrument depends on the nature, shape and size of the foreign body. Optical grasping forceps supersede others as they can be accurately applied with the least amount of trauma. The anaesthetist should be informed once the examination is complete so that appropriate equipment is at hand once the scope is removed.

Fibreoptically transmissible lasers such as Nd-YAG, argon and potassium-titanylphosphate(KTP) canbe effectively delivered down a flexible or rigid bronchoscope.

Fig. 40.5 Bronchoscopic view down the left main bronchus at position (a). (TOP, anterior; bottom, posterior.)

283

The rigid bronchoscope is preferred for photoablation of obstructive intraluminal tumoursbecause of the more effective evacuation of tissue debris and blood clots. The Nd-YAG laser is a gas laser emitted at a wavelength of 1064 nm. Its deeper penetration, maximally at 1.5cm, rendersitmost useful for removal of large vascular lesions in the trachea or bronchi. The argon laser is a gas laser in the blue-green region of visible light. It only penetrates 1-2mm and is useful for vaporising superficial tumours of the tracheobronchial tree. The KTP laser is similar to argon. Its wavelength of 532nm is close to the peak absorption spectrum of haemoglobin, making it more suitable for superficial vascular lesions. The CO, laser has a wavelength of 10600nm and a depth of penetration of approximately 10nm. It is not fibreoptically transmissible. Its minimal scatter allows precise cutting and lessens collateraldamage to surrounding tissues. The CO, laser, however, is inferior to the above-mentioned lasers in its haemostatic ability. It nevertheless remains an effective laser for removing granulation tissue, limited stenosis and respiratory papillomata within the tracheobronchial tree. Respiratory papillomata are pale in colour with small bloodvessels and careful use of the CO, laser allows precise vaporisation without damaging the underlying perichondrium and cartilage. Granulations following a tracheostomy and infiltrates of amyloidosis are also amenable to CO:, laser removal. This laser is less suitableforcytoreduction of malignantintraluminaltumours as bleeding can occur. The CO, laser bronchoscope requires a specially designed coupling device for laser transmission. The method of insertion of the CO, laser bronchoscope is as described above. Whenever possible, the scope should be passed to a more distal position clear of the obstruc-

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Fig. 40.6 Radial laser incisions for circumferential stenosis of the trachea.

tive lesion to optimise ventilation, and one can then work from distal to proximal. The bronchoscope itself often proves to be an effective optically guided dilator. Lasering should be performed from the centre of the lesion, leaving a rim of tissue on the tracheal wall to prevent its penetration. When widening tracheal stenoses, it is importantto use radial incisions (Fig. 40.6) to avoid circumferential laser-induced injury (Shapshay et al., 1987’).It is necessary to uncouple the coupling device intermittently to allow suction or forceps removal of charred tissue. Whichever laser is used, the operator shouldbe familiar with its potential hazards. It is the surgeon’s duty to ensure that the patient and all who are present in the theatre are adequately protected against the dangers of that particular laser.

ornplications of bronchoscopy 1 Injuries to the lips, teeth, gum and tongueare not uncommon.

2 Laryngeal oedema may occursecondary to either rough insertion or prolonged examination. Dexamethasone 10mg IVfollowed by two furtherdoses 8 h apart should be given. The patient is put on airway and oximetric monitoring on the ward. 3 Haemorrhage.Thiscan usually be controlled by tamponadewithapeanut gauze soaked in dilute epinephrine (1:20 000). Epinephrinesolutioncan be instilled via bronchoscope the the into tracheobronchial tree. Electrocautery or the Nd-YAG laser are effective coagulators if available. A Fogarty venous occlusion catheter can be used for more severe haemorrhage. 4 Penetration of the wall of the trachea and bronchi. Sudden development of surgical emphysema, oxygen desaturation and lung collapse can occur and require urgent insertion of chest drains and ventilatory support.

References and further rea Cordasco EM, Jr, Mehta AC & Ahmad M (1991) Bronchoscopicallyinduced bleeding: a summary of nine years’ Cleveland Clinic experience and review of the literature. Chest. 100, 1141-7. Ossoff RH, Karlan MS (1992) Universal endoscopic coupler for carbon dioxide laser surgery. Ann. Otol. Rhinol. Laryngol. 91,608-9. Prakash UBS (1994) Bronchoscopy. New York, Raven Press. Shapshay SM (1990) Laser Bronchoscopy: Lasers in Philadelphia, W.B. Otolaryngology-HeadandNeckSurgery. Saunders, pp. 85-105. Shapshay SM, Beamis JF, Jr, Hybels RL & Bohigian RK (1987) Endoscopic treatment of subglottic and tracheal stenosis by radial laser incision and dilation. Ann. Otol. Rhinol. Laryngol. 99, 6614. Stevenson RS & Guthrie D (1949) A History of Otolaryngology. Edinburgh, E & S Livingstone, pp. 130-7.

ssessrnent of the Paediatric Airway: Laryngotracheobronchoscopy DAVID ALBERT

Introduction Most paediatric airway endoscopies are performed for the investigation of stridor. A standardised techniquein these cases ensures that examination is comprehensive, and this technique is described first. Examinations for otherindications(suchasbronchoscopy for foreign bodies or to specifically assess dynamic conditions such as cord palsies) arebest achieved using modifications of this technique, and these modified techniques will therefore be described separately. Laryngotracheobronchoscopy (LTB) is now a highly technical procedure and thewholeteam(surgeon, anaesthetist and nursing assistant) need to fully understand the equipmentto perform the examination safely, and to optimise the assessment. Ideally, the same surgeon, anaesthetistandnurseshouldroutinely work together. The advent of video has improved training.It has also made the assessment safer, as the anaesthetist can monitor progress on the screen and the nurse can be ready with equipment for the next stage. If the examination is for assessment, it is vital that accuraterecordsarekept to allowcomparisonwith future examinations. Thisis facilitated by using a standardised form within a department (Fig. 41.1). Use of a recognised staging system (Fig. 41.2) is important for publication of results. Polaroid prints from the video form a valid record for static conditions, while for dynamic conditions a videotape is unparalleled.

Indications for bronchoscopy Stridor is thecommonestindication by far. Not all children with congenital stridor require bronchoscopy

(Table 41.1), although stridor that appears later in life and persists doesrequire full investigation. The main indications are given in Table 41.2.

History To determine the cause

First stridor mustbe distinguished from stertor. This can be difficult though an impersonation of each type of noisy breathingmay help. Stertortends to be worse during sleep, while stridor is worse when the child is feeding, upset or exercising. Laryngomalacia usually develops in the first few weeks of life. A history of prolonged intubation may suggest subglottic stenosis, interarytenoid scarring or tracheal stenosis, while previous thoracic surgerymayhave causedacord palsy. An abnormal voice or cry suggests pathology at the laryngeal level, such as papillomatosis or, if congenital, aweb.Patientswitharepairedtracheo-oesophageal (TE) fistula may have associated tracheomalacia or occasionally a laryngeal cleft. Thiscausesrecurrent pneumonias, as well asaspirationduring feeding. In paediatric airway obstruction, the history is seldom so characteristic that a positive diagnosis can be made. To assess the severity of airway obstruction

Most parents will be able accurately to describe recession and the effect of airway obstruction on feeding. Many will be informed about poor growth. However, apnoeic episodes always seemlonger to a parent, although cyanosis, if described, is a suresign that a significant event has occurred.

Chapter 41

286 ~

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~

OPERATI

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. "

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"

-

.

.

"

--

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P

MLB Nature of operation: .......................................... Date carried out: ................................................ Surgeon: ...................................................... Assistant: .................................................... Anaesthetist: ...............................................

History:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Working diagnosis: ..................................... Tracheostomy:

Yes

N o ...........

. . . . . . . . . .

Report

Epiglottis: ..........................................................

Type of laryngoscope: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Aryepiglottic folds: ........................................... Arytenoid mobility: ......................................... ? Laryngeal cleft: .............................................. Vocal cords: Function: .................................. Appearance:

. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Tranchea: .......................................................... ?Suprastoma1 collapse:.................................... Carina: .............................................................. Bronchi:

Size of bronchoscope: ................... Size of ET tube: ..............................

Right: ......................................... Left: ...........................................

Photograph

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ." .

Impression and plan

Yes

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No

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fig. 41.1 A standardised form for documentation.

Table 41.1 When to scope a child with congenital stridor (e.g.

stridor starting within 1 week of birth).

Inspiratory stridor is usually laryngeal while expiratory stridor suggests an intrathoracic cause. Do notbe misled by the child whose stridor seems to have improved, as this may be due toworsening air flow. General examination may reveal features of craniofacial syndromes or isolated maxillary or mandibular hypoplasia. Children withDown'ssyndrome have an increased risk of subglottic stenosis. Cutaneous haemangiomas are present in about 30% of patientswithsubglottic haemangiomas.

Assessment of the Paediatric Airway

287

2 Undamaged light leads. 3 Laryngoscopes (Fig. 41.3):

50% obstruction

70% obstruction

Fig. 41.2 Staging of stenosis. With the permission of Ann. Otol. Rhinol. Laryngol. Table 41.2 Main indication for bronchoscopy.

(a) Benjamin (anterior pathology); (b) Lindholm (posterior pathology); (c) Kleinsasser (general). 4 Laryngostat (Lewy jack is too heavy for neonates) (Fig. 41.4). 5 Laryngeal probes and forceps. 6 Full range of ventilating bronchoscopes to accept Storz-Hopkins telescopes. 7 Spaghetti suckers passed alongside telescope if using >3mm bronchoscope. 8 Side-arm forceps and peanut-extraction forceps (requires extra long telescope) (Fig. 41.5). 9 Video camera attached for microscope. 10 Video cameraattached direct to bronchoscope so that bronchoscopy is performed by looking at video screen. 11 Video printerhide0 recorder, invaluable for documentation. 12 Neurosurgicalmicropattiessoaked in 1:100 000 adrenalineare excellent forcontrolling oedema and bleeding.

Standard technique Anaesthetic

Preoperative investigations (not always necessary) 1 Lateral neck X-ray. 2 Cincinnati view: penetrated anterior -posterior (A-P) chest to show major airways. 3 Barium swallow: this cannotbe used to exclude reflux but screening may demonstrate tracheomalacia.

Key equipment 1 Xenon light source with feedback intensity control.

IM atropine is vital for a drysurgical field and toensure that the topical anaesthetic is effective. An IV induction is preferable for older children, although gas induction may be needed in infants and those with a precarious airway. IV suxamethonium can be given if the patient is stable and should be given prior to the lignocaine spray to avoid laryngeal spasm and to facilitate intubation. Nasotracheal intubation allows the endotracheal tube (ET) to be withdrawn into the nasopharynx once the child is breathing spontaneously. Halothaneand oxygen maintain a level of anaesthesia that allows a thorough examination in a child who is breathing spontaneously. The anaesthetist needs to be able to control anaesthesia in response to surgical conditions and for this a video monitor is invaluable. Preoperative steroids are a good safegaurd if significant stenosis is suspected. In experienced hands, a technique of not intubating at all allows the surgeon a view of the larynx prior to any instrumentation. Microlaryngoscopy

A small sandbag is usually required under the shoulders to greatly extend the neck, and expremature neonates

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Fig. 41.3 Laryngoscopes: (i) paediatric Kleinsasser; (ii) Benjamin; (iii) Lindholm.

Fig. 41.4 Laryngostat.

Assessment of the Paediatric Airway

289

that the arytenoids are splinted, preventing assessment of arytenoid movement. Childrenwithlaryngomalacia tend to have tall (superiorly) but short (anteroposteriorly) aryepiglottic folds which approximate the epiglottis to the arytenoids; this is best appreciated with a Lindholm scope in the vallecula. Finally, use a probe to check the vocal cords and ventricles. Double-check that the appropriate bronchoscope is available before the anaesthetist withdraws the tube into the pharynx under video control. Laryngeal examination with endotracheal tube removed Fig. 41.5 Foreign body extraction forceps. Long telescope forceps.

fits inside

may need sandbags laterally to support their long thin heads. A Mayo table supports the laryngostat clear of the chest. Prepare and check equipment: 1 check microscope and video; (a) use a 400 mm lens to allow use of standard laryngeal instruments; (b) use a 350mm lens to aid manipulation of larynx (particularly in small neonates); 2 check bronchoscope size and telescopes; 3 antifogsolution needs to be freshly applied to the telescope lens to be effective.

Using a probe, gently check for cricoarytenoid fixation by moving the arytenoids independently; then exclude an interarytenoidscar by trying to separatethetwo arytenoids. A posterior laryngeal cleft is excluded by passing the probe between the arytenoids, comparing the lower limit of the interarytenoid groove withthat of the posterior commissure. Finally, move the cords apart to inspect the subglottis. The time available will depend on the airway. In a child breathingspontaneouslywithanormalairway andnormal lung function, anaesthesia can be maintained solely by the use of inhalational agents from the ET withdrawn into the pharynx.In others, the time may be very limited and it is essential to be prepared to move ahead with bronchoscopy at any stage.

Laryngeal examination with endotracheal tube in place

Insert the lubricated laryngoscope, protecting the teeth and lips and keeping the tongue central, if possible, to provide a well-centred view. As in adults, check the overall appearance of supraglottis the and laryngopharynx during introduction of the laryngoscope. Follow the ET, if present, to the tip of the epiglottis and then gently lift the epiglottis forwards. This is easiest witha Benjamin laryngoscope. Make certain that the epiglottis does not curl upin front of the laryngoscope, preventing a complete view of the anterior commissure (Fig. 41.6). If necessary, relubricate the tip of the scope. Check if in doubt by gently withdrawing the laryngoscope, as a curled epiglottis is the commonest fault in those learning the technique of paediatric laryngoscopy. Often this is a particular problem in older children with a tracheostomy, in which case an anaesthetic laryngoscope placed in the vallecula can help. Do not insert the laryngoscope so far into the larynx

Fig. 41.6 To show poor posterior view if epiglottis becomes invaginated.

If anaesthesia is stable, a sucker can be placed in the laryngeal inlet to mimic laryngomalacia -the 'Narcy test'. Photographs can be taken at this stage with a-wide angle Storz photographic telescope. If there is significant subglottic stenosis, an ultrafine telescope passed through the laryngoscope will cause less trauma than a bronchoscope.

Select the age-appropriate bronchoscope (Fig. 41.7') unless stenosis is suspected, but always have available smaller bronchoscopes. Use an anaesthetic laryngoscope in the vallecula to lift thelarynxforward, while passing the bevel of the

bronchoscope through the vocal cords under video control on the monitor. Avoid impacting the ventricle with the bevel of thebronchoscope.Change to a smaller bronchoscope if resistance is felt with the bronchoscope placed centrally to avoid unintenionally dilating any stenosis. Establish a pattern of examination so that the main bronchi, the carina, the trachea and the subglottis areall systematically examined. Avoid the carina if the anaesthesia is at all 'light', as the carina1 mucosa is particularly sensitive. Tracheomalacia should be observed with a small bronchoscope withdrawn from the area in question and without positive airways pressure, in order to avoid splinting. The ratio of cartilage to trachealis is significant in recording the type of malacia and if aortopexy islikely to be successful.

Typically thiscan be achieved by withdrawingthe bronchoscope to just posterior to the tip of the epiglottis. Thisaffordsagood view of the vocal cords to exclude a cordpalsy and of the arytenoidsto exclude the commonposteriorform of laryngomalacia,although anterior collapse of the epiglottis may be masked. In this case a 30" or 70" telescope should be used. If dynamic assessment is crucial, as in a suspected vocal-cord palsy, a fibre-optic bronchoscope can be passed nasally with the ET remaining in thepharynx.Theanaesthetist should call the phase of respiration to check for paradoxical vocal-cord movements.

ies

Fig. 41.7 (a) Ventilating bronchoscope and (b) telescope.

At its most challenging, removal of a long-standing organic foreign body impacted in a bronchus can tax any endoscopist. It is essential, therefore, to optimise the situationwiththe best anaesthetist available and the best equipment. Most patients are sufficiently stable for transfer to a major centre. The only acceptable 'standard of care' now is to use foreign-body extraction forceps which will accept a Storz-Hopkins telescope. The procedure is safer if the anaesthetist is able to monitor progress on a video screen, and the video is also invaluable if trainees are to learn the technique. If the foreign body is engulfed withgranulations, lignocaine 0.5% and adrenaline 1:200 000 left for 5 min prior to removal isvery helpful in maintaininga clear field. Patients

Assessment of thePaediatricAirway

291

should stay in hospital for at least 48 h postoperatively, aslate pyrexias may signal an area of collapse and consolidation.

through three separate sputum traps. The return is often quite low (20-30%). Send for microbiology (?TB)and cytology as appropriate.

Dynamic laryngosco

Laser laryngoscopy

The 'gold standard' for dynamic assessment is to insert a laryngeal mask with afibre-optic bronchoscope passed through this to just above the larynx.If a bilateralvocalcord palsy is suspected andstructuralabnormalities have been excluded with a full microlaryngoscopy and rigid bronchoscopy, the patient should be rescheduled for a further examination. A laryngeal mask and fibreoptic scope are used from the outset, reducing the influence of prolonged anaesthesia on the cord function. An alternative is to use a 30" scope, which gives a view of the larynx without splinting the supraglottis.

This is most useful for small post-intubation granulomas and for laryngeal papillomatosis. Attempts to use the laser for anterior webs or subglottic stenosis are usually unsuccessful. A laser-safe tube needs to be used and thenwithdrawnintothepharynxfor final lasering of the unintubated larynx. Great care must be takennot to damagenormal tissues and producea secondary stenosis.

Bronchial lavage

Either a rigid or a fibre-optic scope can be used. If pathology is suspected in the right upper main bronchus, a flexible scope is preferable, Wedge the end of the bronchoscope into the bronchus in question and inject 0.25ml/kg normal saline through the suction port. On thetablephysiotherapy is helpful before aspirating

Laser bronchoscopy

Modern laser bronchoscopes offer a reasonable view of lesions in the trachea and bronchi, which can then be lasered. The optics are, however, vastly inferior to normal telescopes and the technique is different. At present a 3.5rnrn scope is the smallest available. Smaller childrenwithtrachealpapillomasoftenalready have a tracheostomy and the laser bronchoscope can then be passed through this. Newer KTP laser fibres have solved some of the problems of tracheal laser therapy.


The Oral Cavity,

Pharynx and Larynx


Adenoidectomy and Tonsillectomy PETER M. CLARKE

Adenoidectomy and tonsillectomy are separate procedures, each with theirown specific indications. A patient should not be listed for ‘Ts and As’ unless criteria have been rigorously considered for each procedure.

Bndications Adenoidectomy

Otitis media

Otitis media with effusion, recurrent acute otitis media and nasal obstruction can all be improved by adenoidectomy (Maw & Herod,1986;Gates et al., 1988; Paradise et al., 1990). A sensible approach for both otitis media with effusion and recurrent acute otitis media is initial ventilation-tube (VT) insertion after failure of medical treatment. Adenoidectomy should be reserved for cases requiringtreatment following tube extrusion (Black et al., 1990; Paradise et al., 1990; Dempster et al., 1.993). Obstruction

The triad of snoring, mouth-breathing and hyponasal speech in children is usually caused by a combination of adenoidhypertrophy and allergic rhinitis. Adequate treatment of the rhinitis, including allergen avoidance advice, should be the first line, adenoidectomy being reserved for resistant cases. A relationship between adenoid hypertrophy and the facial skeletal characteristics of ‘adenoid facies’ has been demonstrated (Linder-Aronson, 1970), but it seems unlikely to be causal (Hibbert, 1987). Orthodonticcorrection of any malocclusion should probably be the first line of treatment.

Tonsillectomy

Recurrent acute tonsillitis

The commonest indication fortonsillectomy is recurrent acute tonsillitis. The frequency and severity of attacks have to be carefully assessed at the out-patient visit. It is also necessary to establish whether sore throats are due to true tonsillitis or mild viral pharyngitis. Tonsillitis may sensibly be considered as a sore throat lasting several days, during which the patient is systemically unwell. Parents will often not know whether a child has been pyrexial, had tonsillar erythema or exudate orhad cervical lymph-node enlargement, but these should ideally have been documented by the GP. If there is uncertainty about the severity of sore throats, the help of the GP and parents should be enlisted and the child may be reviewed aftera few months. Five or six episodes of tonsillitis in 1 year or three to four episodes per year over 2-3 years seem reasonable criteria for tonsillectomy in children. Three to four episodes a year for 2-3 years would be reasonable a indicationinadults (Hibbert, 1987; Zalzal & Cotton, 1993). Additionalfactors such astheamount of school or work missed, associated febrile convulsions or medicalconditions such asbrittle diabetes or valvular heart disease will influence the decision to undertake tonsillectomy. Quinsy

A second peritonsillar abscess is an indication for tonsillectomy, either acutely as a ‘quinsy tonsillectomy’ or 6 weeks later. If a general anaesthetic (GA) is required in a child to draina quinsy, a ‘hot tonsillectomy’ should be considered.

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Chapter 42

Malignancy

Lymphoma may present in children as unilateral tonsillar enlargement, and so a progressively enlarging tonsil should be suitably investigated and excised. Suspicion of a squamous cell carcinoma (SCC) in an adult requires biopsy and histology. The investigation of a patient with secondary SCC in a cervical lymph node and noobvious primary source should include excisional biopsy of the ipsilateral tonsil aspart of thehuntforthehidden primary (see Lymph-node Biopsy in theHeadand Neck-Chapter 56, and Panendoscopy-Chapter 38).

investigated, and, if found, surgery should only proceed with the advice and cooperation of a haematologist. A child who has had acleft palate repaired or whohas a submucous cleft should not undergo adenoidectomy or tonsillectomy. In these patients tonsillectomy may further reduce palatal mobility, and following adenoidectomy closure of the nasopharynx may be impossible, leading to hypernasal speech and nasal reflux on swallowing.

Preoperative management

Chronic tonsillitis may be defined as a constant feeling of a sore throat associated with erythematous fauces, debris in tonsillar the crypts and enlarged jugulodigastric nodes. Chronic tonsillitis, halitosis due to debris collection in tonsillar crypts, tonsilloliths and recurrentchoking while eatingareprobably all best treated conservatively. Tonsillectomy may, however, improve symptoms in resistant cases. Tonsillectomy may be performed in adults as an integral part of uvulopalatopharyngoplasty (UPPP) and for access to the styloid process or glossopharyngeal nerve.

The decision to list apatientfor tonsillectomy relies on history, examinationadding little to the available information. Certainly tonsillar sizeis not significant and jugulodigastric nodes are often palpable in healthy children. The concept of ‘unhealthy tonsils’ is doubtful. Examination of the postnasal space is usually impossible in children of the age likely to have significantadenoid tissue. Palatal elevation may give an impression of available space in the nasopharynx and a lateral radiographmay be helpful in assessing adenoid size. It is important that parents and patientsaremade aware that surgery will not completely relieve problems but the frequency and severity of symptoms should be reduced.

Adenotonsillectomy

Relevant anatomy

Obstructive sleep apnoea

The local anatomy is outlined in Figs 42.1 and 42.2.

Other indications

Adenotonsillectomy may commonly be carried out if thereareseparateindicationsfor each. A child with recurrent acute tonsillitis, nasal obstruction and otitis media with effusion may need both adenoidectomy and tonsillectomy. Obstructive sleep apnoea, however, is a single indication for undertaking bothtonsillectomy and adenoidectomy. In children, severe obstruction of the upper airway can lead to obstructive apnoeic episodes during sleep, when respiratory effort continues but no air flow is produced. The resultant hypoxia and hypercapnoea lead to daytime somnolence andpoor concentration at school and may eventually cause pulmonary hypertension, rightheart failure anddeath (Eliaschar et al., 1980).

ontraindications Contraindications to surgery are those of any GA, including a concurrent upper respiratory tract infection. Any suspicion of a coagulation disorderneeds to be fully

Operative technique Adenoidectomy

Under GA, administered via an oral endotracheal tube (ET) or laryngeal mask (Williams & Bailey, 1993), the patient is placed supine on the operating table, with the surgeon standing at the head of the table, wearing a headlight. Overextension of the neck should be avoided, as this brings the odontoid peg and arch of theaxis anteriorly, so impinging on theposteriorpharyngeal wall. This would make damage to the prevertebral muscles more likely during the procedure. 1 A Boyle-Davis gag is inserted into the mouth, thesplit blade of the gag holding the anaesthetic tubeand tongue in the midline as the gag is opened. 2 The palate is palpated to exclude a submucous cleft and the finger can be slipped behind the soft palate to assess adenoid size. 3 An adenoid curette is inserted into the nasopharynx,

Adenoidectomy and Tonsillectomy

297

Fig. 42.1 Sagittal section showing relations of the tonsil and adenoid. The tonsil has been removed to reveal structures on its deep aspect.

I Stylopharyngeus

Fig. 42.2 Axial section at the level of the tonsil.

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Chapter 42

Fig. 42.3 Adenoidectomy. The curette is swept down the nasopharynx using the thumb as a fulcrum.

swab, the area shouldbe checked with a mirroror finger for tags of adenoid tissue, which should be recuretted. Further swabs maybe wetted with hot water or 1 :1000 adrenaline and inserted in the nasopharynx for 5min. Alternatively, a haemostatic pack, such as calcium sodium alginate (Kaltostat), may be used. Troublesome bleeding points may be visualised with a mirror and/or palate retractor and cauterised with diathermy, a silver nitrate stick or suctiondiathermy.Apostnasalpack should be used only as a last resortif bleeding cannot be controlled (Fig. 42.4). 6 At the end of the procedure, the surgeon should be certain that there is no bleeding. After extubation the patient is placed on their side, slightly head-down and transferred to the recovery area.

inferiorly towardsthetongue base. The scissors are turned round and the mucosa is incised over the top of theupper pole to prevent mucosal tearing on to the uvula during later dissection (Fig. 42.5). 4 Blunt dissection with the scissors follows the tonsil capsule laterally to create aplane between the tonsil and pharyngeal musculature. The tonsil forceps can then be repositioned with one blade in this plane, so pulling the whole of the upper tonsil medially. This medial traction should be maintained throughout the procedure. 5 Blunt dissection now proceeds with a Gwynne-Evans tonsil dissector or swab over the upper pole and down towardsthe tongue base. Care should be taken to stay in the relatively avascular plane between tonsil and muscle (see Fig. 42.2);otherwise bleeding may be increased or tonsillar tissue may be left in situ. Adult tonsils, especially after a previous quinsy, may be very adherent to the underlying muscles. In this case, dissection needs to proceed using the scissors. 6 At the junction of tonsil and tongue base, a snare is placed over the tonsil and positioned at the lower extent of dissection, to divide the tonsil from its final fibrous attachment.Alternatively, the lower pole may be clamped with a curved artery forceps and cut with scissors, leaving the forceps in place to allow a ligatureto be tied. Once the tonsil is removed, a swab is placed in the fossa and the second side is attended to. 7 With the swabin the second side, haemostasis of the first can proceed. The anterior pillar of the fauces may

Tonsillectomy

Anaesthesia is administered as for adenoidectomy, but a sandbag is placed under the shoulders, so extending the neck. The surgeon sits at the head of the table wearing a headlight. 1 A Boyle -Davis gag is inserted asforadenoidectomy. If the tongue is not held in the midline by the gag, access to onetonsil base is very difficult. The gag is then suspended, usually with a Draffin bipod. 2 The superior pole of one tonsil is held in Denis Browne tonsil-holding forceps or similar and pulled medially. 3 The mucosa is incised with scissors near the apex of the anterior faucalpillar. The incision is then continued

Fig. 42.4 The insertion of a postnasal pack. The pack has three tapes secured to it. Two soft rubber catheters are passed through the nose into the oropharynx. Two of the tapes are tied to the catheters and pulled back through the nose. The tapes are then tied firmly over a bolster or piece of tubing to protect the columella. The third tape exits via the mouth and is secured to the cheek; it is subsequently used to remove the pack.

Adenoidectomy and Tonsillectomy

299

en Postoperatively, patients who have undergone tonsillectomy or adenoidectomy should be monitored carefully with a view to early detection of any haemorrhage. This will involve regular measurements of pulse rateand observationfor excessive swallowing or anyfrank bleeding from mouth or nose. It appears safe, and will become increasingly common, to undertake day-case adenoidectomy (Sheppard et al., 1993). After tonsillectomy patients may require simple analgesia and should be encouraged to eata normal diet.

Fig. 42.5 Tonsillectomy. The mucosa of the anterior pillar of the fauces is incised down to the tonsil capsule. The incision is extended over the upper pole (arrow).

be reflected witha pillar retractorand the bleeding points visualised with a swab, using a dabbing, rather than wiping motion. The author’s preference is for bipolar diathermy, but surgeons should first become adept at ligature tying. 8 A bleeding vesselis clamped withthetip of a straightartery forceps, takingcare notto include surrounding tissue. A curved clamp is then placed under the tip of the straight clamp, which is removed, and a 2/0 linen or silk tie is placed around the curved clamp, using a Negus knot-pusher (Fig. 42.6). When tying the knot, care must be taken not to abrade the angle of the mouth. 9 Once haemostasis is complete, the postnasal space, pharynx and laryngeal inlet should be cleared of blood clot. The Boyle-Davis gag should be released and the lower poles checked again for bleeding which may have been controlled by the pressure of the gag. 10 As for adenoidectomy, absolute haemostasis should be achieved at the end of the proceduresuch that further pharyngeal suction is not needed. The patient is then placed on their side, slightly head-down, and transferred to the recovery area.

The principal complication of either operation is bleeding. This may be reactionary or secondary. Patients with post-tonsillectomy or adenoidectomy haemorrhage should have an appropriate IV line inserted and blood should be taken for full blood count, clotting studies and cross-match. Any child withaprimaryhaemorrhage lasting more than a few minutes should be returned to theatre to be reintubated by an experienced anaesthetist. If the bleeding is from the tonsillar bed, a single vessel can sometimes be found and ligated. There may be general ooze, requiring the pillars of the fauces to be sutured over some haemostaticagent, such as Surgicel. Bleeding from the adenoid bed should be dealt with as described previously. Atonsillarhaemorrhagein anadult canoften be controlled by pressure with a swab dampened with1m1

Iigatu re

Fig. 42.6 Haemostasis after tonsillectomy. A Negus pusher is used to help position and tighten the knot as shown.

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of 1:1000 adrenaline. Any clot in the tonsil fossa should first be gently sucked out or ‘shelled’ out with a small, warmed laryngeal mirror. Any patient with persistent bleeding should of course be returned to theatre.

l t e r n ~ ~ procedures i~e Both tonsillectomy and adenoidectomy have been described using the laser (Martinez & Akin, 1987). Electrocautery is commonly used in the USA (Zalzal & Cotton, 1993), anda group fromLisbon have described microsurgical bipolar tonsillectomy (Andrea, 1993). Dissection with the bipolarforceps can be helpful in the author’s experience and certainly reduces blood loss, but may be associated with some increased postoperative pain (Leach et al., 1993). An endoscopic approach to adenoidectomy has also been described (Becker et al., 1992).

Reeommendations for further reading Paradise and colleagues’ studies published in 1978 and 1984 provide interesting reading for all surgeons listing patients for tonsillectomy. Fry and Pillsbury (1987) review the indications for adenoidectomy and tonsillectomy concisely.

References Andrea M (1993) Microsurgical bipolar cautery tonsillectomy. Presented at: New Perspectives in Otolaryngology- Head and Neck Surgery, St Thomas’s Hospital, London, England, July 1993. N & Coglianese D (1992) Endoscopic Becker SP, Roberts adenoidectomy for relief of serous otitis media. Laryngoscope 102, 1379-84. Black NA, Sanderson CF, Freeland AP & Vessey MP (1990) A randomized controlled trial of surgery for glue ear. Br. Med.J . 300, 1551-6. Dempster JH, Browning GG & Gatehouse SG (1993) A randomized study of the surgical management of children with persistent otitis I. media with effusion associated withahearingimpairment. Laryngol. Otol. 107, 284-9.

Eliaschar J, Lavie l’, Halperin E, Gordon G & Alroy G (1980) Sleep apnoeic episodes as indicationsfor adenotonsillectomy. Arch. Otolaryngol. 106, 492-6. Fry TL & Pillsbury HC (1987)Implications of ‘controlled’ studies of tonsillectomy and adenoidectomy. Otolaryngol.Clin. North Am. 20,409-1 6. Gates GA, Avery CA & Prikoda TJ (1988) Effect of adenoidectomy upon children with chronic otitis media with effusion. Laryngoscope 98, 58-63. Hibbert J (1987) Tonsils and adenoids. In: Evans JNG (ed.) ScottBrown’s Otolaryngology, Vol. 6, Paediatric Otolaryngology. London, Butterworths, pp. 368-83. Leach J, Manning S & Schaefer S (1993) Comparison of two methods of tonsillectomy. Laryngoscope 103, 619-22. Linder-Aronson S (1970) Adenoids: their effect on mode of breathing and nasal air flow and their relationship to characteristics of the facial skeleton and the dentition: abiometric, rhinomanometric and cephalometric-radiographicstudy on childrenwith andwithout adenoids. Acta Otolaryngol. 69 (Suppl. 265), 1-132. Martinez SA & Akin DP (1987) Laser tonsillectomy and adenoidectomy. Otolaryngol. Clin. North Am. 20, 371-6. Maw AR & Herod F (1986) Otoscopic, impedance and audiometric findings in glue eartreated by adenoidectomy and tonsillectomy: a prospective randomized study. Lancet i, 1399-402. Paradise JL, Bluestone CD, Bachman RZ etal. (1978) History of recurrent sore throat as an indication for tonsillectomy. N. Engl. J . Med. 198,409-13. Paradise JL, Bluestone CD, Bachman RZ etal. (1984) Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials. N. Engl. J . Med. 310, 674-83. al. (1990) Efficacy Paradise JL, Bluestone CD, Rogers KD et of adenoidectomy for recurrent otitis media in children previously treated with tympanostomy-tube placement: results of parallel randomized and nonrandomized trials. JAMA 263, 206673. Sheppard IJ, Moir AA, Thomas RS & Narula AA (1993) Organisation of day-case adenoidectomy in themanagement of chronicotitis media with effusion-preliminary results. Journal of the Royal Society of Medicine 86, 76-8. Williams PJ & Bailey PM (1993) Comparison of the reinforced laryngeal mask airway and tracheal intubation for adenotonsillectomy. Br. J . Anesth. 70, 30-3. Zalzal GH & Cotton RT (1993) Pharyngitis and adenotonsillar disease. In: Cummings CW, Fredrickson JM, Harker LA, Krause CJ & Schuller DE (eds) Otolaryngology --Head and Neck Surgery,Vol. 2. St Louis, Mosby Year Books, pp. 1380-98.

Uvulopalatopharyngoplasty GRANTJ.E.M.BATES

Laugh and the world laughs with you; snore and you sleep alone (Anon.)

Introduction The pathophysiology of snoring and obstructive sleep apnoea

The sounds of snoring originate in the collapsible parts of the airway (between the posterior choanae and the epiglottis). Three main factors contribute to snoring and obstructive sleep apnoea (OSA). Reduction in pharyngeal muscle tone

Contraction of the pharyngeal dilator muscles (genioglossus, tensor palatini, geniohyoid and stylohyoid) occursin advance of diaphragmatic contraction. The action of these muscles keeps the airway open against thenegative pressure of inspiration. Muscle tone is reduced with sleep and if the dilator action is insufficient, airway collapse and snoring result.Alcohol, sedatives, hypothyroidism and some neurological disorders reduce muscle tone and exacerbate snoring. Presence of any space-occupying masses impinging on the airway

The classic example is the snoring and apnoea of childhood which is caused by enlarged tonsils and occasionally adenoids. However, one-third of adults also have tonsils large enough to cause airway obstruction. Bulky andobstructivepharyngeal tissues may also result from obesity. Excessive length of the soft palate

and uvulamay narrowthe nasopharyngealaperture. Retro- or micrognathia produce a relatively large tongue, while true macroglossia occurs in Down’s syndrome and acromegaly. Tumours, polyps or cysts will all narrow the airway. Restriction of nasal airflow

If the nasal resistance is increased, a higher inspiratory pressure is required and this leads to collapse in the compliant parts of the airway. Septal deviation, ostiomeatalandturbinateabnormalitiesand allergic and vasomotor rhinitis all increase nasal resistance. Definitions

Snoring

Snoring occurs because of a partially obstructed airway and the mechanism involves the Bernoulli effect. Reduced muscle tone and/or obstructingtissues narrow the airway and as a result the airflow has to increase, leading to a local fall in pressure. The pharyngeal walls are ‘sucked’ closer together and this reduces the air flow so that the pressure rises and the airway is restored. This sequencecauses vibration of thepharyngeal tissues, which results in snoring. Obstructive apnoea

Obstructiveapnoeaoccurswhenthere is noair flow despite respiratory effort. The airway has totally collapsed and eventually a mismatch between information fromthechest-wall muscles andthelungreceptors arouses the subject so that the ‘resuscitative gasp’ oc-

lking

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curs. Severely affected individuals may have apnoeic episodes lasting over 30s and these events may occur several hundred times a night. The apnoea index (AI)is the number of apnoeas occurring per hour. Hypopnoea

Hypopnoea occurs when there is a reduction in respiratory flow sufficient to cause a drop in oxygen saturation andlor an arousal. Hypopnoeas and apnoeas both cause arousals and so result in poor-quality sleep and daytime sleepinesss. The appnoea-hypopnoea index (AHI)is the number of these episodes occurring in 1h.

Medical risks

The medical risks of severe snoringprobablyequate to the risks of mild hypertension,butthe risks of OSA aresubstantial. In onestudy, men with OSA were 23 times more likely to have myocardial a infarction than matched non-apnoeic controls (Hung et al., 1990).

indications 1 IJvulopalatopharyngoplasty (IJPPP) is indicated for the treatment of heroic snoring. A heroic snorer is one

THE EPVVORTH SLEEPINESS SCALE

How likely are youto doze offor fall asleep inthe situations described in the box below, in contrastto just feelingtired?

Even if you haven't done some of these things recently try to work out how they would

have affected you.

Use the following scaleto choose the most appropriate number for each situation:

0

=

Would never doze

l = Slight chanceofdozing

I

1 1

I 1 and

1

2

=

Moderate chanceofdozing

3

=

High chanceofdozing

I

Sittingandreading Watching TV Sitting, inactive in a public place (e.g. theatre or a meeting)

As a passenger in a carfor an hour withouta break Lying downto rest in the afternoon when circumstances permit Sitting

to someone

I

I

l I I

Sitting quitely after lunch without alcohol In a car, while stopped for a few minutes in the traffic

Thank you for your cooperation

Fig. 43.1 The Epworth sleepiness scale, A score >l1is suggestive of sleep apnoea.

~v~lopalatopba~yngoplasty 303 whose partner often has to sleep in another room because of the noise. Heroic snoringresults in poor-quality sleep, and has deleterious effects on the cardiovascular system. 2 UPPP is indicated in a few individuals with OSA. In those OSA patients likely to benefit, the airway obstruction will be at the level of the oropharynx.

Preoperative History

It is important to estimate the severity of the problem; most men snorebutmost do not need a UPPP! The partner’s history is vital, as anestimate of the severity of the noise and a description of the breathing patternmay be obtained. Daytime sleepiness can be quantified with the use of aquestionnaire (Fig. 43.1).Enquire about lifestyle: exercise or the lack of it, alcohol intake and weight gain. Some individuals only snore when they are overweight. Collar size can increase because of obesity and a collar size over 17 is one of the hallmarks of sleep apnoea.

Examination

Height, weight and blood-pressure should be recorded. A careful assessment of theairwaythen needs to be made, looking particularly for factors that may cause obstruction (Fig. 43.2). Endoscopic examination of the nose may reveal inflammation or mechanical obstruction. Hypopharyngealobstruction will notrespond to UPPP and so a careful evaluation of thetongue and mandible needs to be made. Dental crowding, retrognathia and a large lingual tonsil are all associated with hypopharyngeal obstruction. A patient suitable for aUPPP will have obstruction at the level of the oropharynx. Large tonsils, a long soft palate, oedematous uvula and excessive lateral pharyngeal tissues are the hallmarksof oropharyngeal obstruction. A good candidate for a UPPP will have oropharyngeal obstruction and a larynx that is easily visible on mirror examination. Flexible nasendoscopy Thepatency of theupperairway changes withthe respiratory cycle and the best way to observe this is witha flexible endoscope. It is helpful to observe theairway attwo different levels (Fig. 43.3).With theend of theinstrumentinthenasopharynx,the closure of the soft palate can be observed (ask the patient to say ‘ng’). The amount of excess soft palate can then be judged. The Mueller manoeuvre is like a reversed Valsalva. Inspiratory effort is made against a closed mouth and nose. During the manoeuvre an attempt is made to see whether the airway collapses at the level of the palate (oropharynx) or whether the collapse is at the level of the tongue base (hypopharynx). Sleep nasendoscopy In this technique the patient is given IVsedation, preferably by an anaesthetist. Nasopharyngoscopy can then be carried out with the patient ‘asleep’, which allows a further assessment of the level of obstruction. The Mueller manoeuvre and sleep nasendoscopy may provide useful information concerning the level of collapse.

Fig. 43.2 Normal nose and pharynx on one side. Abnormalities associated with snoring on the other side: long soft palate and uvula, large tongue and lingual tonsil, large palatine tonsil and deviated nasal septum.

Sleep study

The history and examination alorie cannot confidently distinguish between heroic snorers and those who have OSA and therefore a sleep study is an essential part of

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er The principle of UPPP is to maximise thepotential oropharyngeal airspace without jeopardising the physiological functions of the soft palate (swallowing and speech). The patient is given a general anaesthetic (GA), using an oralendotracheal tube (ET).At the startof the operation, 600mg of amoxycillin and clavulinic acid are given intravenously. The patient is placed supine with a sandbag under the shoulders and a horseshoe to support the head, which is extended.The lips are greased with Vaseline and a Boyle-Davis gag is inserted. If the tonsils are present, they are removed. Meticulousattention should be paid to haemostasis of the tonsil bed, using bipolar diathermy. If the patient has already had a tonsillectomy the mucosa between the two pillars is removed. lncisio

Fig. 43.3 Fibre-optic nasendoscopy. (a) The palatal closure is viewed. (b) The tongue base and larynx are viewed.

their investigation. Thedistinction needs to be made because continuous positive airway pressure (CPAP) should be the first-line treatmentforthemajority of patients who have OSA. The sleep study also provides a preoperative objective measurement of the severity of snoring. One night in a sleep laboratory does not always provide sufficient representative information, and home recordings are useful. A noise-activated taperecorder(witha small microphone clipped to a headband) is used while the patient sleeps in hidher own bed.

Resecting the correct amountof palate is of vital importance. The attachment of the levator palatini makes a dimple in the palate that can be seen preoperatively and the resection line should be well below this dimple. The author finds preoperative nasendoscopy useful for estimating the amount of excess soft palate. In addition, in the anaesthetised patient the palate can be pushed back against the posterior pharyngeal wall (Fig. 43.4). The point of contact with the pharyngeal wall is noted and the incision is started below this. The incision is then carried from this point in a horizontal direction until it joins the anterior pillar. Part of the anterior pillar is resected but it is advisable to preserve most of the posterior pillar.

General advice and preoperative counselling

If appropriate, weight loss and alcohol reduction should be strongly recommended. Nasal obstruction should be treated either medically or surgically. If nasal surgery is required, it is best to do this first and then reassess the need for UPPP. Finally, before proceeding to UPPP, thepatient should be warned that theoperation is painful, and the potential complications discussed. The patient can then be told that the operation is usually successful, significantly reducing snoring in over 90% of patients.

Fig. 43.4 the Judging

amount of soft palate to resect.

~

Uuulopalatopba~yngoplasty 305 needle) is used and the needle should pass through the muscle layer as well as through the leading edge of the soft palate. The sutures should be cut short to avoid irritation. At the end of the procedure the anteroposterior diameter as well the as lateral dimension of the oropharyngeal airway should have been increased. An injection of 0.5% marcaine is then made slowly into the lateral margins of the soft palate and infiltrated between the tonsil pillars. A nasopharyngeal airway, trimmed so that it just hangs down behind thepalate, is then inserted.

Postoperative m ~ n a ~ e m e ~ t Control of pain

Fig. 43.5 A box-like resection.

The aim should be to produce a box-like resection (Fig. 43.5) with conservationof the middle of the palate (when resecting the soft palate it is best to err on the conservative side). The resection can be performed with a scalpel, cutting diathermy or CO,, Nd-YAG or KTP laser. The author now uses an Nd-YAG contact laser. Necessary precautions for thelaser include saline drapes around the patient’s mouth, and glasses for all theatre personnel.

UPPP is a painful procedure and a diclofenac suppository, a small dose of opiate and local anaesthetic are given during the operation. Postoperatively, a combination of effervesent diclofenac, paracetamol and local anaesthetic lozenges keeps the opiate requirements to a minimum. Starting with a soft diet, patients should be encouraged to eat and drink as soon as possible. Patients with heroic snoring without significant apnoea should be nursed on the main ward in full view of the nursing staff. Sleep-apnoea patientsshould spend at least the first postoperative night on a highdependency unit.

Resection of the palate is easier if it is held under tension. This can be accomplished by grasping the leading edge of the palate with a haemostat or by placing a suturethrough it, and then pulling itforwards.The edges of the palatal incision should be bevelled so that the excision line pointsforwards.The gag should be released intermittently to avoid prolonged tongue compression. Two small arteries are present on each side of the uvula and they canretractintothe soft tissues, which makes bipolar diathermy difficult. If necessary, clip each artery and tie with 3/0 catgut.

The posterior pillar is pulled forwards and sewn to the anterior pillar (Fig. 43.6).The incision lines should pointforward,awayfromtheposterior pharyngeal wall. A3/0chromiccatgutsuture (21mm taper-cut

Fig. 43.6 Reconstruction. Deep sutures pulling the posterior pillar forwards.

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Chapter 43

Complicati Themajority of postoperative sequelae are mild but occasionally significant morbidity and even mortality can occur (Fairbanks, 1990). 1 The immediate postoperative period can be associatedwithairway problems because of the combined effects of sedation, narcotics, muscle relaxants, oedema and haemorrhage. The author inserts a nasopharyngeal airway and keeps this in place until the patient is awake and sitting up in recovery. 2 Primary haemorrhage is rare and is managed in the same way as a tonsil bleed. Postoperative oedema and the presence of blood can make reintubation difficult and anelective tracheostomy may be necessary. Secondary haemorrhage may occur as a result of postoperative infection and usually requires antibiotics only. 3 Temporary velopharyngeal incompetence occurs in themajority of patients. Usually there is mild nasal regurgitation,particularly if thehead is flexed while drinking. Provided the patient has been warned preoperatively that this will occur, it doesnot appear to be troublesome and thesymptoms subside after 2-3 weeks. Persistent nasal regurgitation is very rare. Hypernasal speech is also manifestation a of velopharyngeal incompetence. It is an unusual complaint but occasionally fricative sounds are weak. The loss of the uvula may be associated with loss of vocal trill. Vocal trill is asound used in French, German, Greek and Spanish. It is worth enquiring preoperatively to see if your patient speaks anyof these languages. 4 Nasopharyngeal stenosis is rare a troublesome complication.Minimalposterior pillar resection and meticulous suturing seem to be the best way of avoiding it. 5 Relatively minor symptoms are common and include ‘a dry throat’ ‘food sticking’ and ‘altered taste’. Almost invariably these symptoms settle with time.

Alternative procedures Tonsillectomy alone

If the majority of the obstruction is due to large tonsils, then a tonsillectomy alone may be sufficient. Tonsillectomy also has a role in selected patients with OSA. Palatal stiffening

This is an operation devised by Peter Ellis (Ellis et al.,

Fig. 43.7 The laser-assisted uvulopalatoplasty technique.

1993). Sleep nasendoscopy is used to see if the snoringis caused by palatal flutter. In these patients a longitudinal section of mucosa is removed from the palatalsurface of thesoftpalate and a uvulectomy is performed.The scarring that is induced stiffens the whole length of the soft palate and reduces palatal vibration. The laser-assisted uvulopalatoplasty technique

This technique was devised by Dr Yves-Victor Kamami. Theprocedure is performedunder local anaesthetic with the patient sitting upright in a dental chair. A special CO, laser hand-piece with a backstopto protect the posterior pharyngeal wall is used. Vertical incisions are made through the palate on each side of the uvula (Fig. 43.7). The uvula is then shortened and reshaped.Theprocedure is usually done in one stage, although itis perfectly feasible to do a numberof similar procedures, continuing until the snoring has ceased. It has been used in patients with OSA but it will only help those who have obstruction at the level of the soft palate.

References and further reading Ellis DDM,Williams JE & Shneerson JM (1993) Surgical reliefof snoring due to palatal flutter: a preliminary report. Ann. Roy. Coll. Surg. Engl. 75, 286-90.

.

\

Fairbanks DNF(1990) Uvulopalatopharyngoplasty complications and avoidance strategies. Otolaryngol. Head Neck Surg. 102,23945. Fairbanks DNF & Fujita S (eds) (1994)Snoring and Obstructive Sleep Apnea, 2nd edn. New York, Raven Press.

~ v ~ l o p a l a t o p ~ a r y n g o p l a s t3y07 Hung J, Whitford EG, Parsons RW & Millman DR (1990) Association of sleep apnoeawith myocardial infarction in men. Lancet 336, 26 1-4. Stradling JR (1993) Handhook of Sleep-relatedBreathingDisorders. Oxford, Oxford University Press.

Surgery for Benign Lesions of the Oral Cavity ROBERT M. SUDDERICK

Introduction The oral cavity extends from the lips to the anterior pillar of the fauces. It includes the buccal mucosa, upper and lower alveolus and gingiva, floor of themouth, anterior two-thirds of the tongue and hard palate. The mouth is lined by a mucous membrane covered with stratified squamous epithelium and adherent to deeper structures, thus preventing damage by the teeth when chewing. On the lips, cheeks and tongue it is attached to the underlying musculature, and on the hard palate and alveolus to the periosteum, thus creating a mucoperiosteum. Small mucousglandsarescattered throughout the mouth, especially the lower lip. A great variety of benign lesions can be found arising from or beneath the oral mucosa. Most of these are inflammatory hyperplasias and granulomas,but it is essential that, despite their generally benign appearance, these lesions are excised and sent for histological examination. This can invariably be achieved under local anaesthesia, using a simple infiltration technique, although local blocks are used whenappropriateand general anaesthesia is usually employed for children.

Buccal, alveolar and gingival lesions Discrete lesions arising fromthe gingiva aretermed epulides and areoften an inflammatory overgrowth containing immature vascular granulation tissue (compare with pyogenic granuloma and pregnancy epulis). Conservative local excision is usually sufficient. A proprietaryperiodontal pack is oftenrequired tocontrol bleeding from the raw surface left behind and toprotect it until it has healed. Other characteristic lesions arising from the mucosa

overlying the alveolar processes are the denture granuloma(hyperplasia) usually seen in the buccal sulcus, either singly or as parallel lesions, in relation to the flange of an overextended denture and the diffuse gingival enlargements seen with certain drug treatments, e.g. phenytoin. The need to remove dentures when examining the oralcavity is dramatically illustrated by the lesion found under an upper denture, the aptly named leaf granuloma (or fibroma or fibroepithelial polyp). This sits happily concealed, flattened between the palate and denture, and yet falls into view on removal of the plate. All types of benign tumours may be found throughout the oral cavity. Papillomas arethe most common lesions, occurring equally on the cheeks, soft palate, fauces and tongue. They appear as a wart-like white or pink swelling with finger-like processes of stratified squamous epithelium, the larger ones with a vascular connective-tissue core. Dysplastic changes are very rare and simple excision is all that is required. Fibroepithelial polyps are found throughout the oral cavity (although true fibromas are rare). These pedunculated lesions are moreeasily excised by transfixing with a suture which, when placed under tension, allows easy identification of the base or pedicle, thus making removal more simple (Fig, 44.1). A special mentionshould be made of leucoplakia (literally: whitepatch),aterm which is reserved for those lesions that cannot be wiped off, where no other diagnosis can be made and which has traditionally implied malignant potential. The commonest sites lie on the buccal mucosa, gingiva and tongue. Biopsy is mandatory andclose follow-up is necessary, especially when found in the floor of mouth and lateral border of the tongue, where malignant change is morecommon.

Surgery for Benign Lesions of the Oral Cavity \

309

I

isotope’ of iodine (I23I or ?I). The second entity is median rhomboid glossitis, a smooth, ovoid, red lesion in the midline dorsum of thetongue(anterior to the circumvalate papillae and foramencaecum), which is said to represent a persistent tuberculum impar. Candida infection in such a lesion may lead to pain and a neoplastic appearance hence a biopsy is invariably performed, but it shouldbe remembered that carcinoma in this site is extremely rare. Fig. 44.1 Excision of lesions of oral mucosa.

Floor-of-mouth lesions Two important lesions found in the floor of the mouth are the dermoid cyst and the ranula.

Speckled leucoplakia, with its high malignant potential, occurs in the dyskeratoticstage, where patchyloss of the keratinised layer leads to the classic red-and-white appearance.

Lip lesions The lips are the common site for lesions of the minor salivary glands, accounting for 15% of minor salivary neoplasms (mostly in theupperlip). Excision biopsy of the lesion, togetherwiththe underlying salivary gland is mandatory,duetothe increased risk of malignancy compared with lesions of the major salivary glands. However, the commonest lesion is the mucusretention cyst or mucocele, found more in thelower lip in association with a minor salivary gland. The aetiology is invariably traumatic and the lesion appears as a firm, well-circumscribed bluish white swelling beneath the mucosa, withprominent blood-vessels frequently seen on the surface. There is often a history of repeated spontaneous rupture with therelease of a viscous liquid, followed by recurrence. Local excision of the lesion, associated gland and overlying mucosa with simple primary closure is required,but recurrence is not uncommon.

Tongue lesions Two specific lesions of the tongue occur, both of which require special mention, and which are thought to be developmental. First, the lingual thyroid presents as a nodular mass at the base of the tongue in or near the foramen caecum and usually in the midline. This lesion is far more rare than is generally thought, and is more common in women. It is important to make sure that it is not the only functioning thyroid tissue before proceeding to surgical excision. This is achieved by a thyroid scan, usually withtechnetium-99m orwithan

Dermoid cysts

These may be present at birth or appearlater, usually in adolescents or young adults. They are commonly found in the midline floor of themouth,withthe lingual frenulumindentingthesuperior surface of larger lesions. Lying superficial to the geniohyoid muscle, they may cause difficulty in mastication and speech due to elevation of thetongue base. Those lying below the mylohyoid present asa midline submental mass but may rarely be found in the submandibular region. On palpation, they are soft to firm and do not transilluminate. They are true cysts lined by squamous epithelium, the commonest epidermoid variety containing keratin and squamousmaterial and the true dermoid containing skin appendages, such as hair and sebaceous and sweat glands. Their aetiology is thought to be from epithelial cell rests left after fusion of the mandibular and hyoid arches. Simple surgical excision is all that is required. Ranulas

A ranula presents as a bluish translucent cystic swelling in the floor of the mouth, to one side of the lingual frenulum. The name ranuladerives from the Latinrana, meaning frog, because of its supposed resemblance to the underbelly of a frog. They are predominantly found in children and young adults, although no age limits exist. Two types are recognised, both arising from the sublingual salivary gland or its ducts: the simple ranula,which is confined to the floor of the mouth, and the plunging ranula,with its cervical extension through or behind the mylohyoid muscle. The plunging ranula is always a mucous extravasation cyst, with a lining of condensed connective tissue. The simple ranula may be either a small localised extravasation cyst or a

310

Chapter 44 Operative technique (excision of ranula) Preparation

Fig. 44.2 Anatomy of the floor of the mouth.

retention cyst, which has an epithelial lining. Surgery consists of removal of the sublingual gland on the affected side, together with simple enucleation or drainage of the cyst contents as appropriate. Extensive dissection of the floor of the mouth or the neck is completely unnecessary and increases the risk of complications. In cases of plunging ranula, a history of trauma is often elicited. An increased incidence of ranulaformation has been noted following translocation of thesubmandibular ducts. Bimanual palpation should always be performed to identify the possibility of a plunging ranula.

1 Local anaesthesia may be successfully used in adults, where an inferior dental (ID) nerve block (Fig. 44.3) is achieved, using a dental cartridge syringe loaded with a proprietary solution of lignocaine 2% with 1:80000 adrenaline and a disposable 35-mm-length needle. 2 Facing the patient, whose mouth is open wide, the surgeon's finger palpates the junction of the horizontal and ascending ramus of the mandible. With the syringe held in the other hand, the needle enters the mucosa at approximately the midpoint of the palpating finger tip at an angle of 45". 3 The needle is advanced until bone is felt, at which point the tip is adjacent to the lingula that guards the entrance to the inferior dental canal. Theneedle is withdrawn 1mm and 1m1of anaesthetic deposited; the remaining 1m1 is deposited during withdrawal in order to obtain lingual anaesthesia. Success is judged by numbness o f the lower lip and tongue, usually within a couple of minutes. 4 General anaesthesia is invariably required in children and a nasal endotracheal tube (ET) with adequate pharyngeal packing is employed. The patientshould be lying supine with the head supported in a head ring and with about 15" upward tilt. AMushindentalmouth prop is inserted on the contralateral side to hold the mouth open. Submucosal infiltration of local anaesthetic containing 1:80 000adrenaline helps to reduce bleeding during surgery.

Relevant anatomy (floor of mouth)

The two sublingual glands are the smallest of the main salivary glands. They lie beneath the oral mucosa, anterior to the border of the hyoglossus. Each is in contact laterally with a smoothdepression on the lingual aspect of themandible close to the midline, the sublingual fossa. Medially the lingual nerve andsubmandibular duct separate it from the genioglossus and below lies the mylohyoid. Above, the mucosa of the floor of the mouth is raised as the sublingual fold and it is here that the submandibularduct also terminates. Each gland has 10-20 excretoryducts which open directly intothe submandibular duct or separately on to the sublingual fold (Fig. 44.2).

l Fig. 44.3 Inferior dental nerve block.

\

"

Surgery f o r Benign Lesions o f the Oral Cavity *

I

z

~

*

* *

3 II

"

circle cutting needle is used and, by suturing through the intezdeatal space, brings together the lingual and buccal papillae, producing excellent healing (Fig. 44.6). Postoperative management

No special measures are necessary and thepatient is allowed to eat anddrink assoonas helshe is able. Simple oral analgesia is usually all that is required. Complications

Fig. 44.4 Incision for exision of ranula.

Incision

Damage to the lingual nerve will result in paraesthesia or anaesthesia of the floor of the mouth, the lingual gingiva and the anterior two-thirds of the tongue, as well as some loss of taste. Injury to Wbarton's duct may result in stenosis and hence sialadenitis of the submandibular gland.

An incision is made along the gingival margin on the lingual side from the first molar to the canine on the opposite side, using a no. 15 Bard-Parker (BP) detachable blade on a no. 3 BP-type scalpel handle held parallel to the long axis of the teeth (Fig. 44.4). Procedure

1 This gingival-margin incision, which divides the interdental papillae, allows a full-thickness mucoperiosteal flap to be raised lingually, using a Freer elevator, and is made easier by the thick collar of attached gingiva, which helps to prevent tearing. No sizeable blood-vessels are divided when raising a flap in this manner. 2 The elevation of the flap continues until theattachment of the mylohyoid is reached. At this point, the flap is retracted posteromedially (i.e. towards thetongue)andthe sublingual gland is identified as a bulge through the periosteum (Fig. 44.5). 3 The periosteum is incised, allowing the gland to protrude through, where, by a combination of blunt and sharp dissection, the gland is freed. Care must be taken on the medial (deep) surface, as itis here that the lingual nerve and submandibular duct lie. Blood-vessels enter the gland on its posterior and medial surfaces and are divided under direct vision after coagulation with bipolar diathermy.

Fig. 44.5 Retraction of flap in excision of ranula.

Closure

No drain is necessary, and primary closure is achieved by absorbable interrupted sutures. A 21- or 22mm half-

Fig. 44.6 Suturingthe lingual flap.

3 I 2,

Chapter 44

Alternative procedures

Otherauthors havedescribedsimple enucleation or marsupialisation, with or withoutpacking, for the treatment of ranulas butall report recurrencein a proportion of cases. It seems clear that these methodsareonly reliable in cases of a simple ranula with an epithelial lining. In the case of the more common extravasation cyst with its connective-tissue lining, incomplete enucleation andlor fistula formation is likely, and hence recurrence inevitable.

Palatal lesions A number of lesions of the palate have already been mentioned, all of which may be simply excised with local infiltration. More extensive lesions require a different approach. Such lesions include the minor salivarygland tumours and a torus palatinus.Of minor salivary tumours, 60% occur on the palate and, although the pleomorphic adenoma is the most common, there is a higher risk of malignant tumours. Several hundred palatine glands are foundover the hard andsoft palates, but they do notoccur over the palatalprocesses, i.e. anterior to a line between the first upper molars. They are usually well circumscribed and encapsulated, with excision being relatively easy. However, large defects may require closure with aflap orobturator.Toruspalatinus is found in up to20% of people, although size isextremely variable. Thereis also racial variation, withan increased incidence in mongoloid and Inuit peoples. There is a 2 :1 female predominance. The lesion probably develops at puberty and invariably presents before 30 years of age. Itprobablyrepresents an overgrowth of thepalatal processes of the maxilla, and is a true exostosis, comprising lamellae of compact bone. The torus may be a ridge along the midline of the palate or be flat, nodular or lobulated. The growth rate isvery slow and it is rarely treated unless interfering with the fitment of a dental plate.

mucous and salivary glands. A number of foramina perforate the palate. Anteriorly the nasopalatine foramen lies in the midline, posterior to the incisor teeth between the premaxilla and maxilla. The greater palatine foramen lies between the maxilla and the crest of the palatine bone, medial to the second or third molar tooth, and posterior to this the palatine bone is perforated by twoor three lesser palatineforamina.The blood supply to the palate isvia the greater palatine artery (a branch of the maxillary artery), which passes through the greater palatine canal and runs forward to enter the nasopalatine canal. Veins pass backward along the artery to the pterygoid plexus. The nerve supply is from branches of the maxillary nerve via the pterygopalatineganglion,theanteriorpalatine nerve emerging through the greater palatine foramen to supply thepalateasfarforwardasthenasopalatine foramen, from which the nasopalatinenerves emerge to supply the area behind the incisor teeth (Fig. 44.7). Operative technique (palatal lesions, including torus palatinus) Preparation

Smaller lesions, especially those aroundthe gingival margin, may be removed under local anaesthesia using simple infiltration; however, larger masses and those in the midline or posterior hard palate are excised more easily by blocking the palatine nerves by infiltration at thesite of thepalatineforamina. A dentalcartridge syringe loaded with a proprietary solutionof lignocaine 2% with 1:80000 adrenaline and a disposable 35mm

Relevant anatomy (palate)

The palate is a bony shelf enclosed on its anterior and lateralborders by thedownward-projectingalveolar processes of the maxilla. The main part is composed of the palatal processes of the maxilla, with the horizontal plate of the palatine bone posteriorly and a small anteriorcontributionfromthepremaxilla.Thewhole is covered by mucousmembrane,which is inseparable from periosteum anteriorly, whereas posteriorly the two are separated by connective tissue containing numerous

Fig. 44.7 Anatomy of the roof

of the mouth.

Surgery f o r Benign Lesions of the Oral Cavity needle is required. The nasopalatine nerves are blocked by infiltrating as they exit the nasopalatine canal,and by bending the needle it is possible to directly enter the canal. The greater palatine foramen may be found approximately medial to the second molar tooth, halfway between the gingival margin and midline of the palate, and again palpation with the needle point allows accurate localisation for the block. When excising large lesions of the palate, it is necessary preoperatively to take an impression of the upper jaw to enable the construction of a temporary acrylic plate. Postoperatively, either alone or in conjunction with soft gutta percha, this enables palatal flaps to approximate accurately and lessens the risk of haematoma formation. Incision

Themost useful incision is thepalatal gingival in thedentatepatient(alongthe alveolar crest in the edentulous). Using ano. 15 blade held parallel to the long axis of the teeth, an incision is made following the gingival margin from last molar to last molar on the opposite side. Procedure

A full-thickness mucoperiosteal flap is mobilised medially and posteriorly. Anteriorly the nasopalatine neurovascular bundle is divided by sharp dissection (usually with little bleeding), but the greater palatine vessels should be preserved in the flap (Fig. 44.8). Care

Fig. 44.8 Retraction of palatal flap to show torus palatinus.

3 I3

should be taken when elevating the flap in the midline, especially over a torus palatinus, as theflap is often very thin and easily tears. The flap is elevated only as far as is necessary to enable removal of the lesion. The torus is best removed using a drill with arosehead burr; alternatively, in large lesions a fissure burr may be used to section the lesion first. Irrigation with normal saline is used throughout the drilling and afterwards, to remove any bone debris created. Closure

The flap is replaced and suturedinterdentally,as described earlier. When a large torus has been removed, there is excess flap in the midline, and in this situation a small midline elipse is removed to allow even approximation of the flap. The previously prepared acrylic plate ensures adaptation of the flap to the underlying bone and prevents haematoma formation. Postoperative management

Otherthan ensuringproperoral hygiene by regular brushing and theuse of a chlorhexidine mouthwash,no special precautions are necessary. The acrylic plate is retained for 5 days, after which time it can be removed safely. Alternative procedures

For small midline lesions a straight incision up the centre of the palate will avoid the greater palatine arteries.

Fig. 44.9 Palatal rotation flap.

Anteriorly, the incision is made into a ‘Y’ to avoid the nasopalatine neurovascular bundle. Separately, the two flaps may then be elevatedlaterally. On replacing the flaps, excess tissueisremoved fromoneorbothto enable edge-to-edge approximation. When removing other lesions(e.g. apleomorphic adenoma),themucosaofthepalatemay need to be sacrificed. In this situation a small pack of Whitehead’s varnish onribbon gauze is placed in thedefectand sutured securely to the surrounding mucosa. After 7-10 days,thismay be removedandafreshlygranulating area will be revealed. Larger lesions may have caused a

palatal fenestration, or during the resection one may be created. In these circumstances, there are two options. First, a plate may be constructed t o act as an obturator. Second, a palatal rotation flap may be used to seal the defect (Fig. 44.9). This is a posteriorly based flap on the greater palatine artery of the opposite side. A strip of full-thickness mucoperiosteum is raised and, provided the artery is approximately central, thewidth of the flap may be up to half of thepalate. Rotating the flap causes a secondary defect, which canbe dealt with as described above.

onosurgery and aryngeal Surgery MEREDYDD HARRIES AND MURRAYMORRISON

Phonosurgery Introduction

The first part of this chapter discusses the two main phonosurgical approaches currently in use for rehabilitation of voice in a patient with a unilateral vocalfold paralysis, namely vocal-fold injection and laryngeal-framework surgery. The term ‘phonosurgery’ refers to any surgery designed primarily for theimprovement or restoration of voice (Von Leden, 1991). Itis not intended to include surgery where voice is a secondary consideration and must be distinguished from conservation laryngeal surgery, wheretheprimaryaim is to eradicate cancer and voice conservation or restoration is of secondary importance. Phonosurgery includes a wide variety of surgical techniques such as vocal-fold injection, microlaryngoscopic surgery, laryngeal framework surgery, nerve grafting and neuromuscular surgery. Microlaryngeal techniques are reviewed in the second part of this chapter and there is current debate regarding the role of nerve grafting and neuromuscular surgery in phonosurgery. Theformation of multidisciplinary voice clinics allows an academic and scientific approachto voice disorders,Completepatient assessment should now include videolaryngoscopy, stroboscopy and other laboratory measures, including laryngeal electromyography. Stroboscopy is essential in the assessment of the mucosal wave of the vocal fold, and electromyography can aid in the localisation of lesions in the vaguslsuperior laryngeallrecurrent laryngeal nerve network and identify signs of reinnervation in a paralysed vocal fold.

Vocabfold injection

Selection of material Teflon

First used in 1962, this is still the commonest material being used in the UK. Teflon is a polymer of polytetrafluoroethylene and is sold as a paste consisting of 50% glycerine. This glycerine component is absorbed in the first few weeks and its volume is partially replaced, initially by an acute inflammatory reaction and later by a localised chronicinflammatory response, which encapsulates the remaining Teflon. This is in effect a localised granuloma, but the difference in the initial volume injected and the final space-occupying lesion is unpredictable, which may cause good immediate results to deteriorate with time (Kasperbauer et al., 1993). If Teflon is incorrectly placed superficially and erosion of the overlying mucosa occurs, this can lead to granulomas on the surface of the fold, and a 36% incidence of granuloma production has been reported (Gardener & Parnes, 1991). Teflon particle sizes in the paste are sold as 50-100 pm, too large for immediate lymphatic drainage since macrophagelymphaticcutoffis 40pm. Studies on a commercial preparation of Teflon, however, have found particles of Teflon of440 pm, which must lead to the question of distal spread. A study on Teflon injection into the periurethral area has shown spread to both regional and distal organs, but,although local spread to lymph nodes and the thyroid gland has been shown with laryngeal injection (Ellis et al., 1987),no distal spreadhas yetbeen documented.

31.5

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Chapter 45

Celfoarn Initially developed as a haemostatic material, this has been used in a mixture with saline to augment the vocal fold. It is atemporarymaterial, only lasting up to 3 months, and is commonly used in conjunction with a reinnervation procedure to provide temporary improvement while neural regeneration occurs.

Pat This autogenous material has numerous advantages: it is easily harvested, readily available and does not give a foreign-body reaction(Mikaelian et al., 1991). Although it can be harvested via liposuction, this can lead to up to 30% cell destruction, with increased hypersensitivity reactions, and fat harvested through a larger incision therefore causes less tissue disruption. The fatis washed in saline, loaded into a Brunings’ syringe and injected superficially into the vocal fold.

Collagen Thisprotein is anaturalconstituent of thelamina propria of the vocal fold. Widely used in dermal augmentation, it has been popularised by Ford et al. (1992) for use in the larynx,where it becomes incorporated and even replaced by new host tissue. It has been used to augmentthe paralysed andlorscarred vocal fold by injection superficially into the vocal ligament. Problems include hypersensitivity reactions, which necessitate skin testing preoperatively, and irregularity in its mode of absorption and replacement. Selection of operative method

These may be subdivided as follows: l general anaesthesia: direct laryngoscopic method; 2 local anaesthesia; (a) direct laryngoscopic method; (b) indirect laryngoscopic method; (c) transcutaneousroutethroughthecricothyroid membrane; (d) transcutaneous route through the thyroid cartilage. General anaesthesia is thecommonestmethod in the TJK. Drawbacks include visualisation problems due to the anaesthetic tubeor some other means of ventilation, the abnormal anatomical positioning of the neck, difficulty in gaining access to the larynx in patients with cervical-spine problems or otheranatomical factors preventing direct laryngoscopy and, most significantly, lack

of patient feedback via phonation during injection. This last factor plays an essential role in deciding the amount of material to inject at the time of surgery in patients undergoing procedures under local anaesthesia. Direct laryngoscopy under local anaesthesia allows patient cooperation in order to adjust the amount of injected material, but is technically demanding, requires the use of the operating theatre and still has the head in an abnormal position. The indirect laryngoscopic technique can be carried out as an out-patient procedure and therefore does not require operating-theatre time or the frequent delay in obtaining it. This is desirable where the life expectancy of the patient is short and there is a high general anaesthetic (GA) complication risk due to the frail medical condition of the patient. Although in expert hands it is reported to give excellent results, many find the technique difficult to master. The head position is still abnormal and, due to the length of the instruments, it is difficult to assess the depth of penetration into the fold. Some needle tips have a side opening andlor ashield that prevents the tip from passing too deep, although this does not guarantee correct positioning. Transcutaneous techniques maintain the benefits of being procedures that can be carried out inthe outpatient setting and have the great advantage that the head can be placed inaneutral,moreanatomically correct, position (Hirano et al., 1990; Strasnick et al., 1991; McCaffrey, 1993). Penetratingthecricothyroid membrane is becoming a more familiar technique, now that botulinum-toxin injections into the thyroarytenoid muscle for adductor spasmodic dysphonia are increasing. The injection needle can either pass directly into the cord without entering the laryngeal lumen or pass initially into the lumen and then across into the fold while being visualised via the nasendoscope. Correct needle position is almost guaranteed when penetration is lateral through the inferior half of the thyroid cartilage, but difficulty can occur when the cartilage is ossified. There are, therefore, benefits and drawbacks for each technique and in many ways it is for the surgeon to use the technique thatworks best inhidher hands. The transcutaneous method under local anaesthesia is described below. Selection of patients

Teflon injection isused in patientswithaunilateral vocal-fold paralysis due tomalignant disease, whose life espectancy is short, i.e. those who require an immediate and short-term result.

Phonosurgery and ~ ~ c r o l a r y n g eSurgery al Method Nasendoscopiccontrol is essential for this technique and requires an assistant with a flexible fibrescope and preferably acamera and television screen. Following informed consent, the patient is positioned sitting upright in an examination chair with a headrest. Topical anaesthesia of the nose, oropharynx and larynx, using a 4 % xylocaine spray, is achieved and the skin of the neck prepared with povidone-iodine solution for asepsis. A solution of lignocaine (1%),(maximum dosage =7mg/ kg body weight) with adrenaline (1in 100 000) is infiltrated locally into the skin over the cricothyroid membrane and then adeeper injection on tothe membrane is made. A 4 % xylocaine solution is now used on a 21gauge needle to penetrate the cricothyroid membranein the midline, carefully keeping the needle close to the cricoid cartilage to avoid the cricothyroid artery (Fig. 45.1). After warning the patient, 2 4 m l of this solution is instilled into the trachea,which will make the patient coughbut will anaesthetise thesubglotticarea.A flexible nasendoscope with a video camera is then inserted by the assistant into theanaesthetised nose and an image of the larynx obtained on the television screen. A 90" smoothly curved 18-gauge needle (which is bent by the surgeon beforehand, using artery forceps) is preloaded with Teflon on a Luer-lock 5ml syringe. A plastic push-on hub will not allow enough pressure for injection, due to the density of the Teflon paste, and the use of a clear, as opposed to a Brunings', syringe allows easier estimation of the amount injected. The needle is then introduced through theskin and cricothyroid membrane in the midline, enters the subglotticlumen and can be seen on the television screen. The needle is then

Fig. 45.1 Insertion of needle for transcutaneous Teflon injection via the cricothyroid membrane.

3 I7

rotated to enter the inferior surface of the vocal fold at the level of thetip of the vocal process and placed laterally, close to the medial surface of the thyroid cartilage (Fig. 45.2a7b).Teflon can thenbe injected until the fold lies in the desired position.The needle is then withdrawn back into the subglottic lumen and the patient asked to phonate. Patient cooperation by phonation gives a clear indication of the amount of material required for good voice, and direct vision allows correct placement of the desired amount of Teflon required for glottic closure. If necessary, a second injection can be placed anteriorly, usually at the junction of the anterior and middle third of the fold, although this will vary with each individual case. When a good voice has been obtained the needle is completely removed, the entry site covered witha plaster and the nasendoscope withdrawn. The authors do not routinely use antibiotic or steroid cover, and a mild oral analgesic seems to suffice. Patients are put on strict voice rest for 48 h, to theoretically prevent Teflon extruding from theneedle tract, and advised not toeat or drink for at least 4 h until the effect of the topical anaesthetic has worn off. The patient is then kept in hospital overnight to watch for any local-

Fig. 45.2 (a) Monitoring needle-position via television screen. (b) Anatomical position of needle.

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Chapter 45

ised oedema that may cause airwaycompromise,although this is unlikely using this technique. Complications Early

These include haemorrhage, infection, airway compromise, overinjection, underinjection, incorrect placement of Teflon and acute inflammatory reaction.

Late Migration of the material, granulomaformation, absence of the mucosal wave and a non-compliant vocal fold. Laryngeal-framework surgery

Payer in 191S is credited with the first description of laryngeal-framework surgery. This hasbeen refined over many years by other surgeons, but Isshiki was thefirst to describe use of an alloplastic material (Silastic) to medialise the vocal fold, and it is his name and classification of laryngeal-framework surgery, with four types of thyroplasty, that is recognised (Isshiki et aE., 197’4).It is only the Isshiki type 1 thyroplasty-now also called ‘medialisation laryngoplasty’- that is commonly practised, although it may be combined with other modifications, as mentioned below. Selection of patients

Medialisation laryngoplasty can be performed in any patient with a unilateral vocal-cord paralysis. Waiting 12, monthsinidiopathic cases is still recommended, although, if there is severe aspiration or in exceptional cases where the vocal needs of the patient require early intervention, surgery may be carried out sooner as an alternative to repeated Gelfoam injections. The reversibility and adjustability of medialisation laryngoplasty is thereforeagreatadvantage over Teflon injection in these cases. Medialisation laryngoplasty can also be used in cases of unilateral or bilateral bowed vocal cords, caused by ageing and may be useful to correct soft-tissue defects in the vocal fold as a result of previous surgery, such as laser removal of Teflon.

local anaesthesia. An assistantwitha nasendoscope, preferably withacamera and television monitor, is required. Thepatient,withinformed consent, is placed in a supine position, with the head minimally extended on a pillow andthepatientmadecomfortableenough to tolerate this position. for approximately 45min. Sedation of the surgeon’s choice, either preoperativeoral agents or peroperative intravenous agents with monitoring, is required. The nose, pharynx and larynx are topically anaesthetised with 4% xylocaine spray and the neck prepared and drapedin a sterile manner. It is useful to use a suspension table to keep thedrapes off the patient’s face and to allow access forinsertion of a nasendoscope at a later stage. The thyroid and cricoid cartilages are palpated and marked on the skin. Local anaesthetic (LA), 1% lignocaine with adrenaline (1 in lOOOOO), is infiltrated into the wound area, around theinternal laryngeal nerve asitentersthe thyrohyoid membrane and on to the thyroid cartilage ala of the affected side. A horizontal incision, preferably in a skin crease, is made at the level of the vertical midpoint of the thyroid cartilage. This extends from2cm beyond the midline on thecontralateral side to theanteriorborder of the sternocleidomastoid on the affected side. Bipolar cautery is used to achieve haemostasis. Superior and inferior subplatysmal flaps are raised so that the upper and lower borders of the thyroid cartilage are easily palpable, and the wound is held open with a self-retaining retractor (Fig. 45.3). The sternohyoid muscles are separatedinthe midline and retracted laterally, using a Langenbeck retractor; if thisdoesnot give adequate exposure, dividing the medial half of the muscle with a cutting diathermy is recommended, with repositioning of the self-retaining retractor. Exposure is usually easier

Method

This is carried out in theoperatingtheatreunder

Fig. 45.3 Exposure of the thyroid cartilage.

Phonosurgery and ~icrolaryngealSurgery in the male due to the prominence of the thyroid cartilage; in difficult cases, adouble-pronged skin hook placed at the thyroid cartilage prominence can retract the larynx towards the contralateral side for better access. The thyrohyoid muscle is elevated from the thyroid lamina, which is exposedwith its overlying perichondrium intact. A line parallel with its inferior border at its vertical midpoint is marked across the surface of the thyroid cartilage and, using callipers, a point is marked 7mrn (female) or 9 mm (male) posterior to the midline. Avoid the superior half of the cartilage, as placing an implant here will displace the false cords and supraglottic structures rather than the true cords. Using callipers, a window is marked out from this reference point of the dimensions 10 X 4 mm (female) or 12 X 5 mm (male) (Fig. 45.4). If the cartilage is not ossified, it is possible to cut out this window using a scalpel, but this is unusual and most require a drill, using a 1mm side-cutting burr for the margins and a large polishing burr toremove the cartilage. Preserving the cartilage island was originally described but has caused complications with its later displacement, and it is preferable to remove it completely. Using magnification for this procedure, either loupes or the microscope, is recommended. It is important tokeep the inner perichondrium intact so that the implant will be lateral to the body of the vocal fold, as opposed to Teflon, which sits in themuscle. This explains theloss of mucosal wave seen following the use of Teflon but its preservation with this procedure (Gardener & Parnes, 1991). The cartilage is thinnest anteriorly and superiorly, so that itis easier to drill posteroinferiorly; once an opening in the cartilage is present in thisarea,the perichondrium can be depressed with an annularcurette

to.keep it awayfromthe drill, thus decreasing the chance of perforation. At the anteroinferior corner there is often a vessel, which can bleed into the cord, making voice assessment difficult and occasionally leading to the procedure having to be abandoned. Adrenaline-soaked patties and bipolar cautery may control this. Following removal of the cartilage plate, theperichondrium is elevated, using the annular curette and then a curved Freers elevator, but only a few millimetres’ dissection is required anteriorly, where there is thin perichondrium. Now is the time for insertion of the nasendoscope so that an image of the larynx is seen on the television screen. The patient is now asked to phonate and the elevator used to displace the cord medially until the best result for closure and voice is obtained. The depth of medial displacement can then be measured and the correctly sized Silastic implant inserted. To save operating time a selection of implants previously cutshould be present, buttheimplantcan be trimmed at this time for fine individual adjustment. These are cut from a soft Silastic block, using a scalpel and to the dimensions shown in Figs 45.5 and 45.6.

Fig. 45.5 Dimensions of starting block.

Fig. 45.4 Position and dimensions of cartilage window.

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Fig. 45.6 Modifications to produce correctly sized implant.

Fig. 45.7 Sequence of inserting implant.

They should beof varying depth (3-6mm), with two superiormethod to Teflon injection, certainly in the partial parallelincisions so that it can be folded to ease long term, is increasing (Sasaki et al., 1990). Whether iGsertion. Put the posterior flange in first and, holding this gives a goodresult in patients with lateralised a cord thisinpositionwithatoothed forceps, theanterior inasuperior plane is still debatable, and many now portion is bent forward and with steady gentle pressure combine it with an arytenoid adduction procedure for snapped into position (Figs 45.7). To ensure that the closure of the posterior commisure (Netterville et al., i&plant is sitting correctly, it is useful to run around the 1993). edges of the window with the annular curette and, when Two kits for medialisation laryngoplasty are currently cdnfident of its correct placement and that it is the being developed. appropriate size, the nasendoscope is removed. The 1 The first uses a preformed plastic implant (eight availstrap muscles and ,platysma1 flaps areapproximated able sizes) withalateral flange that allowsit to be with 3J0 Vicryl and the skin closed with4/0 nylon inserted easily and tolock into position. Itcomes with a sutures. A drain is not routinely used unless there has templateformarkingthewindow dimensions and a been excessive haemorrhage. A plastic spray dressing is measuring device for the depthof implant required. The applied to the wound, which is left uncovered. If there design of the implant is said to give a better chance of has been perforation of the perichondrium, antibiotics closing the posterior commissure (Montgomery et al., ‘are added, but otherwisedo notuse steroids or antibiot1993). ics routinely. The patient is kept on the ward for 24 in h 2 The second also comes with a measuring device, a window template and preformed implants of different case of anyairway compromise, but does not require sizes which are made of hydroxylapatite and require a any voice rest and a mild oral analgesic is sufficient. At shim to be fitted into the windowof the thyroid cartilage 1 week the sutures are removed and the position of the to keep them in position (Flint & Cummings, 1993). It cord noted at laryngoscopy. is likely to be expensive and, as this is a biointegratable material and studies have shown evidence of Complications osteoneogenesis on the inner plate of the cartilage, it is unlikely to be reversible. Early .

I.

”

Haemorrhage, haematoma, infection, undercorrection, overcorrection, airway compromise due to oedema or too large an implant.

Late Extrusion or displacement of implant. Alternative techniques and developments

Evidence supporting rnedialisation laryngoplasty asa

Microlaryngeal surgery The second part of this chapter deals with the surgery of benign disease of the adult larynx,leaving conservation surgery for laryngeal malignancy to other chapters. Althoughtherehas recently been an. increase in the amount of laryngeal surgery carried out via an indirect methodunder local anaesthesia,theauthors prefer a direct method, using suspension microlaryngoscopy under general anaesthesia with either a cuffed endotracheal tube (ET) or jet ventilation. Micro-

laryngoscopy has the following advantages over‘indirect laryngoscopy: 1 binocular vision; 2 magnification; 3 ability to use both hands for instrumentation; 4 ability to use carbondioxide(CO,) laser-beam surgery; 5 protection of the distal airway via a cuffed tube; 6 controlled surgical conditions with no patient movement, thus allowing millimetres of precision. Microlaryngoscopy concentrates mainly on the glottic area in cases where the diagnosis is already established and, unlike direct laryngoscopy, is not primarily concerned withotherareas of thepharynxandlarynx, which should have been assessed preoperatively. Surgical principles There are important principles to adhere to in suspension microlaryngoscopic surgery. 1 A knowledge of the anatomy of the larynx, specifically the microarchitecture of the vocal folds and location of the pathology, is essential. The layered structure of the vocal fold (Hirano,1977) (Fig. 45.8) and its different mechanical and physical properties allow the superficial layer to oscillate independently for phonation. This coverlbody theory explains the vibratory dynamics of the mucosal wave seen on stroboscopy (Hirano & Kakita, 1985). Poor lymphatic drainage of Reinke’s space predisposes this layer to collect tissue fluid. 2 Pre- and postoperative analysis is importantand should always include stroboscopy, as the specific concern is preservation of the mucosal wave of the vocal folds, which can only be assessed this way. Pathology, such as intracordal cysts or nodules, may be difficult to diagnose with white light and their true character only becomes visible on stroboscopy. Some authors divide

lesions intohardand soft lesions, based on their preoperativeevaluationwithstroboscopy, suggesting that soft lesions are more amenable to cure with voice therapy, which again highlights theimportance of stroboscopy (Ross et al., 1993).Postoperative recording of the mucosal wave will show how much scarring has occurred between the superficial epithelium and the underlying ligament and muscle, and there is a direct relationship between preservation of this mucosal wave and quality of voice. An academic approachshouldalso utilise acoustic parameters for objective pre- and postsurgery analysis. 3 Properinstrumentation,witharange of laryngoscopes and microinstruments, is required. Exposure can be difficult and using a selection of endoscopes with a wider proximal end and distal illumination will usually allowadequate access. Instruments need to be fine, sharp and well maintained to allow precise removal of the lesion with minimal scarring. Wrenching and tearing of the mucosa leads to excessive scarring. Benign disease is usually located in the mucosal layer or in the superficial part of the intermediate layer (Reinke’s space). Surgery should therefore be superficial, staying out of the vocal ligament, with limited mucosal excision only. There is currently no role for stripping ofthe mucosa of the vocal fold for benign disease. 4 The underlying cause of the lesion must be ascertained; a multitudeof factors, such as smoking, alcohol, voice abuse (both speaking and singing), gastrooesophageal reflux and muscle misuse, should be assessed and a reasonable trialof therapy for these factors attempted. Conservative treatment with medication and expert voice therapy or postural adjustment can often promote the healing of benign mucosal disease without resorting to surgery (Bastien, 1993). It is also important that these measures should be continued postoperatively to prevent recurrence, as surgery can often temporarily remove the pathological lesion without addressing the underlying aetiology. 5 Laser versus microsurgical instrumentation? This is, to anextent, a matterof personal choice but the authors prefer to limit laser use to vascular lesions or those that may bleed on removal, such aspapillomatosis or granulomas, to the removal of cartilage and when excising large areas of tissue. The laser is not merely a precise surgical knife and the surgeon musthave an understanding of the effects of spot size, wattage and mode (pulsed or continuous) and theirsoft-tissue interaction and, importantly, the hazards linked to its use. Patient selection

Fig. 45.8 Layered structure of the vocal fold.

Microlaryngoscopycan be used foranypatientwith

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symptomatic benign mucosal lesions, provided the aetiology and other contributing factors have been assessed and a period of appropriate therapy given. Surgical method

After intubation with a small oral cuffed ET, the vocal folds are sprayed with topical anaesthetic. The tube is secured in position on the left side of the mouth andthe patient’s neck flexed and the head extended. Protecting the upper teeth with a mouth-guard, the laryngoscope is inserted via the right side of the mouth and under the epiglottis. Onceagood viewis obtained,the laryngoscope is attached to its suspension arm andfixed in position. This usually gives adequate exposure, but firm downward pressure on the thyroid cartilage may provide a better view, especially for lesions of the anterior commissure area. An operating microscope with a 350 or 400mm lens aids precision, and small neurosurgical patties soaked in topical vasoconstrictor areuseful during dissection of the vocal fold. If the CO, laser is being used, jet-ventilation anaesthesia may be used and essential safety precautions must be adhered to, including eye protectionforbothpatient and operatingtheatre personnel, wet drapes around the patient’s face and lips and, if present, ET protection. Nodules

These are bilateral lesions of functional aetiology and they usually respond to voice therapy. They are found at the midpoint of the vocal folds and are confined to the superficial squamous epithelium and underlying Reinke’s space. The centre of the nodule is held with grasping forceps (not cupped forceps, which are cutting forceps) and pulled medially towards the opposite cord. Microscissors are then used to cut the mucosa close to its base, thus preserving normalmucosa, keeping a straight vibratory edge and preventing secondary notching. Theoppositenodulecanthen be removed ina similar fashion, taking care not to damage the mucosa of the anterior commissure. There is no contraindication to removing both nodules at the same operation, using this precision technique. A microweb has been reported to be present in up to 22% of patients with nodules, and this can be divided, as can any other thin anterior web, with an arrowknife, using a specifically designed vocalfold spreadinginstrument to place the tissue under tension (Bouchayer & Cornut, 1991) (Fig. 45.9). Postoperative voice rest for 48 h is recommended, but correct technique of voice production is essential to prevent recurrence.

Fig. 45.9 Location of nodules and an associated microweb.

Polyps

These are usually unilateral, localised areas of oedematous tissue, although some may be angiomatous and containareas of haemorrhage. The site of pathology is again superficial to the vocal ligament, and careful examination may showacontact response onthe contralateral vocal fold. Gentle, steady traction is applied via grasping forceps toward the opposite cord and the base of the polyp cut with microscissors. Preservation of mucosa is essential, too little resulting in reformation of the polyp, too much resection giving a notched, scarred cord with tethering of the layers of the vocal fold. Voice rest for 48 h is recommended, as is correction of any predisposing factors. Reinke’s oedema

This is abilateral diffuse conditionwherethere is a collection of polypoidal tissue in the superficial part of the intermediate layer of both cords. A cordotomy incision is made on the lateral aspect of the superior surface of the vocal fold with an arrow-headed knife (Fig. 45.10). The median vibrating edge of the vocal fold is therefore preserved. The mucosa is then elevated with a blunt dissector and the myxomatous contents either aspirated or removed with cupped forceps (Fig. 45.11). Care must be taken to avoid damaging the vocal ligament or traumatising the overlying mucosa with excess suction.

Phonosurgery and ~ ~ c r o l a r y n g eSurgery al

3 23

Fig. 45.10 (a) Endoscopic view of superior cordotomy incision. (b)Coronal section through vocal fold showing placement of incision.

Fig. 45.11 Elevation of mucosa and removal of myxomatous contents.

Fig. 45.12 Trimming of redundant nwcosa and primary closure of the ‘wound’.

Following removal of the contents, themucosal flap is replaced and any excess epithelium trimmedwith microscissors (Fig. 45.12). There is an increasing trend to use fibrin glue or microspot laser to maintain this flap in position, but these require specific equipment that is expensive and may not give superior results over simply laying the flap in its new position. Providing care is taken in the region of the anterior commissure, there is no contraindication to operating on both folds at the same time. Voice rest and attention tounderlying causes are again essential.

nosis. The cyst is located submucosally and is best approached via a lateral cordotomyon its superior surface. Blunt dissection along the surgical planes releases the overlying mucosa and the vocal ligament beneath (Fig. 45.13). Microscissors are used to release the cyst anteriorly and posteriorly and the cavity is cleaned witha neuropattie soaked in topical vasoconstrictor to check for any remaining cyst wall, which can be compared to cholesteatoma in the middle ear. Fibrin glue or welding microspot laser may be used to replace the mucosal flap.

Intracordal cysts

These may be mucosal retention or epidermoid cysts, and stroboscopy has greatly increased the ease of diag-

Papillomas

Unlike paediatric papillomas, adult lesions tend to be

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Chapter 45 self-limiting process that ‘burns itself out’whenthe arytenoid cartilagescleroses (Benjamin & Roche, 1993). The endoscope may be set to give a better view of the posterior commissure, and thegranuloma is grasped and pulled anteromedially to expose its attachment to the arytenoid. The CO, laser (6W, 0.8 mm, 0.1 S pulsed) is used to remove the lesion flush withthe perichondrium. The patient is placed on a strict antireflux protocol, together with intensive voice therapy. Arytenoidectomy

Fig. 45.13 Exposure of cyst via superior cordotomy incision.

less florid, specifically found at areas of constriction in the upper aerodigestive tract, where there is increased air turbulence, dryingand cooling of mucosa, and at the change of ciliary to squamous epithelium (Haskins et aE., 1993). The humanpapillomavirus is the underlying cause, and CO, laser excision is the treatment of choice, with minimal trauma to surrounding tissue that may contain dormant virus. An endoscopewitha smokeevacuation channel is useful. Settings of 4 W on pulsed laser (0.1S ) with a spot size of 0.3 mm are used and, as viral particles have been identified in the smoke plume, specific laser masks for protection are available. Single papillomata are grasped gently, as they may be friable, and the laser is used to excise the base. Multiple lesions are approached in a similar manner, lasering peripherally first to deliniate the lesion and prevent trauma to surrounding tissue.

Patientswith bilateral vocal-cord paralysis withthe cords lying in a midline position compromising the airway are candidates forthis procedure. Most will already A balance between have atracheostomyinposition. obtaining a good airway and producing a good voice is difficult and this must be explained to thepatient preoperatively. Using the CO, laser (6W, 0.8 mm, 0.1 S pulsed), an incision is made at the level of the tip of the vocal process of thearytenoid cartilage on one side, completely dividing the thyroarytenoid muscle. A second linear incision is then made at the lateral border of the released vocal fold through the mucosa only (Fig. 45.14). As this incision heals, it will retract the vocal fold laterally, thus improving theairway. The vocal process is now excised, using the CO, laser (low, 0.6mm, continuous), withregular suctioning to remove the char that accumulates, and an adequate airway is obtained (Fig. 45.15). Postoperative care

Following any of the abovemicrosurgery, the endoscope

Granulomas These are located on the vocal process of the arytenoid cartilage andare unilateral, sessile, bilobed lesions. Aetiology includes endotracheal-intubation trauma, gastro-oesophageal reflux and hyperfunctional voice disorders. Granulomas frequently recur and a combination of surgery to confirm histological diagnosis, togetherwithpostoperative gastro-oesophageal-reflux treatment, injection of steroidsinto the base, oral prostaglandins, speech therapy,osteopathyfor neck manipulation and even botulinum-toxin injection into the cord to prevent movement, has been tried. Surgery alone is unlikely to cure the granuloma, and medical/ behavioural treatment is proving to be the most efficient treatment. A recent paper states that a granuloma is a

Fig. 45.14 Order of initial laser incisions for partial arytenoidectomy.

PhonosurgeryandMicrolaryngealSurgery ‘

Fig. 45.15 Vocal process of arytenoid removed.

is released from its suspending apparatusand withdrawn from the right side of the mouth, taking care not to dislodge theanaesthetictube.Thetooth-guard is removed and the teethchecked for damageor loosening. Any trauma to the soft tissues of the mouth, lips or pharynx is also noted and the surgeon should remain in the operating room until the patient is extubated andthe anaesthetist satisfied with the patient’s airway.

References Bastien R (1993) Benign mucosal and saccular disorders: benign laryngeal tumors. In: Cummings C (ed.)Otolaryngology, Head and Neck Surgery, Vol. 3, 2nd edn. St Louis, CV Mosby, pp. 1897-924. Benjamin B & Roche J (1993) Vocal granuloma, including sclerosis of the arytenoid cartilage: radiographic findings. Ann. Otol. Rhinol. Laryngol. 102, 756-60. Bouchayer M & Cornut G (1991) Instrumental microscopy of benign lesions of the vocal folds. In: Ford C & Bless D (eds)Phonosurgery: AssessmentandSurgicalManagementofVoiceDisorders. New York, Raven Press, pp. 143-65. Ellis J, McCaffery T, Destano L & Rieman H (1987) Migration of Teflon after vocal cord injection. Otolaryngol. Head Neck Surg.96, 63-6. Flint P & Cummings C (1993) Phonosurgical procedures. In:

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f

Cummings C*(ed.)Otolaryngology, Head and Neck Surgery, Vol. 3, 2nd edn:’St Louis, CV Mosby, pp. 2072-109. Ford C, Bless D & Loftus J (1992) Role of collagen in the treatment of glottic insufficiency: a study of 119 patients. Ann. Otol. Rhinol. Laryngol. 101, 237-47. Gardener G & Parnes S (1991) Status of the mucosal wave post vocal cord injection versus thyroplasty. J Voice 5, 64-73. Haskins H,Mounts P, Leventhal B & Hruban R (1993) Sites of predilection in recurrentrespiratory papillomatosis. Ann. Otol. Rhinol. Laryngol. 102, 580-3. Hirano M (1977) Structure of the vocal fold in normal and diseased states: anatomical and physical studies. In: Ludlow C & Hart M (eds) Proceedings of the Conference on the Assessment of Vocal Pathology. Bethesda, American Speech-Language-Hearing Association, pp. 11-30. Hirano M & Kakita Y (1985) Cover-body theory of vocal fold vibration. In: Daniloff R (ed:) Speech Science. San Diego, College Hill Press, pp. 1-46. Hirano M, Tanaka S, Tanaka Y & Hibi S (1990) Transcutaneous intrafold injection forunilateral vocal fold paralysis: functional results. Ann. Otol. Rhinol. Laryngol. 99, 142-8, Isshiki N, Morita H, Okamura H & Hiramoto M (1974) Thyroplasty as a new phonosurgical technique. Acta Otolaryngol. 78,451-7. Kasperbauer J, Slavit D & Maragos N (1993) Teflon granulomas and overinjection of Teflon: therapeutic a challenge forthe otorhinolaryngologist. Ann. Otol. Rhinol. Laryngol. 102, 748-51. McCaffrey T (1993) Transcutaneous Teflon injection for vocal cord paralysis. Otolaryngol. Head Neck Surg. 109, 54-9. Mikaelian D, Lowry L & Sataloff R (1991) Lipoinjection for unilateral vocal cord paralysis. Laryngoscope 101, 465-8. Montgomery W, Blaugrund S & Varvares M (1993) Thyroplasty: a new approach. Ann. Otol. Rhinol. Laryngol. 102, 571-9. Netterville J, Stone R & Luken E (1993) Silastic medialisation and arytenoid adduction: the Vanderbilt experience. Ann. Otol. Rhinol. Laryngol. 102, 413-24. Ross J, Izdebski K & Hilsinger R, Jr(1993) Efficacy of surgical treatment of primary vs. secondary benign lesions of the free vocal edge. In: Proceedings of the 6th Annual Pacific Voice Conference, San Francisco, California, 2 993. Sasaki C, Leder S, Pectu L & Friedman C (1990) Longitudinal voice quality changes following Isshiki thyroplasty type 1: the Yale experience. Laryngoscope 101, 849-52. Strasnick B, Berke G & Ward P (1991) Transcutaneous Teflon injection for unilateral vocal cord paralysis: an update. Laryngoscope 101, 785-7. Von Leden H (1991) Thehistory of phonosurgery. In: Ford C & Bless D(eds) Phonosurgery:AssessmentandSurgicalManagement of Voice Disorders. New York, Raven Press, pp. 3-23.

Tracheostomy VICTOR ABDULLAH

Tracheostomy, derived from two Greek words, ‘traxus’ meaning roughand ‘stoma’ meaning mouth(Rosas Meneses & Betancourt Landeros, 1970), is one of the oldest operations in surgery. Egyptian engravings dating back to 3600 BC included fascinating records of this procedureinancient times (Shehata, 1981). The first knowntracheostomy was performed by Asclepiades of Bithynia, a Greek physician (128-56 BC), who performedtheoperation in Rome at theCentrefor Croupous Diseases of theLarynx. George Martin,a Scottish physician, wasthe first to performa tracheostomy in England for a case of diphtheria in 1730 (Stell, 1973). It was, however, to the credit of Chevalier Jackson that tracheostomy became standardised a procedure at the beginning of twentieth the century (Jackson, 1909). Thethought of a ‘tracheostomy’ oftenimpartsa certain amount of fear and hesitation to surgeons less familiar with the procedure. Yet many non-surgical intensive-care physicians are highly skilled minitracheostomists, which leaves little room for even the mostjunior surgical trainee to shy awayfrom mastering this procedure. With the availability of quality tracheostomy tubes and aftercare in most surgical units, a properly performed and managed tracheostomy is associated with minimal morbidity.

lndications The foremost indication for a tracheostomy is Moser’s dictum ‘when a surgeon thinks about it’. This simple statementshould be treasured and will help solve many problems. Thepathologicalindicationsfora tracheostomy may be summarised as follows:

Upper airway obstruction, real or anticipated

Thiscan be congenital, acquired or part of amajor head-and-neck procedure. Pulmonary ventilation

Tracheostomy allows effective medium- to long-term intermittent positive or assisted airway ventilation. A tracheostomy should be performed in a patient still requiring ventilation through an endotracheal tube (ET) extending beyond 1 week. Pulmonary toilet

A tracheostomy provides a port for effective pulmonary toilet. The properly supervised use of a low-pressure, high-volume cuffed tracheostomytube provides only temporary control of pulmonary aspiration and is no substituteforformalairway diversion proceduresin selected cases of chronic aspiration (Eibling, 1992).

Relevant anatomy (Fig. 46.1) The trachea lies in the midline of the neck, extending from the cricoid cartilage superiorly (C6) to the sternal notch inferiorly, then passing retrosternally to the tracheal bifurcation at the level of the sternal angle (T.5).It comprises 16-20 C-shaped cartilage rings separated by fibrous tissue. The incompressible complete cartilage ring of the cricoid is a valuable landmark,andthe palpable tracheal rings allow easy identification of the trachea at surgery. Posteriorly, the circumference is completed by the trachealis muscle. The lumen is lined

Tracheostomy

3 27

Fig. 46.1 Anatomical relations of the trachea.

by respiratory ciliated epithelium, and the external surface is covered by pre-tracheal fascia. The trachea is 1012cm long and 15-20 mm in diameter in theadult, being smaller in females and adolescents. The cervical length may be-increased at tracheostomy by extending the neck and head.

artery laying more deeply, and both may be at risk, alongwiththe inferior thyroid veins, if dissection is carried too far inferiorly withinadequateexposure. Similarly, the apexof the pleura ascends into theneck in infants and small children and may be vulnerable during tracheostomy.

Relatiions

Elective tracheost

Superficially, the thyroid isthmuscovers rings two, three and four, with the lobes of the thyroid overlaying the trachea inferiorly for another one to two rings. More superficially are the strap muscles, deep and superficial fasciae, anterior jugular veins (AJVs), platysma, subcutaneous tisue and skin. The recurrent laryngeal nerves lie in the tracheo-oesophageal grooves bilaterally, with the common carotid and internal jugular vein (IJV) running parallel to the trachea more laterally. Deep to the trachea are the cervical oesophagus, pre-vertebral fascia and the vertebral bodies. Inferiorly, the brachiocephalic vein crosses the trachea obliquely, with the innominate

An elective tracheostomy can be performed under local or general anaesthesia. The operating theatre is the safest and most comfortable place in which to perform a tracheostomy and thereshould always be time, with adequate resuscitative support, to transporta patient to the operating room. If one elects to fashion a tracheostomy by the bedside on the ward or in the intensive care unit, one should expect the level and promptness of the assistance to be suboptimal. A certain amount of experience with the procedure is recommended prior to such an undertaking. Most ward beds are much wider than the operating

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table and it is wise to move thepatient to the edge of the bed to save bending over. A headlight is recommended for this procedure outside the operating room. A diathermy machine should be connected and ready for use. The patient ought to have at least a pulse oximeter connected for monitoring.The surgeon should check that all the instruments he/she requires are available and laid out in the correct sequence for the procedure. These few points can save the surgeon a lot of frustration during a bedside tracheostomy. Positioning the patient

The patient is placed supine with shoulders supported and thehead tilted backwards on a head ring. This position brings the trachea to the surface of the neck and stretches the neck skin taut, If neck extension is not possible, thesurgeonhas to rely on pre- and intraoperative palpation and direct manipulation of the laryngotracheal skeleton during the operation. Palpatbn of the anatomy (Fig. 46.2)

The laryngotracheal skeleton should be palpated carefully. Locate the thyroid cartilage, the thyroid eminence and thenthemoreprominent cricoid ring. The individual tracheal rings can then be palpated. Procedure

The incision

1 A horizontal incision is recommended for an elective tracheostomy as the resultantscar with or without revi-

sion is usually cosmetically more acceptable than the blemish after an equally long vertical scar. Nevertheless, in an emergency situation,when cosmesis takes low priority, a long vertical incision provides the shortest route with the least bleeding to the trachea. 2 The best position for the tracheostomy is at the level of the third and fourth tracheal rings, well away from the cricoid. If the tracheal rings are not palpable, the incision can be placed halfway between the cricoid cartilage and the jugular notch and the rings located intraoperatively. 3 In the case of a short fat neck, place the incision 1cm above the medial ends of the clavicles in order to avoid the flanges of the tracheostomy tube abutting on them and then establish the anatomy of the tracheal skeleton intraoperatively. The development of skin flaps and tissue planes

The incision does not need to extend beyond the anterior borders of the sternocleidomastoid muscles. Incise the skin and stroke the platysma1 layer with the scalpel to separate its fibres (Fig. 46.3). Thesubplatysmal planes are developed withthe scalpel or scissors above and below, with the help of skin hooks and countertraction with a finger and swab. The AJVs can usually be swept away quite easily from the undersurface of the platysma. The raising of skin flaps allows adequate exposure of the surgical field and creates space for the comfortable insertion of retractors for the remaining procedure. A self-retaining retractor can be used to hold the skin flaps apart. Division of the anterior jugular veins and the separation of the strap muscles

The AJVs are best divided between clamps and tied. They can be cauterised if they are small or left undis-

Fig. 46.2 Palpation of anatomy.

Fig. 46.3 Raising of skin flaps.

Tracheostomy turbed and retracted away from the midline if they are wide apart. Blunt dissection is recommended forthe opening of the midline plane. As the fascial fibres are spread apart, they are retracted with small Langenbeck retractors, which will, in addition, draw the strap muscles apart.Duringthe dissection, thesurgeonshould palpate for the trachea intermittentlyso that the correct midline course is maintained. This dissection brings the surgeon to the anterior trachealwall and the isthmus of the thyroid (Fig. 46.4). Division of the thyroid isthmus

This is best done between clamps. If the isthmus is long, more than one clamp can be applied on each side and the division can be done from top to bottom in short segments in the midline. Care should be taken at the lower end to avoid injury to thesubmanubrialbrachiocephalic vessels. The stump on each side after division should be transfixed and firmly tied (Fig. 46.5). Sometimes the isthmusis tiny and may be well out of the way of the third and fourth tracheal rings. This can be safely left but it is best not tomobilise an isthmus if one does not plan to divide it.

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the trachea (Fig. 46.6)

Prior to entering the trachea, the surgeon should check that theappropriate-sizetracheostomytubewith an inflatable cuff is available for insertion. The anaesthetist should be informed.Thetracheacan be entered in different ways- a midline slit, a cruciate incision, a windowor asuperiorly or inferiorly based (Bjork) flap-each having its advocates. The author favours the fashioning of a small window. The window spans two tracheal rings in length and approximately one-third of theanteriortracheal wall inwidth.Mostsurgeons would agree that the best level to enter the trachea is at the third and fourth tracheal rings. A size 15 blade is plunged through themucosa between the fourth and the fifth ring. The cutting edge of the blade is then turned upwards to cut through the fourth and the third rings. The blade is then taken through themucosa between the third and the second tracheal rings horizontally. A pair of toothed forceps isused to firmly gripthe piece of partially excised trachea and its excision is then completed. Insertion of the tracheostomy tube (Fig. 46.7’)

The anaesthetic tube is now withdrawn to a level just above the window. At this point the secretions in the tracheobronchial tree shouldbe aspirated with a suction catheter. The right-handed surgeon should now insert the tipof a tracheal dilator into the window with left the hand. As it is opened, gentle superior traction brings the trachea to the surface and the lubricated tracheostomy tube can be inserted from the side and gently rotated into the trachea. The anaesthetic circuit is nowconnected to the tube andthe cuff is inflated sufficiently to obtain a seal. Fig. 46.4 Exposure of the thyroid isthmus.

Fig. 46.5 Transfixion of the thyroid isthmus.

Fig. 46.6 Entering the trachea.

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Fig. 46.7 Insertion of the tracheostomy tube.

Suturing the wound and securing the tracheostomy tube

The wound can be sutured on the two sides butthe centre should be left loose around the tube to avoid surgical emphysema. A paraffin gauze dressing is placed around the tube, which serves well to keep the wound clean. The tube flanges can then be sutured with a 2/0 silk stitch to big bites of skin on both sides. The tube should then be further secured with tapes on each side withthe patient’s head flexed to avoid slack. Secure knots should be used as these tapes can always be cut and replaced. With these simple measures, a dislodged tube in the early postoperative period can be effectively prevented. The tracheostomy tract is well formed by 72h and a tube change can be performed safely and comfortably after this time.

Tracheostomy under local anaesthesia A tracheostomycan be safely performed under local anaesthesia, although thisis best done by a surgeon with some experience of the procedure. The skin and the subcutaneous tissue are the painful layers and require infiltration with 1 or 2% lignocaine. Fascial tissue and thethyroidisthmusare relatively painless and do not require infiltration. It is best not to infiltrate the trachea until it is ready to be opened, when a few drops of 4% lignocaine can be instilled. The patient must fully understand the procedure and the surgeon should remember that the patient is awake and ensure that a calm atmosphere is maintained.

Emergency tracheostomy This procedure should not be regarded as a rushed job

Fig. 46.8 Controlled longitudinal incision for a n emergency tracheostomy.

in a crisis. It should be a controlled operation, calmly conducted, in which every stroke of theoperator is purposeful, progressing to thetrachea in thecorrect direction. A long midline incision is recommended to allow the quickest and the best possible exposure with the least amount of haemorrhage. The surgeon should be encouraged that with every controlledstrokethe patient is brought closer to safety. The patient should be positioned correctly as for an elective tracheostomy and attempts to administer oxygen by anyother means such as by Ambu bag and oropharyngeal airway should not be discontinued. The right-handed surgeon should grip the thyroid and the cricoid cartilages with the left hand and pull the laryngeal skeleton towards the head. The long midline incision should incise through skin and subcutaneous tissue on the first strokefromthe cricoid to the jugular notch (Fig. 46.8). The surgeon can then use the fingers on the left hand to push apart the skin and the forefinger to palpate for the trachea, while the assistant clears the blood by mopping or suction. The second stroke of the scalpel aims to reach the front of the trachea. More strokes can always be made and they take little time. Once the trachea is reached, it can be entered via a midline slit wherever convenient. The cricoid is best avoided if possible. The tracheostomy tube can be inserted with the help of a dilator or the back end of the scalpel, which can be

Tracheostomy used to stent open the tracheal slit. The cuff is then inflated and haemostasis secured.

Physiological changes after a tracheostomy 1 A 10-50% reduction in anatomical dead space. This contributes to better pulmonary ventilation. 2 Loss of voice. Theair bypass of atracheostomy makes it difficult for the patient to phonate. Provided that a phonating larynx is present, the patient can be trained to phonate either by finger occlusion of the tube or by the use of special phonating valved tubes. 3 Difficulty in swallowing. This is secondary to tethering of the trachea to theskin by the tracheostomy tube, which impedes the swallowing motion. An overinflated cuff can compress the oesophagus, causing dysphagia. 4 Loss of humidification. In the presence of a tracheostomy, cool dry air directly hits the tracheobronchial tree. This interferes with ciliary function, allowing accumulation of secretions. 5 Loss of glottic valve closurerequiredfor effective coughing.

Post-tracheostomy care 1 Humidified warm air shouldbe provided for 48-72 h to prevent crusting and tube obstruction. 2 Regular suction and physiotherapy should be carried out for the chest in the early postoperative days. 3 A writing-pad should be provided to aid communication and whenpossible train the patientto vocalise with the tracheostomy tube in situ. 4 As far as possible, encourage the patient to care for hidher own tracheostomy tube.

Complications Immediate

1 Haemorrhage,

33 I

2 Recurrent laryngeal nerve injury. 3 Apnoea secondary to the loss of hypoxic drive. 4 Cardiac arrest secondary to the adrenaline surge and the sudden rise in pH as CO, is washed out. 5 Air embolism. 6 Pneumothorax. Intermediate

1 Cellulitis. 2 Surgical emphysema. 3 Tube dislodgement. 4 Tracheal-wall ulceration or necrosis. 5 Dysphagia. 6 Pneumomediastinum. 7 Tube obstruction Late

at four 1 Stenosis of the trachea can occur sites-suprastomal, stomal, cuff and tip. 2 Tracheocutaneous fistula can follow if traa cheostomytubehas been inserted formorethan 3 months. Surgical closure is required.

References and further reading Eibling DE, Bacon G & Snyderman CH (1992) Surgical management Adv.Otolaryngol.HeadNeck Surg. 6, of chronicaspiration. 93-113. Jackson C (1909) Tracheostomy. Trans. Am. Laryngol. Rhinol. Otol. Soc. l, 337-45. Rosas Meneses M H & Betancourt Landeros VM (1970) History of tracheostomy. Semana Med. Mexico 64, 21. Shehata MA (1981) History of laryngeal intubation. Middle East J. Anaestb. 6, 49-55. Stell PM (1973) Tracheotomy and tracheostomy. In: Ransome J, Holden H & Bull TR (eds) Recent Advances in Otolaryngology. Edinburgh, Churchill Livingstone, pp. 275-94.

Surgery of Paediatric Laryngotracheal Stenosis DAVID ALBERT

Introduction

between the split to fill in, eventually with new cartilage. (b) Augmentation uses grafts to expand the lumen by adding to the existing cartilaginous framework. Autograft costalcartilage is most oftenused, although bone or even allografts have been tried. (c) Stenting is animportantadjuncttotheabove techniques to stabilise reconstructions and to prevent restenosis. The expansion of the lumen may be at the expense of the function of the larynx. Substantial anterior and posterior grafts may allow achild to be decannulated, but the further the cords are separated, the more the function suffers. There are many combinations and modifications of the techniques described above. The relatively small number of patients requiring surgery mitigates against comparative studies. The choice of technique presented is more proactive than many readers may be used to, and also favours single-stage surgery where possible, as this avoids the dangers and difficulties of tracheostomy.

Surgery of laryngotracheal stenosis (LTS) involves more than expansion of the stenotic airway. It is complicated by the need to maintainthefunction of thelarynx to phonate and to provide protection for the airway. Stenosis offers a surgical challenge at many sites in the body but in few is the interrelationship with functionso delicate. Expansion of the stenotic airway canbe achieved in a number of complementary ways. 1 Natural resolution of stenosis fromgrowth of the surrounding cartilaginous structure appears an attractive option. However, resolution of significant acquired stenosis is rare. 2 Dilatation aims to stretch stenosis but is seldom successful, asacquired stenosis contains elastic elements which contract unless dilatation is combinedwith steriting. 3 Laser vaporisation offers a promise of instantaneous elimination of stenosis. This promise is often unfulfilled, as stenosis re-forms. 4 Resection of thestenotic segment withend-to-end anastomosis is only possible if the stenosis is separate from the glottis. This is very rarely the case in acquired stenosis; hence theauthor’s preference fortheterm ‘laryngotracheal’ stenosis. Restenosis at the anastomotic site may also occur. 5 Most surgeons now rely on splitting and augmentation to treat significant stenosis, with costal cartilage grafting being the preferred option. (a) Splitting divides thecartilaginousframework. Splits can be anterior, posterior, lateral or castellated, asinlaryngotracheoplasty.Whencombinedwith stenting, splitting increases the lumen but leaves areas

General indications and choice of technique There are three main groups of children who require laryngeal reconstruction. Intubated patients who cannot be extubated because of laryngotracheal stenosis

Conservative measures should be tried first, such as antirefluxtreatment,steroids and at least 5 days between attempts at extubation. If these fail the alterna33”

Surgery of Saediatric ~ a r y n g o t ~ ~Stenosis c b e ~ ~ 33 3 ~.

tives to tracheostomy are as follows: 1 cricoid split; 2 single-stage laryngeal reconstruction (without tracheostomy). The single-stage procedure is a modified cricoid split in which a cartilage graft is inserted inthe split. This improves therate of successful extubationand,as it does not seem to be associated withany higher complication rate, would seem to be the procedure of choice. ”

\”-

Tracheostomised patients with laryngotracheal stenosis

Mild stenosis may improve sufficiently to allow decannulation without surgery but almost all patients with grade 111-IV stenosis (see under Preoperative evaluation) will require surgery before decannulationcan proceed. Laryngeal reconstruction is now being undertaken at an earlier age, as technically this provides few real difficulties. There are obvious advantages of early decannulation for both the parents and the child. Ideally all children should be decannulated well before starting school. The options are: 1 cartilage grafting with tracheostomy maintained; 2 cartilage graftingwithtracheostomy closed at the same time as a single-stage procedure; 3 cricoid split “anterior, posterior or lateral splits-or laryngotracheoplasty. Thetraditionalapproach is to use anteriorcartilage grafts for mild stenosis (grades 1-11), with addition of a posteriorgraft if the stenosis is severe or prominent posteriorly. Some surgeons would use a posterior graft for interarytenoid scarring, although a Z-plasty to the scar is more appropriate. A more recent development is to close and support the tracheostomy site at the same time as the reconstruction in a sin&-stage procedure, if significant suprastomal collapse is present. Congenital stenosis in which the cricoid is small but not scarredhas conventionally been treatedwitha laryngotracheoplasty. Anterior cartilage grafting is an alternative, particularly if the stenosis is severe. A larynx scarred and disorganised by previous surgery can be salvaged by a four-way cricoid split and the long-term use of a stent. A posterior split without grafting can be used in mild to moderate stenosis to allow the cricoid to spring open sufficiently to use a reasonable-size anterior graft without separating the posterior commissure.

Patient.s . without a tracheostomy but*who have recurrent croup, increasing stridor, reduced exercise tolerance or failure to thrive ~

~

.~

Prior to the introduction of single-stage procedures the decision to operate on these children was very difficult, as a tracheostomy was required. A single-stage procedure using a simple anteriorgraftandaperiod of postoperative intubation is now the method of choice and is very successful, as the stenosis is usually relatively mild. Surgery should be considered in children with stenosis requiring intubation for croup on more than two occasions. Some prematureneonatesareextubated only to develop progressive stridor as they grow and their stenosis does not. If the indication is reduced exercise tolerance, arespiratoryopinionshould be sought to exclude an element of asthma. Similarly, children with failure to thrive need to have other possible causes excluded.

Contraindications Single-stage procedures contraindicated are if pulmonaryfunction is inadequate or if the child is under 1.5kg. Surgery is also contraindicated unless appropriatepaediatric ITU facilities are available, as the child will need postoperative intubation. Any other medical problem may adversely affect thechance of success. In conventionalreconstruction,posteriorgraftsare contraindicated in children with arytenoid fixation, as the resulting larynx will be incompetent. If the larynx is still full of active granulations, indicating active perichondritis, surgery is best delayed.

Preoperative evaluation Endoscopic assessment

Endoscopic assessment is essential to decide if and when surgery is indicated and to choose the most appropriate technique.

Degree of stenosis

A number of different grading systems have been used but the only system to have been tested against prognosis is that of Cotton, which relies on the percentage of the lumen obstructed by stenosis.

334

Chapter 47

Grade I 0-50% Grade I1 51-70% Grade I11 71-99% (lumenpresent) Grade IV No lumen The length or thickness is much less important, unless the stenosis is sufficiently thin tobe almost aweb, which can then sometimes be lasered segmentally. Site of stenosis

Whether the site is anterior, posterior or lateral determines where to split thelarynx and insert cartilage grafts. Arytenoid mobility

Arytenoid fixation is easily missed unless specifically excluded and will adversely affect results. There is no reliable treatment. Interarytenoid scar

This needs to be excluded by separating the arytenoids with two probes. Gastro=oesophagealreflux

This hasrecently been shown tohave a marked effect on the healing of the larynx, both at the time of the initial injury and after laryngeal reconstruction. Barium swallow is a poor indicatorof reflux. Although pH studies or isotope milk scans are better, they do not usually measure upper oesophageal or pharyngeal pH. Double pH studies, which simultaneously measure upper and lower oesophageal pH, are the ‘gold standard’, but there are few normative data to determine how much acid reflux is needed to affect thelarynx. At present, therefore, there is a case to treat all patients undergoing laryngeal surgery with a 6-week course of H,-blockers, extending this to 3 months if reflux is demonstrated by whatever means. informed consent

In grade 11-111 stenosis, initial success should be in the order of 70-85%, with over 95% achieving decannulation after further surgery. In grade IV stenosis, in which no lumen is present, the results are much worse, with 60% initial success and only 75% being eventually decannulated. Most potential complications, while important, would not sway parents against surgery. The possibility

of poor vocal quality after surgery needs to be carefully discussed. Overall, one-third will have a normal voice, one-third anabnormalbutunderstandable voice and one-third a sufficiently poor voice to make communication difficult. These lastpatientsare usually those with a complete or near-complete stenosis who had no voice preoperatively. There are no large studies yet with pre- and postoperative voice results to determine how often surgery has an adverse or a beneficial effect on the voice.

Prophylactic a n t i ~ i o t i c ~ Thereare no studies to show efficacy of antibiotic prophylaxis in paediatric LTS surgery. If a graft is inserted and particularly if a stent is used, prophylaxis is recommended. A broad-spectrum antibiotic suitable for upper respiratory organisms such as amoxycillin is often used. In sick neonates undergoing cricoid split, the trachea is probably not sterile; antibiotics should therefore be chosen on the basis of tracheal aspirates and with the agreement of the neonatologist.

Relevant anatomy In paediatric and neonatal tracheostomy, tracheostomy stay sutures areessential, as even in neonates the trachea lies quite deep. It is also possible to pull almost all of the intrathoracic trachea up into theneck, so excessive neck extension should be avoided. The left brachiocephalic vein and the pleural apex are relatively higher in the paediatric neck. In neonates the distance from stoma to carina can be as little as 2.5 cm, making tubepositioning critical. The standard approach to the paediatric larynx is a midline laryngofissure. In the previously operated neck, staying strictly inthe midline will avoid interference with the major neck vessels. The dissection in tracheal resection has to remain right up against the trachea to avoid damage to the recurrent laryngeal nerves. Posterior and lateral cricoid cuts must only just broach the cricoid, in order to avoid damage to the oesophagus and the recurrent laryngeal nerves respectively.

Operative technique Thestandard laryngofissure is described first and in detail. The more extended procedures which follow do not repeat the description of this basic approach unless there are important variations.

Surgery of Paediatric Laryngotracheal Stenosis

335

Procedure

Fig. 47.1 Tape passed around chin to elevate upper skin flap.

(a) Basic laryngofissure Preparation

General anaesthesia This is initiated via the tracheostomy tube,which is then changed for anarmouredendotrachealtube (ET) secured caudally. Theanaesthetictechniqueforpatientswithouta tracheostomy is covered in single-stage procedures (Sections c and e).

1 Soft-tissue dissection should be in themidline through fascia and strap muscles. The author routinely divides the thyroid isthmus with diathermy and thenretracts the two halves with a stay suture. Two Aberdeen retractors (Fig. 47.2) provide good access, while most other selfretaining retractors get in the way. 2 The anterior laryngofissure is started inferiorly and then carried superiorly. A Beales dissector placed in the midline between the vocal cords ensures that, if needed, division of the anterior commissure is central. Often the laryngofissure only needs to be taken halfway up the thyroidcartilageand inferiorly through the first ring (Fig. 47.3). 3 Posterior division of the cricoid, if required, should not proceed until bleeding from the anteriorincision has been controlledwithadrenaline-soaked neurosurgical patties. Harvesting and placement of cartilage grafts are dealt with in Section c. 4 Closure is important, as the scar will be visible. A subcuticular nylon suture is easily removed in any child and gives an excellent cosmetic result. A drain is required if there is an air leak or if haemostasis is incom-

Surgical drapes and equipment Forthose used to operating in adultsthestandard drapes are rather cumbersome. The author prefers following the usual skin preparation with plaster remover to provide good adhesion for a perforatedplastic drape. A piece of adhesive’tape fixed tightly to the head of the table and under the chin provides skin traction on the upper flap and gives a clear field (Fig. 47.1). It is especially important in revision surgery to keep thehead central in order to maintain a midline laryngofissure. Surgical instrumentsshould be appropriateforthe child’s age. Microbipolar forceps aremore helpful than. skin infiltration in preserving adryoperative field.

Fig. 47.2 Aberdeen skin retractors.

Incision

A horizontal skin-crease incision should be at the level of the cricoid. The length depends on the need for access to thetracheostome and to the upperborder of the thyroid cartilage.

Fig. 47.3 Laryngo fissure, showing vertical extent.

3 36

Chapter 4’7

plete. Saline poured into the wound as the anaesthetist increases the airway pressure will detect an air leak. A dressing is not required unless an open drainage system is used. Postoperative intubation and sedation are covered in Section b. Complications

Damage to the anterior commissure can occur if the laryngofissure is not in the midline. Surgical emphysema will occur if an air leak is present andnodrain is inserted. Occasionally the wound will become infected; this is more likely to occur if a stent is secured with a buried suture. (b) Splits of the cricoid cartilage: anterior/

Procedure

1 Oncetheanterior split is complete, the ET can be withdrawn temporarily to allow the posteriorsplit to be performed. It is usually necessary to feed the tube back past the split for ventilation on a number of occasions until the split is complete. 2 Bleeding needs to be carefully controlled before and duringposteriorandlateral splits in order to prevent damage to the oesophagus or recurrent laryngeal nerves. A useful sign that posterior division of the cricoid is complete is that the two halves of the larynx should become much easier to separate (Figs 47.447.6). 3 A larger-size nasotracheal tube can now be inserted. This is simply achieved by reintubation in the normal

posterior/lateral/four=way

Specific indications 1 Anterior t- posterior split in long-term ventilated neonates andother children withoutatracheostomy who fail extubation. 2 Anterior split in patients with a tracheostomy and a soft, mild stenosis (Cotton grades 1-11). 3 Four-way split in severely disrupted larynges and revision surgery (tracheostomised children). Specific contraindications

1 Weight under 1.5kg. 2 Poor pulmonary function. 3 Significant otherairwaypathology

such asinter-

Fig. 47.4 Posterior split of the cricoid cartilage.

arytenoid scarring or tracheomalacia. Particular points of operative technique

The technique of laryngofissure as described above is used with the following modifications. Preparation

Antireflux cover should commence preoperatively, withsteroidsstarted on the fifth postoperativeday (dexamethasone0.25 mg/kg initially, then 0.1 mg/kg 4.d.s. until 24 h postextubation). Initial intubation will be with a smaller-than-expected ET. As the child will need to be reintubated with a larger tube after thesplit is complete, access to the face must be available to the anaesthetist. Fig. 47.5 Scissors used to check division of posterior cricoid lamina.


3 37

Complications

Traumaticreintubationcancreatea false passage throughthe split andinto the neck, complicating attempts at resuscitation. Failed extubationcan be managed with a further period of intubation, a repeat cricoid split, a single-stage laryngeal reconstruction or a tracheostomy. (c) Single-stage reconstruction to avoid tracheostomy

Specific indications Fig. 47.6

way, with the surgeonhelping the tube past the split and into the trachea. 4 A tubeone size larger than predicted can be used if this is possible without trauma to the mucosa. The nasotracheal tube is secured with a Tunstall connector to a headband. 5 A drain is required to manage the air leak, as the anterior split is neither closed nor covered Postoperative management

Postoperative sedation should be reduced as much as possible so that the child is awake and responding, but without risking accidental extubation.Most children with normal lung function can cope with continuous positive airway pressure (CPAP)rather than assisted ventilation. Postoperative paralysis and ventilation are used by some surgeons to prevent extubation, but their strategy has significant side-effects of muscle weakness and lung collapse. Testing for an air leak aroundthetubecan help determine whento extubate. Thisis achieved by increasing the ventilatory pressure and listening at the mouth or with a stethoscope over the larynx. This has been shownto be goodpredictor of eventual successful extubationin paralysed ventilated patients,butin lightly sedated patients an air leak may be absent because the cords are clamped around the tube. In nonparalysed non-ventilated patients, a workable protocol is to extubate on the third postoperative day if a leak is present or otherwise on the fifth day. If the child requires reintubation after accidental or planned extubation, there should be time to return the child to theatre and reintubate carefully, with the bevel turned posteriorly to avoid the anterior split.

l Failed extubation, particularly in long-term ventilated neonates. 2 Recurrent croup due to mild subglottic stenosis. 3 Progressive stridor. 4 Reduced exercise tolerance. 5 Failure to thrive. Specific contraindications

As for cricoid split (Section b). Particular points of operative technique

Apart from the graftplacement, moit points arecovered under basic laryngofissure andthe section on cricoid split. Anaesthesia

If the child is not already intubated, it is important not to force a larger ET than will fit comfortably, asthis will disrupt the subglottic mucosa. As anaesthesia may be suboptimal with a small tube, the laryngofissure should be performed quickly and efficiently to allow placement of a larger tube. A posterior graft is very seldom necessary in this group of patients, but, if it is, a separate, low, temporary tracheostomy can be used to continue anaesthesia while the posterior graft is placed. Respirationshould be spontaneous,as this allows more time for tube changes and for graft placement. Procedure

1 The anterior split should be from the first tracheal ring to halfway upthethyroid, being extended if needed. 2 Graft harvest is from the right costal margin. In girls a submammaryincision can be used, although, while the scar may be preferable, there are some concerns that the

338

Chapter 47’ Postoperative care and complications

These are the same as in the basic laryngofissure and the cricoid split (Sections a and b). Laryngotracheoplasty Specific indications

Congenital stenosis in tracheostomised children. Particular points of operative technique Fig. 47.7 Notch for the cricoid.

Anaesthesia As these children have a tracheostomy, this is as in the

basic laryngofissure (Section a). Procedure

The approach and preparation are similar to those for an anterior cricoid split, but the incision is castellated from the thyroid, through half the cricoid and through Fig. 47.8 Bevelledgraft.

breast function couldbe impaired. Cartilage of sufficient size and shapeshould be harvested, takingcare to preserve perichondrium on one side. Test for a pneumothorax, using saline irrigation. A drain is not usually needed. Marcaineinfiltration or a lignocaine infusion will help control postoperative pain. 3 Graft sculpturing should result in a graft which provides significant expansion of the lumen, while being extremely stable. This is essential in a single-stage procedure,asthestenting benefit of thetube is lost at extubation. A relatively thick graft, grooved laterally for the thyroid, cricoid and first ring, should be sufficiently secure for it not to be displaced even prior to sutures (Figs 47.7-47.10). If the cartilage is very thin or soft, a T-shaped piece of cartilage is less likely to prolapse into the lumen (Fig. 47.1 1). 4 Graftsuturesshould be 510 or 6/0 absorbable synthetics, placed through each side of the cricoid andwith ‘U’ suturesthroughthethyroid and first tracheal ring. A minimum of foursuturesarethus required.Thesuturesshouldnotprotrude into the lumen. 5 A drain should be used unless the resulting graft fit is airtight, particularly if the child could need a period of ventilation.

Fig. 47.9 Grooved graft.

I

Fig. 47.10 Sutures.


3 39

(d) a4.aryngotracheal reconstruction with anterior It posterior graft in tracheostomised children

Specific indications

1 Subglottic stenosis which is unsuitable for a singlestage procedure, i.e. severe (Cotton grades 111-IV) stenosis. 2 Other medical problems. Fig. 47.11 Anterior graft: T-shaped cartilage.

Particular points of operative technique

Anaesthesia Anaesthesia and approach are laryngofissure (Section a).

for as a

basic

Procedure

I

Fig. 47.12 Laryngotracheoplasty: castellated incision.

Once the larynx has been opened, the need for a posterior graft can be assessed. A pair of callipers will help ensure that suitable-length grafts are obtained, as described above in single-stage procedures. Some surgeons prefer to groove the posterior graft (Fig. 47.13) to fit between the cricoid laminae, although a thick graft is needed. A square-edged graft is thinner andcan be equally secure (Fig. 47.14).Perichondriumshould be preserved internally. Placement of the four to six: 6/0 absorbable sutures is aided by preloading of all sutures through graft and cricoid prior to final ligation (Fig. 47.15). A stent is advisable if a posterior graft has been necessary. A Silastic-roll or an Aboulker stent can be used. The stent is secured with a 0-Prolene suture, which is taken out laterally through the strapmuscles and is tied once the anterior graft has been placed.

alternate tracheal.rings (Fig. 47.12). The fingers of the incision are ineffect multiple advancement flaps and, by separatingthe two sides of the incision, thetracheal diameter is increased without the need for a separate graft.The space between thecartilage fills in with fibrous tissue and native cartilage. Absorbable 5/0 sutures are required. A drainwill be required, as theresult is never airtight. Postoperative care and complications

These are the same as in the basic laryngofissure (Section a).

Fig. 47.13 Grooved posterior graft.

340

Chapter 47 Particular points of operative technique Anaesthesia

If the tracheostome is to be closed at the same time as the reconstruction, this tube must be accessible so that it can be removed when the patient is nasotracheally intubated. Procedure

Fig. 47.14 Square posterior graft with preserved internal perichondrium.

The stoma is excised by extending the anterior laryngofissure. Thepatient is thenreintubated and the stenotic segment and the stoma grafted (Fig. 47.16). Cotton uses a lower ‘T’ graft, which supportsthe stomal area, but a single long graft will often suffice. A drain should be used unless the resulting graft fit is airtight, particularly if the child could need a period of ventilation. Postoperative care and complications

These are thesame as in thebasic laryngofissure and the cricoid split (Sections a and b). (f) Surgical decannulation

Specific indication Fig. 47.15 Four to six preloaded sutures.

Patients whose stenosis has resolved or been treated but who have significant suprastomal collapse.

Complications

The stent is probably helpful only in the first 2 weeks and can act as a conduit for reflux on to the repaired larynx. Granulations occur at the top of the Silasticroll stent but settle once it is removed. To remove the stent, the sutureis cut in the neck and thestent removed endoscopically. Further examinations are required once thestenthas been removed to ensure that the airway is adequate and stable prior to decannulation. If suprastomal collapse is present, a surgical decannulation (see below) may be necessary. (e) Single-stage reconstruction and closure Specific indication

Tracheostomised patients with grade 11-111 stenosis and no medical or other contraindications.

~

Fig. 47.16 Anterior graft with tracheostome closure.

Surgery of Paediatric ~ ~ r y n g o t ~ ~Stenosis c b e a ~ 3 4I Particular points of operative technique Anaesthesia

The child is intubated nasotracheally.

sternomastoids,which help preventtracheal collapse. A drain prevents surgical emphysema. Occasionally a cartilage graft confined to the stomal area is used.

Procedure

Conclusion

The tracheostomy tract is excised, taking care not to tent the stoma and preserving tracheal cartilage. The stoma is closed in layers, minimising any air leak and on to the using a couple of stronglateralsutures

The successful paediatric laryngeal surgeon is one who is able to assess the patient pre-and postoperatively andthen flexibly apply surgical techniques to the individual.

Surgery of Hypopharyngeal Diverticula ALEXANDER C . VLANTIS

Surgery forsymptomatichypopharyngeal diverticula cures 80% of patients and improves symptoms in the remaining 20%. In skilful hands, the procedure results in no mortality and alowrate of complications (Barthlen et al., 1990).

Bndications Ahypopharyngeal(Zenker’s) diverticulum that becomes symptomatic. Symptoms include long-standing dysphagia, which may be progressive. The patient has a sensationof food sticking in the throat and requires several attempts to swallow it, lengthening the time taken to eat a meal. Foul-smelling undigested food may be regurgitated, and aspiration of contents leads to episodes of coughing, with orwithout aspirationpneumonia and lung abscesses. Hoarseness and weight loss may occur. There are usually no signs, but a gurgling sound on palpation of the neck is occasionally present. Indirect laryngoscopy may show pooling of secretions in the hypopharynx. Plain soft-tissue films of the neck may showa retropharyngeal fullness or an air-fluid level. Contrast swallow shows a smooth rounded sac or diverticulum arising posteriorly in the midline at the level of C6, which usually extends to the left posterolateral region of the neck.

Preoperative management Any consequences of the diverticulum, such as malnutrition, dehydration and lung infections, should be treated. Fine-bore enteral feeding tubes are particularlyuseful in the malnourished patient.

The size of the diverticulum should be assessed on the contrast swallow, gradedaccording to Brombart and appropriate treatment planned (Barthlen et al., 1990). Clear fluids are given for 24 h prior to surgery.

Relevant anatomy The inferior pharyngeal constrictor consists of two parts,thethyropharyngeus and thecricopharyngeus muscles (Fig. 48.1).Thethyropharyngeus arises from the oblique line on the thyroid cartilage and a fibrous arch between the thyroid and cricoid cartilage, and inserts into the pharyngeal raphein the posterior midline. Theupper fibres pass obliquely posterosuperior and overlap the middle constrictor. The lower fibres lie horizontally, parallel to the cricopharyngeus. Thecricopharyngeus muscle is thicker thanthe thyropharyngeus, passes uninterrupted from one side of the cricoid to the other around theback of the pharynx, and has no muscular raphe. The circular muscle fibres of the oesophagus lie below and parallel to the cricopharyngeus, and may blend with it. Below the level of the glottis, the thyropharyngeus is unsupported by the middle constrictor, resulting in a posteriorarea of weakness at thejunction of the thyropharyngeus and cricopharyngeus muscles, known as Killian’s dehiscence. Reduced cricopharyngeal compliance (Cook et al., 1992) leads to the posterior herniation of mucosa and submucosathrough Killian’s dehiscence to forma diverticulum-Zenker’s diverticulum-which lies posteriorly between the pharyngo-oesophagus and the prevertebral fascia. Therecurrent laryngeal nerve lies in thetracheooesophageal groove, and usually crosses behind the infe-

Surgery of ~ y ~ o ~ b a r y n gDiverticula eal Table 48.1 Stage and management.

343

to the sac and is at risk of damage during exposure of the diverticulum.

Anaesthesia

Before induction of general anaesthesia, voluntary selfinduced regurgitation of food by the patient should be encouraged, as it may empty the pouch (Thiagarajah et al., 1990). Thesmoothinduction of anaesthesia and a cuffed endotracheal tube (ET) prevent aspiration and tracheobronchial Contamination, permitting safe controlled ventilation and oxygenation. Local anaesthesia is an acceptable alternative in patients unfit for general anaesthesia (Schmit & Zuckerbraun, 1992). rior thyroid artery as it runs superiorly, accompanied by the laryngeal branch of the inferior thyroid artery. The nerve continues in the groove, passing medial to the inferior margin of the cricopharyngeus, behind the articulation of the inferior cornu of the thyroid cartilage withthe cricoid cartilage, and so entersthelarynx behind the cricothyroid joint. The nerve passes anterior

Fig. 48.1 Lateral view of the pharyngooesophagus.

Antibiotics

Broad-spectrum antibiotic cover is given at induction. Pharyngoscopy

The sac is identified posterior to theopening

of the

344

Chapter 48

oesophagus, washed, the contents aspirated to remove all food and barium, and inspected carefully to exclude malignancy. It is then packed withribbon gauze to allow easy identification, with one endremaining out of the mouth to allow the anaesthetist to remove it with ease when required. A fine-bore nasogastric tube is inserted under direct vision into the oesophagus.

the wound. The correct subplatysmal plane is reached when there is a sudden ‘give’ in the wound. The cut edges of platysma part with ease, causing a widening of the field. The great auricular nerve should be preserved. Procedure (Fig. 48.2)

Position of the patient

Skin flaps

The patient is placed supine, with the occiput resting on a head ring and pack a under the shoulders to hyperextend the neck. The chin is turned away from the side of the incision.

Superior and inferior myocutaneous skin flaps are elevated in the subplatysmal plane above the superficial veins of the neck, to widely expose the anterior border of the sternocleidomastoid muscle. Large self-retaining retractors or sutures are used to keep the operating field exposed.

cisio

The preferred technique isvia alongitudinal cervical incision positioned along the anterior border of the left sternocleidomastoid muscle, from the level of the hyoid bone to just above the clavicle. Do not use the left side if the patient has a right-cord palsy. Alternatively a left transverse cervical incision in a skin crease may be used, placed at the level of the cricoid cartilage. The neck incison is carriedthroughthe platysma muscle while applying countertraction on each side of

Division of omohyoid muscle

The superficial layer of the deep cervical fascia is incised alongtheanteriorborder of thesternocleidomastoid muscle, and the plane between the muscle laterally and the larynx and strapmuscles medially is opened. Dissection is carried from the level of the thyroid notch to the clavicle. The sternocleidomastoidmuscle isretracted laterally to expose the carotid sheath and anterior belly of the omohyoid muscle, which passes in an oblique direc-

Fig. 48.2 Cross-section through lower neck before and after dissection.

Surgery of ~ y p o p b a r y n g e a lDiverticula tion across theoperative field fromsuperomedial to inferolateral. A combination of sharp and blunt dissection is used to expose the omohyoid and strap muscles. The omohyoid muscle is divided, taking care to observe the internal jugular vein (IJV), which lies deep to it. Exposure of the infrahyoid muscles

The field of exposure is deepened by keeping the larynx and strap muscles as the medial border of the dissection and thecarotidsheathasthelateralboundary.The sheath is gently retracted laterally to avoid undue pressure on thecarotid.Theposteriorborder of the sternohyoid and sternothyroid muscles are dissected to reveal the thyroid lobe, and are retracted anteriorly, but they may be divided if necessary. The middle thyroid vein, which empties into the IJV, straddles the field and is divided. The recurrent nerve is hidden by the lobe of the thyroid gland, and lies anterior to the oesophagus in the tracheo-oesophageal groove. It runs to the lateral junction of the trachea, oesophagus and cricoid cartilage. Care is taken to identify and preserve therecurrent laryngeal nerve, which often appears as a flat, white, tortuousstructure, so thatitcan be avoided in the dissection of the sac. However, the technique described shouldallowtheprocedure to be carried out safely

Fig. 48.3 Cricopharyngeal myotomy. Note incision o f thyropharyngeus, cricopharyngeus and circular muscle fibres of the oesophagus.

345

when the recurrentlaryngeal nerve is not identified. The ipsilateral lobe of the thyroid glandis turned forward to expose the posterolateralsurface of the pharynx and the oesophagus within the operative field. Entry into the retropharyngeal space

When the anterolateral border of the vertebral bodies has been reached, finger dissection opens a plane between the pharyngo-oesophagus and the pre-vertebral fascia, so that theretropharyngeal space is entered anterior to the vertebral bodies at a level superior to the inferior cornu of the thyroid cartilage. This avoids injury to the recurrent laryngeal nerve, since the lateral dissection is all above the inferior cornu of the thyroid cartilage, thepointat which therecurrent laryngeal nerve enters the larynx. Once the retropharyngeal space is entered, dissection is carried from above downwards towards the posterior aspect of the cricoid cartilage (Levine et d., 1979). The pharynx is freed from the pre-vertebral fascia so that the larynx can be rotated away from the field to reveal the posterior aspect of the pharynx. In this way it becomes possible to rotate the larynx away from the surgeon and to identify the sac without injury to the recurrent laryngeal nerve. If rotation of the larynx is achieved using a hook, it should not be applied below

346

Chapter 48

the midpoint of the thyroid cartilage since the recurrent laryngeal nerve passes behind the inferior cornu of the thyroid cartilage and may be damaged(McKenna &: Dedo, 1992). The sac is therefore approached from the posterior midline and notlaterally. If the inferior extent of dissection requires extension, it may be necessary to ligate the inferior thyroid vessels, which approachthethyroid gland from the thyrocervical trunk behind the carotid sheath. The inferior thyroid artery is divided well away from the thyroid gland and clear of the recurrent laryngeal nerve, which should be identified. Location and dissection of the sac

The sac is usually palpated and identified without difficulty. It is dissected from the surrounding structures by sweeping tissue away from the fundus, which may be gently grasped with a Babcock forceps and pulled out of the wound. Continuesweeping tissue towards the pharynx until the neck of the sac is exposed. When only mucosa remains, the diverticulum is completely mobilised. The neck is dissected to thepoint where the mucosal sac protrudes through the muscular defect of the pharynx. Directly inferior to the neck of the sac lies the cricopharyngeus muscle. Care must be taken not to pull normal mucosa outthrough the deficiency and make it part of the sac. Cricopharyngeal myotomy (Fig, 48.3)

Thecricopharyngeal myotomy is performedprior to excision of the sac and is mandatory in all patients with Zenker’s diverticulum. Once the pharyngeal pack has been withdrawn and the pouch collapsed, a 32-French-gauge Maloney bougie or cuffed ET is passed and guided by the surgeon into the proximal oesophagus. An extramucosalplane is developed just inferior to the neck of the sac, using a fine-pointed curved forceps. The bougie or inflated endotracheal cuff causes the cricopharyngeal muscle to be stretched in order to accurately divide fibres without damage to the underlying mucosa. The transverse fibres of the cricopharyngeus are divided foradistance of Scm, and thecut edge of the muscle is dissected away from the mucosa for 1-2 cm. The myotomy should be extended up to the thyropharyngeus to ensure that all fibres of the cricopharyngeusare divided, and distally for 4cm into the circular musculature of the oesophagus (Fig,

48.3). If the plane is difficult to establish, the muscle fibres must be sectioned carefully witha blade. The mucosa of the pharynx and oesophagus should protrude freely when the myotomy is adequate. Resection of the sac

The operative field isnow loosely packed with dissecting swabs to prevent contamination. Insert a sutureat either side of the neck of the pouch, but keep the suture long and clamp the end of it with a forceps (Fig. 48.4). This allows better control of the mucosa during resection and closure. Use a sharp blade to divide the neck, leaving a stump of mucosa for closure. The bougie prevents the removal of too much oesophageal mucosa and so avoids cicatrisation of the oesophagus. The oesophageal lumen can be inspected to exclude intra-oesophageal pathology such as webs. A cut-and-sew technique may be employed. Repair of the pharyngeal wall

The pharynx is closed with absorbable suture material, using a continuous Connell suture placed in the horizontal plane from each corner,ina similar way to the pharyngeal closure following a laryngectomy. The mucosal suture line is reinforced with a second layer of interrupted sutures. Alternatively, a linear stapler may be used. The anaesthetist fills the oesophagus and pharynx with air while the wound is immersed in saline to ensure there is no leak.

Fig. 48.4 Resection and closure.

Surgery of ~ y p o p b a r y n ~ eDiverticula al Closure

Once complete haemostasis is obtained, the wound is washed with warm saline. A suction drain is placed into the retropharyngeal space and brought out through a separate stab incision or the lower border of the wound. The platysma and subcutaneous tissue are closed with interrupted sutures, and the skin is closed with sutures or clips.

IV fluids are given for 24 h until tube feeding is established. A water-soluble contrast swallow is performed on the fifth postoperative day to exclude a leak. If a leak is present, thepatient is kept off oral feeding fora refurtherperiod, usually 7 days, andtheswallow peated. If no leak is present and drainage is minimal, the drain is removed and a soft diet commenced.

1 Mediastinitis may be alethalcomplication, and is usually secondary to a leak, which may be excluded ith the aid of a contrast swallow. A pharyngocutaneous fistula should, after aperiod of feeding through a nasogastric tube,close spontaneously. 3 Unilateral vocal-cord paresis is due to injury to the recurrent laryngeal nerve. This can be avoided by approaching the sac from the posterior midline rather than the lateral approach. Recurrence of dysphagia will occur if the cricopharyngeal myotomy is inadequate or incomplete. 5 Pharyngeal stenosis may result from excessive mucosal resection.

1 Dilatation of the cricopharyngeal sphincter consistently fails and recurrence rate is 100%. 2 Dohlman’s operation or endoscopic diathermic treatment of apharyngealpouch involves division of the upper part of thecommon wall of mucosa and cricopharyngeus muscle that separates the diverticulum from the oesophagus,and which acts as the sphincterto the pouch. The divided tissue includes mucosa and circular fibres of the cricopharyngeus. Thisis thus nomore thanan endoscopic division of thecricopharyngeus muscle. Instruments devised by Dohlman are essential. The special endoscope is passed so that its anterior lip

347

enters the oesophagus and the posterior lip enters the pouch, Thetransverse ridge so formed is then divided by diathermy or staple gun (Wouters & van Overbeek, 1990). The carbon dioxide or alternativelaser and the operating microscope may also be used. However,most patients require two or more operations, while the risk of mediastinitis and of missing a carcinoma are some of the disadvantages.

1 Cricopharyngeal myotomy alone can be used (Schmit & Zuckerbraun, 1992). 2 Diverticulopexy (Duranceau et al., 1983; Konowitz & Biller, 1989) ordiverticulum suspension avoids opening into the pharynx and its associated complications. After the diverticulum is completely free, the apex is sutured superiorly, without tension, to the pre-vertebral fascia. This allows the sac to drain continually, shrink and become asymptomatic. It is an alternative technique for the high-risk elderly patient. 3 Inversion (Bowdler & Stell, 1987; Morton & Bartley, 1993) or invagination of a small diverticulum into the oesophageal lumen avoids opening the pharynx and its associated complications.Resumption of oralintake, operation time and hospital stay arereported to be shorter.

Barthlen W, Feussner H, Hannig C, Holscher AH & Siewert JR (1990) Surgical therapy of Zenker’s diverticulum: low risk and high efficiency. Dysphagia 5 , 13-19. Bowdler DA & Stell PM (1987) Surgical management of posterior pharyngeal pulsion diverticula: inversion versus one-stage excision. BY. J . Surg. 74, 988-90. Cook IJ, Blumbergs P, Cash K,Jamieson GG & Shearman DJ (1992) Structural abnormalities of the cricopharyngeus muscle in patients with pharyngeal (Zenker’s)diverticulum. J . Gastroenterol. Hepatol. (Aust.) 7, 556-62. Duranceau A, RheaultMJ & Jamieson GG (1983) Physiologic response to cricopharyngeal myotomy and diverticulum suspension. Surgery 94, 655-62. Gregoire J & Duranceau A (1991) Surgical management of Zenker’s diverticulum. Hepato-Gastroenterology 39, 132-8. (1989) Diverticulopexy and Konowitz PM & Biller HF cricopharyngeal myotomy: treatment for the high-risk patient with a pharyngoesophageal (Zenker’s) diverticulum. Otolaryngol. Head Neck Surg. 100, 146-53. Levine H, Wood B & Tucker H (1979) Hypopharyngeal diverticulum and thecricopharyngeus muscle: aposterior surgical approach. Laryngoscope 89, 1600-7. McKenna JA & Dedo HH (1992) Cricopharyngeal myotomy: indications and technique. Ann. Otol. Rhinol. Laryngol. 101, 216-21. Morton RP & Bartley JR (1993) Inversion of Zenker’s diverticulum:

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’

the preferred option. HeadNeck 15, 253-6. Schnlit PJ & Zuckerbraun L (1992) Treatment of Zenker’s diverticula by cricopharyngeus myotomy under local anesthesia. Am. Surg. 5 8 , 710-16. Belg. Thiagarajah S, Lear E & Keh M (1990) Anesthetic implications of

Zenker’s diverticulum. Anesth. Analg. 70, 109-1 1. Wouters B & van Overbeek JJ (1990) Pathogenesis and endoscopic treatment of thehypopharyngeal(Zenker’s) diverticulum. Acta Gastroenterol. 53, 323-9.

r

r

r Maligna ongue, F and Alve NICHOLASD.STAFFORD

indications Unless the tumour is so advanced as to beobviously incurable, a tumour of any T stage can be treated surgically. For small (T1 and T2) primaries, the S-year survival rate is similar for radiotherapy andsurgery; a cure rate in the region of 70--7’S% should be expected. Primary surgery is preferableforlarger lesions (T3 and T4), particularly when there is involvement of the mandible, although planned postoperative radiotherapy will often provide the patient with the best chance of cure (Vikram et al., 1980). Such radiotherapy should commence approximately 6 weeks after surgery. Surgery is contraindicated where: 1 there is no realistic chance of long-term survival; 2 the disabilities produced by surgery (e.g. poor speech, impaired swallowingand facial disfigurement) are unacceptable to the patient. Many surgeons view total glossectomy as unacceptable; theauthor does not. If the patient has received radiotherapy and the tumour remains within the confines of the tongue musculature, then glossectomy is the only therapy left. Ultimately, the decision rests on what offers the best quality oflife for the individual patient.

orthopantomogram (OPG) remains very helpful in assessing mandibular invasion. Full upper aerodigestive tract endoscopy is mandatory in every case. Pain or trismus often prevents adequate assessment and biopsy of the tumourin the clinic situation. Endoscopy will also allow a second, synchronous primary to be excluded. Any suspect cervical nodesshouldundergo fineneedle aspiration for cytological assessment. Many of these patients havebeenheavy smokers and drinkers. Their generalmedical status is often poor. It is essential to assess theirnutritionalstatuspreoperatively and,if indicated, obtain respiratory function tests and an anaesthetic opinion before proceeding with surgery. A feeding gastrostomy should be considered at this stage for patients who have large primaries and who are going to require prolonged rehabilitation of their swallowing.

Preoperative management The presence of trismus should alert the surgeon to the possibility of tumour invasion of the pterygoid muscles. All patientsshould have a chest X-ray to excludea pulmonary primary or pulmonary metastasis. Imaging of T3 and T4 tumours should include CT and/or MRI scanning,fromtheskull base to thethoracic inlet, and preferablyperformed in thecoronal plane. An 349

Anatomy The boundaries of the floor of the mouth comprise the medial aspects of the horizontal rami and anterior arch of themandible. Its mobility is provided by the mylohyoid muscle, which takes origin from the mylohyoid line on thelingual surfaceof each horizontal ramus. The muscle inserts into a midline raphe and the centralportion of the hyoid bone. Along withthe digastric and stylohyoid muscles, mylohyoid maintains the hyoid bone in its suspended position. The digastric muscle subdivides the upper neck into the submental and submandibulartriangles. The former contains a few lymph nodes, which should always be dissected out when undertaking a neck dissection for a tumour of the anterior floor of the mouth or tongue.

3 50

Chapter 49

The submandibular triangle contains the submandibular salivary gland, whose deep portion wraps around the posterior free edge of mylohyoid, to lie between this muscle and hyoglossus. The submandibular (Wharton’s) ductrunsforward to its ostium in the anterior floor of the mouth. Thehypoglossal nerve runs in the floor of the triangle, passing between the mylohyoid and genioglossus muscles as it runs forward to supply the intrinsic and extrinsic muscles of the tongue (Fig. 49.1).

Fig. 49.1 Diagram of a coronal section through the mandible and floor of the mouth to show the relationships o f the Submandibular gland.

The lingual nerve provides the afferent supply to the mucosa of theanterior floor of themouthand tongue. It leaves the infratemporal fossa, crossing the stylopharyngeus to lie in the same plane as the hypoglossal nerve. The nerve is tethered to the superior part of the submandibular gland by the submandibular ganglion. Figure 49.2 illustrates the lymphatic drainage of the tongue and floor of the mouth. There is evidence that marginal vessels drain unilaterally while central vessels drain bilaterally. Contralateralnodal involvement is unusual unless the tumour is midline or large (T3 or T4), orthere has been a previous ipsilateral neck dissection. Figure 49.2 demonstrates that a supraomohyoid neck dissection (SOHND) will remove all of the ‘primary’ nodes draining the area. The procedure therefore allows the opportunity to sample and perform frozensection analysis on these nodes. However, a SOHND should not be undertaken if there is known neck disease; in such a situation a functional or radical neck dissection should be performed, as appropriate. From a surgical point of view, there are three other structures which merit special consideration when undertaking surgery in this region. The inferior alveolar nerve, a branch of the third division of the trigeminal nerve, runs into the mandibular foramen with the inferior alveolar artery (a branch of the maxillary artery) after the latter has given off its mylohyoid branch. It provides the nerve supply to the teeth of the lower jaw

Fig. 49.2 (a) Lymphatic drainage o f the tongue. (b) Lymphatic drainage o f the tongue, showing bilateral dis~ri~ution of the central vessels.

Surgery for ~ a ~ i g n Lesions an~ and theadjacent gingiva andthen emerges fromthe mentalforamenasthemental nerve. When raising a visor type of neck flap or approaching the oralcavity via an anterior mandibulotomy approach, care should be taken to preserve the nerves whenever possible; since anaesthesia of the lower lip is associated with a significant morbidity, especially in a patient whose oral function is already compromised. The lingual artery is the third branch of the external carotid artery (ECA) andbegins its course at the level of the greater horn of the hyoid bone. Characteristically, it loops over the tip of the greater horn before running anteriorly into themuscle bulk of the tongue. The vessel is prone to trauma at this site; while this is rarely of consequence if the tumour is ipsilateral, damage to the contralateral artery occasionally results in infarction of the hemitongue. Justasdamagetothe lingual arterycan render a normal ‘hemitongue’ functionally useless, trauma to the hypoglossal nerve after a contralateralhemiglossectomy or floor-of-mouth resection can result, from a functional point of view, in atotal glossectomy. The nerve is in danger while dissecting the submandibular triangle duringa neck dissection and also duringapartial glossectomy where the tumour has crossed the midline. Traction on tongue tissues can cause sufficient distortion to draw the contralateral nerve into the surgical field. If such a situation is anticipated, the safest manoeuvre is to demonstrate the path of the contralateral nerve by dissecting it out in the triangle.

A general anaesthetic (GA) is almost mandatory; it allows control of theairway and facilitates adequate haemostasis. Local anaesthesia, using infiltration of the soft tissues with l-2% lignocaine with 1 in 200000 adrenaline,shouldonly be used forthe smallest of anterior tumours in patients deemed unfit for general anaesthesia. Prophylactic antibiotic cover is advisable in any case where the intraoral resection is continuous with dissection in the neck. In such a situation, antibiotics reduce the risk of fistula formation. A 5-day regimen of cefuroxime (500mg q.d.s.) and metronidazole (400mg t.d.s.) or Augmentin (500mg t.d.s.) is very effective. Steroids are inappropriate unless the patient has a medical problem indicating their use. Patients on warfarin should be anticoagulated perioperatively using heparin,theINR being keptwithinthetherapeutic range. The patient is positioned supine with the head sup-

3 5I

ported on a ring. A sandbag under the shouldersis only necessary if a neck dissection is also being undertaken. Overhead lighting can be supplemented by the use of a good headlight. It is the author’s practice to perform tracheostomy a for all cases except a simple hemiglossectomy without neck dissection. Particularly in situations where the excision site is closed primarily or reconstructed using a local or regional flap, the risk of haematoma formation and airway obstructionis considerable. If a tracheostomyis not performed, the intra-oral work is more easily undertaken if the patient has been intubated nasally. It is theauthor’s policy to undertake anSOHND when surgically treating a T2, NO tumour. Any suspicious nodes are sent for frozen-section analysis and the dissection is converted to a full functional or radical neck dissection as appropriate. Node-negative T3 and T4 tumours should undergo an ipsilateral full functional neck dissection. If theprimarytumour crosses the midline, the clinically negative contralateral neck should ND. Whentheprimarytumour is anteriorly sited, particular care should be taken to dissect the nodes fromthesubmental triangle. Both submental triangles should be cleared if the primary is in the anterior midline. Cutting diathermy shouldbe available in all cases. For resecting tumours of thetongue,a CO, laser iseven better. Before proceeding with surgery, the tumour shouldbe reassessed with regard to its site and size. If not previously undertaken, the patient should undergo a thorough upper aerodigestive tract endoscopy to exclude a second primary tumour.

Unless a mandibulectorny is required,the excision of a small intraoraltumourcan usually be undertaken via aperoralapproach. Sixty-five per cent of small tongue lesions occur on thelateralborder and for these a hemi- orpartial glossectorny is necessary (a partial glossectomy being anything less than a formal hemiglossectomy).

Insulated cheek retractors are used to provide goodexposure of theoperative field. Stay sutures should be placed on either side of thetonguetip to provide stability. Theproposed lines of excision are marked out with methylene blue dye, cutting diathermy or the CO, laser. A margin of at least 1cm, and prefer-

3 52

Chapter 49 videaccess to them, care being taken not to disrupt either hypoglossal nerve or lingual artery unless this is necessary in order to clear the tumour. The tongue can then be repaired using Vicryl. It is fortunate thattongue tiplesions are unusual (5%) in that they require a wedge excision of the tip, which will be considerably shortened when thedefect is closed (Fig. 49.4). Small floor of mouth tumours, not invading the mandible, can be dealtwith similarly. A suture is placed through the tongue tip to provide traction over to the uninvolved side. A 1-2 cm margin is marked out andthe excision accomplished perorally, the dissection being taken downto the planes of the genioglossus and mylohyoid muscles. .More deeply infiltrating tumours will requirea‘through-and-through’ resection. If the tumour abuts on but is not fixed to the mandible, then the adjacentperiosteum of the mandible should be taken with the specimen.

Fig. 49.3 Lines of resection for a standard hemiglossectomy.

ably 2cm, should be allowed around the tumour, using frozen-section analysis of the excision margins. 1 Lines of resection for a standardhemiglossectomy are as shown in Fig. 49.3. 2 Using the stay suturesforretraction,thetongue is divided in the midline from the tip back to the midline circumvallate papilla. 3 The tongue tip is elevated to allow simultaneous dissection along the floor of the mouth, just medial to the course of the submandibular duct. 4 The excision line is then taken posterolaterally to the root of the tongue, just anterior to the anterior faucial pillar. It is at this stage that the lingual artery will be located. Carefuldissection will allow sutureligation and division of the artery withminimal blood loss. Virtually all other bleeding can be dealt with using coagulation diathermy or defocused laser beam. 5 Elaborate reconstruction is rarely required. Two or three Vicryl sutures can be placed anteriorly to provide a tongue tip but the entire raw surface of the tongue should not be closed; not only is the risk of a haematoma and airways obstruction considerable but tethering the tonguein this way will also producesignificantlong-term problems witharticulation. Split-skin grafting the defect looks very effective in the short term, but in reality most of the graft sloughs off, providing nothing more than a temporary dressing. Thirty per cent of small tongue tumours occur on the dorsum. It may be necessary to split the tongue to pro-

Marginal mandibulectomy

If atumour isfixed to themandiblebutthere is no clinical or radiological evidence of cortical invasion, then marginal a rather than a segmental mandibulectomy can be performed. The cross-sectional area of the mandible can be reduced by 50-75% before any structural weakness results. There three are basic types of marginal mandibulectomy (Fig. 49.5). While the inferior dental artery may be sacrificed safely during the procedure, itis

Fig. 49.4 Carcinoma of the tongue tip. Adequate resection margins are important.

Surgery f o r Malignant Lesions

important to preserve intact the periosteum over the remaining bone; it is through the periosteal vessels that the mandible will receive its blood supply. The mental nerves should be preserved whenever possible. While an upper alveolectomy can be undertaken by a peroralapproach, an inner-tablemandibulectomy is best carried out through a combined intra-oral/external dissection. l The planned lines of excision are marked out. 2 A stay suture through the tongue tip will allow retraction of this structure. 3 Any teeth at the sites of theplannedosteotomies should be removed. 4 The mucosal and mucoperiosteal incisions are made using cutting diathermy, a scalpel or the CO, laser. 5 The mucoperiosteum is raised for a distance of 3 mm on each side of the incision. With the bone exposed, the osteotomies are then fashioned with a fissure burr. It is important to protect adjacent soft tissues from trauma due to contact with the burr. Malleable copper retractorsare useful forthispurpose. Do notattempt to complete the osteotomy from just one approach; create bony cuts on both sides of the mandible and connect these using the burr. Subsequent covering of the mandible with a flap will be much easier to achieve if the bony edges are ‘cut back’, providing a free edge of intact mucoperiosteum to which a skin or mucosal flap can be sewn. It is not advisable to use an osteotome to make the osteotomies as this technique can result in uncontrolled fracturing of the bone. 6 The soft-tissue part of the dissection is then undertaken perorally. The soft-tissue and bony portions of the specimen should be kept in continuity to allow its correct orientation after excision. 7 After the resection margins have been sent for frozensection analysis, the defect is closed. It is rarely possible to close the defect primarily without significantly compromising tongue mobility. Small defects are best reconstructed using anasolabial, local tongue or radial

3 53

forearm free flap. The nasolabial flap is simple to raise and does not require a functioning facial artery; it is viable even after dividing the artery during a neck dissection. The maindisadvantage of the flap is that it introduces hair-bearing skin into the oralcavity in men.

Large tumours of the tongue will commonly involve the floor of the mouth, and vice versa. Adequate exposure of such tumours can rarely be provided by a peroral approach. Anterior rnandibulotorny

The best approach forlarge lesions which do notrequire a segmental or marginal mandibulectomy is an anterior mandibulotomy. The soft-tissue incision can be incorporated into that used for the neck dissection (Fig. 49.6). The lower lip is pinched firmly on each side of the incision until bleeding from the inferior labial arteries is controlled by diathermy. The mentumof the jaw is then exposed for 1.S cm on each side and astepped mandibular osteotomy is marked out. Two holes are drilled on each side of the osteotomy for the appropriate plates, and the osteotomy is then undertaken using an oscillating saw. It is far more difficult to position the plates correctly if the holes are not drilled until the osteotomy has been completed. Having split the lower jaw, the two halves can then be retracted laterally, using Langenbeck retractors, allowing excellent exposure of the floor of the mouth and the anterior tongue (Fig. 49.7). An appropriate excision is thenundertaken, based on the principles outlined above. Large tumours will often necessitate resection of the adjacent mylohyoid, creating a defect extending through to the neck. Preservation of the contralateral hypoglossal nerve and lingual artery is essential if a functioning tongue remnant is to be preserved. During the excision, keep palpating the tumour to assess the clearance margins. In any event, the deep

margins (tongue musculature) must be sent for frozensection analysis. Segmental or marginal mandibulectomy

Fig. 49.6 Skin incision for an anterior-mandibulotomy approach to the oral cavity.

Fig. 49.7 Resection of an extensive tumour of the mobile tongue via an anterior-mandibulotomy approach.

If a segmental or marginal mandibulectomyis necessary, then such a midline approach is inappropriate unless the tumour involves the anterior floor of the mouth. In such a situation, a visor-flap approach will provide excellent access to the anterior mandibular arch (Fig. 49.8), but should only be performed if the mental nerves are going to be sacrificed as part of the resection. Otherwise the mandible is best approached laterally, after adequate elevation of the superior cervical flap and clearance of the submandibular triangle. Any teeth adjacent to the planned osteotomy sites are removed. The mucosal incisions are then made, but no more soft-tissue work is undertaken intra-orally until the osteotomies have been performed. The lateral aspect of the mandible is exposed down to periosteum, along the length of the planned resection; the lingual surface is only exposed at the sites of the osteotomies. The periosteum is incised and elevated to allow these to be performed using an oscillating drill. The soft tissues of the floor of the mouth and tongue are protectedby passing malleable retractors up through the tunnels created on the lingual face of themandible. As much of the buccoalveolar mucosa is preserved as is possible. Bleeding from the inferior dental artery is stopped using diathermy or bone wax. Theintra-oralpart of the dissection canthen be completed. Large intra-oral defects can only be reconstructed withthe aid of a pedicled myocutaneous(pectoralis major) flap or a free (radialforearm orgroin) flap. While the former has the advantage of speed and simplicity, it is very bulky and will not allowoptimum mobility of the remaining tongue and floor of the mouth. The problem of bulk can be reduced by raising the muscle without a skin paddle; however, the problem of poor tongue mobility remains. The radial forearm flap overcomes this problem and has the added advantage that it can be raised with a segment of vascularised radius for reconstruction of a segmental defect in the mandible. Sensate radial free flaps appear to offer even better intra-oral rehabilitation (Urken et al., 1991). Total glossectomy

A total glossectomy is occasionally the only option for curing a large tongue carcinoma. It should only be considered under the following conditions. 1 The tumour is confined to the tonguemusculature and the operation is oncologically appropriate.

Surgery for ~ a ~ i g n a Lesions nt

3 55

Fig. 49.8 Skin incision for the ‘visor flap’ approach to the anterior and cavity.

2 The patient has alreadybeen treated by external beam or implant radiotherapy. 3 The patient appreciates the inevitable problems with speech and swallowing that will follow surgery. 4 Thepatientappreciates that asubsequentlaryngectomy may well be necessary for intractable aspiration. In any event, it is sensible to carry out a gastrostomy at the time of the glossectomy. Theoperation is best accomplished via ananteriormandibulotomy approach. Mucosal incisions are then made around the perimeter of the floor of the mouth, leaving a good rim of mucosa attached to the lingual plate of the mandible, if tumour clearance allows. This will facilitate easier insetting of the flap. The excison is commenced anteriorly; if the valleculae and tongue base can be preserved then the patientis less likelyto develop aspiration and requireasubsequent laryngectomy. A pedicled or free latissimus dorsi myocutaneous flap provides good bulk and reliability for the reconstruction (Keyserlingk et al., 1989). Suction drainage should be employed whenever the resection extends into the neck. Care must be taken that the suction tubewill not traumatise the vascular pedicle of a reconstructive flap. The wound should be closed with Vicryl and interrupted nylon sutures, or clips. A nasogastric tube should be passed in all patients who have not already had a preoperative gastrostomy.

Postoperative care Drains should remain in situ for at least 48 h-longer if there is significant continueddrainage or a high

risk of fistula formation.Thetracheostomycan be ‘corked’ at 48-72hbut is best left insitu untiloral feeding has commenced and there is no problem of aspiration. Oral feeding should start at 7 days, or 10 days if the patient has previously received radiotherapy. Obviously, it should be delayed if there is evidence of woundbreakdown, soft-tissue infection or flap necrosis.

The most common specific complication is the formation of an orocutaneous salivary fistula. The most common predisposing factors are as follows: 1 previous radiotherapy; 2 poor .preoperative nutritional status; 3 wound dehiscence; 4 reconstructive flap necrosis. Small fistulae in the absence of significant soft-tissue necrosis can be managed conservatively; most will close with time. Appropriate antibiotics should be given and nasogastric feeding continued. If there is significant soft-tissue loss, usually caused by necrosis of the skin flap, or exposure of the great vessels in the neck, then a conservative approach is dangerous. The neck should be re-explored and anydead tissue excised. The defect should be repaired and a pectoralis or latissimus dorsi myocutaneous flap should be inset, with or without a skin paddle. The muscle pedicle provides excellent cover for the vascular tree in the neck, and its ‘external’ surface can be split-skin-grafted if necessary.

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erences and further reading Keyserlingk J, de Francisco J, Stafford N, Rhys-Evans P, Breach N & Mott A (1989) Recent experience with reconstructive surgery following major glossectomy. Arch.Otolaryngol. Head Neck Surg. 115, 331-8. Langdon JD tk Henk JM (eds) (1995) MalignantTumours of the Mouth, Jaws and Salivary Glands. London, Edward Arnold, Chapter 7. Stafford N & Waldron J (eds) (1989) Management of Oral Cancer. Oxford, Oxford University Press, Chapters 9 and 10.

Thawley SE & Panje WR (eds) (1987) Comprehensive Managementof Head and Neck Tumors, Vol. 1. Philadelphia, W.B. Saunders, Chapters 22, 25 and 27. Urken ML, Buchbinder D,Weinberg H et al. (1991) Functional evaluation following microvascular oromandibular reconstruction of the of reconstructed and oral cancer patient: acomparativestudy nonreconstructed patients. Laryngoscope 101, 935-50. Vikram B, Strong EW, Shah J & Spiro RH (1980) Elective postoperative radiation therapy in stages I11 and IV epidermoid carcinoma of the head and neck. Am. J.Surg. 140, 5 8 0 4 .

Surgery for Malignant Lesi of the Oropharynx JOHN WALDRON

indications When considering malignant tumours, the oropharynx is subdivided into four subsites-the tonsil, tongue base, soft palate and posterior pharyngeal wall. The tonsil is the most common site for malignant tumours arising in the oropharynx, followed by the tongue base, and the great majority of these are squamous-cell carcinomas. However, at the time of presentation tumours of the oropharynxoften involve more thanone of these subsites, and it may be difficult to establish the original area from which the tumour has arisen. When planning the treatment, the size of the primary tumourand theextent of nodal involvement are moreimportantthanthearea of theoropharynx from which the primary originated. As a general rule, smaller tumours (T1 and T2)with limited nodal disease (NO or N1) may be treated as effectively with radiotherapy as with surgery. When the primary tumour is larger (T3 and T4) or there are lymph nodes present which are greater than 2-3cm in diameter, then radiotherapy on its own has a much reduced success rate. In these more advanced tumours, surgery, in many cases withplannedpostoperativeradiotherapy, is the preferred treatment option (Stell & Nash, 1987; Stafford et aE., 1989). Surgery is also the only viable option for treatment of a tumour which recurs after primary radiotherapy. The tendency forprimarytumours to have spread across two or more subsites (such as from the tonsil to the tongue base or soft palate) by the time of surgery means that the actual resection performed for the primary tumour will vary from case to case, depending on the extentof the tumour. However, the majority of cases involve the tonsil, and many of the resections can be

considered to be essentially resections of the tonsil with extensions to the tongue base, soft palate or posterior pharyngeal wall. In this chapter the operation forresection of a tonsillar carcinoma, including removal of the ascending ramus of the mandible, will be described in detail, and variations of this technique, together with alternative approaches to deal with tumours arising at other specific sites in the oropharynx, will be considered later.

Preoperative management The most common presenting symptoms of these tumours are: (i) pain, which may be localised to the pharynx or referred to the ear; (ii) alteration of swallowing and speech caused by the primary; and (iii) neck swelling resulting from associated lymphadenopathy, There is often a history of heavy smoking and high alcohol consumption, and this may have led to chronic chest and metabolic problems. A preoperativebiopsy to obtaina histological diagnosis is mandatory prior to treatment planning. If there is doubt about nodalinvolvement, then fine-needle aspiration biopsy may be useful. An examination under anaesthetic (EUA) to accurately assess theextent of the primary disease, and also to look for a synchronoussecondprimary in theupper aerodigestive tract, is also essential. CT and MRI scanning give useful information on the extent both of the primary and of nodal disease, and may show the soft-tissue spread to be more extensive than is obvious on clinical examination. Although CT shows bone involvement more clearly, MRI appears to be better at assessing tumour extent in the soft tissues. Tumours extending to the skull base or extensively in-

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volving theparapharyngeal space are unlikely to be cured by surgery. A plain chest X-ray is necessary to look for pulmonary metastases, or a synchronous bronchial primary, arising as a result of heavy smoking. A full blood count, urea and electrolytes, and liverfunction tests should be performed to ensure that the patient does not have problems resulting from a high alcohol intake or other medical conditions prior to undertaking surgery. Liver ultrasound andlor bone scans may be required to exclude distant metastases.

The oropharynx is that part of the pharynx between a plane at the level of the hard palate above and a plane at the level of the hyoid bone below. It is continuous with the oral cavity anteriorly and includes the soft palate, base of the tongue and both faucial pillars. When considering malignant tumours of this region the most relevantpart of the anatomyis the relationship of the oropharynx to surroundingstructures. An understanding of these relationships allows an appreciation of the possible routes of tumour spreadand helps avoid potential operative complications(Fig. 50.1). The close proximity of the great vessels and in particular theinternalcarotidartery(ICA)must be considered during surgery.These vessels ascend alongside thefascia covering the constrictormuscles which form the wall of

the oropharynx and, if they are not identified and retracted, they may be damaged, particularly when performing the posterior part of the resection. The position of the hypoglossal nerves and lingual arteriesis of paramount importance whenresecting tongue-base tumours, as inadvertent damage to these bilaterally may result in an immobile or non-viable tongue.

Operatiue tee Preparation 1 These procedures should be performed under general should be performed anaesthesia. A tracheostomy to protect the airway during the operation and postoperatively until the swelling has settled. Itis better to performthis at the start of theoperation,asthe endotracheal tube (ET) can then be removed from the surgical field. 2 Broad-spectrumantibiotics, covering bothaerobic and anaerobic bacteria, are given intravenously at the induction of anaesthesia. CO-amoxyclav or a combination of abroad-spectrumcephalosporinwithmetronidazole is suitable. The antibioticsarecontinued intravenouslyuntilnasogastric feeding is established, usually on the second postoperative day. They can then be administered via the nasogastric tube until the fifth postoperative day, when they are stopped unless there is a clinically obvious infection present. 3 Thepatient is positionedsupine ontheoperating

Fig. 50.1 Relationship of oropharynx to surrounding structures: cross-sectional anatomy at the level of the oropharynx. The dotted line indicates the extent of the incision in a standard tonsil commando operation. Note the close proximity of the great vessels.

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Fig. 50.2 Incisions for neck dissection.

table. A support is placed under the shoulders to extend the neck and the head is placed on a head ring. The patient is draped to allow access to the whole of the neck and face on the affected side, as well as to the mouth. In addition, the donor site for the proposed reconstruction should also be prepared at this time. This is possible forall reconstructive options except forthe latissimus dorsi flap, the use of which necessitates the patient being turned on tothe side and redraped during the operation.

In almost allcases a neck dissection will be performed as part of the procedure. The incision will therefore be the appropriate one to give access for the neck dissection (Fig. 50.2). An apron incision, with or withouta vertical extension, will give suitable access. However, if the patient has been irradiated, then two parallel incisions (McFee) may be a better choice, as they give wide exposureinthe neck while avoiding athree-point junction. If adequate access is not obtained using a combination approach via the neck and through the oral cavity, then the neck incision should be extended to split the lower lip inthe midline (Fig. 50.3). This gives wide exposure of the oral cavity and oropharynx. In cases where the mandible is not involved by tumour and a mandibular resection is not necessary, a lower-lipsplitting incision combined with an anterior mandibulotomy gives excellent exposure, particularly for tumours

Fig. 50.3 Extension of incision to split the lower lip in the midline.

that extend forwards into the anterior two-thirdsof the tongue (Fig. 50.4).

The neck dissection is performed first, and the neckdissection specimen is left pedicled on the periosteum of the mandible.

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Fig. 50.4 Anterior-mandibulotomy approach for a tumour of the tongue base which extends anteriorly. The incision is continued along the floor of the mouth and the mylohyoid is divided to allow the mandible to be retracted laterally.

The primary tumour is subsequently resected, using a combined approach externally fromthe neck and perorally. 1 The tumour is first inspected perorally and the extent of the soft-tissue resection and the site of the mandibular osteotomy are planned. The tumour should be resected with a 2cm cuff of normal mucosa and soft tissue surrounding it. Theosteotomyshould be sited approximately 1cm anterior to the anterior mucosal incision inorder to leave a rim of mucoperiosteum to whichthe flap can be suturedwhenthe defect is reconstructed. It is useful to markthe mucosal incisions with methylene blue dye at this stage. This will aid accurate excision, as there will inevitably be significant bleeding into the oral cavity as the soft-tissue excision is being performed. If it is necessary to remove a tooth to allow the osteotomy to be performed, then it is done at this stage. 2 Thenext stage of the excision is approached via the neck. Theupper skin flap is retracted and the periosteum is divided along the inferior border of the mandible fromthe site of the planned osteotomy posteriorly. The periosteum and soft tissues arethen elevated from the lateralaspect of the mandible from the site of the planned osteotomy posteriorly, including the

whole of the ascending ramus. Thisis best accomplished by a combination of sharp and blunt dissection, using a Farrabough periosteal elevator. 3 The periosteum and muscle attachments are elevated from the medial aspect of the mandible at the planned osteotomy site. Malleable copper retractors are placed medial to the mandible and the osteotomy is performed using either an oscillating or a Gigli saw. Bleeding from the cut bone and from theinferior alveolar vessels which run within the mandible is controlled with bone wax or diathermy. 4 The muscular insertions to the coronoid process are freed, using heavy curved scissors. The condyle of the mandible is freed in the same manner. Alternatively, the ascending ramus can be freed by dividing the coronoid process and condyle with a saw and leaving them attached to the soft tissues (Fig. 50.5). S The inferior alveolar vessels are identified entering the medial surface of the mandible at the lingula and are coagulated, or ligated, and divided. 6 The mobilised ascending ramus of mandible is rotated laterally, using a bone hook orheavy bone forceps, and theoral cavity is enteredfromthe neck at the anterior limit of the planned resection. When the initial incision is made through the mucosa from the neck, its site should be checked by looking through the mouth to ensure that it allows adequate clearance of the tumour. The anterior incision is then extended superiorly and inferiorly, using a knife or scissors. The soft tissues are rotated laterally into the neck with the ascending ramus of the mandible, allowing the tumour to be visualised directly (Fig. 50.6).

Fig. 50.5 Site of osteotomy incisions.

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Fig. 50.6 Lateral rotation of the ascending ramus of the mandible. Exposure of tumour after performing the osteotomy and rotating the posterior segment of the mandible laterally.

7 The excision is extended posteriorly along the superior and inferior margins. If adequate exposure is obtained from the neck, then it can be accomplished by thisroute.However,it is often necessary to perform part of the resection perorally, using a headlight for illumination, The excision may need to encompass part of the soft palate, hard palateor posterior pharyngeal wall in order to obtain adequate clearance of the tumour. The soft palate may be excised up to the midline without grossly compromising its function. However, totalor near-total resection of the soft palate creates a significant functional problem and considerable difficulties; hypernasal speech and nasal regurgitation of fluids and food can be anticipated postoperatively in this situation. If part of the hard palate needs to be resected, this is best done using an oscillating saw and osteotome. As the dissection proceeds posteriorly, it is important that the surgeon is aware of the position of the carotid arteries, which areclose to the constrictormuscles of the pharynx and can be inadvertently damaged if they are not protected (Fig. 50.1). As the inferior part of the resection is performed, the hypoglossal nerve and lingual artery should be identified and preserved unless thiswouldcompromisetumour clearance. 8 The posterior part of the excision is then completed by dividing the mucosa and musculature of the posterior pharyngeal wall with curved scissors, while protecting

the carotid arteries. The remaining muscular and ligamentousattachments of the mandible are divided with heavy curved scissors and the specimen is removed. 9 Haemostasis is obtained using a Combination of diathermy and ligation. There is often significant bleeding from the venous plexus in the pterygoid muscles, and a warm moist pack placed in the wound for 5min will control much of the bleeding. The specimen is then inspected to assess the adequacy o f excision, and frozen sections may be sent to the laboratory to check that the margins are clear of tumour. 10 Reconstruction of the defect whenthe ascending ramus of the mandible has been resected is best accomplished with a pedicled myocutaneous flap. The pectoralis major and latissimus dorsi flaps both provide reliable flaps whose bulk fills the defect left after this excision. The pectoralis major is the first choice as it is easier to raise and does not involve turning the patient. However, the latissimus dorsi can be used without causing deformity of the breast and should be considered in female patients. In both cases the flap is raised so that the skin paddle of the flap is sutured to the mucosa and the muscle of the flap to the surrounding pharyngeal muscles. Closure

The flap is sutured using a synthetic absorbable suture, such as 3/0 Vicryl. A large, round, cutting needle facili-

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tates the suturing, which should start with the posterior margin and move anteriorly. This, like the resection, is best accomplished by acombination of external and peroral approaches. A nasogastric tube shouldbe passed under direct vision before the flap is completely sutured in position. The neck should be drained, using either suction, tube or corrugated drains. If suction drains are used, care should be taken to ensure that they do not cross the pedicle of the flap, as direct pressure or suction applied to the pedicle may impair the blood supply. The neck is closed in two layers, withabsorbable sutures to platysma and surgical clips or non-absorbable sutures to skin. The donor site for the myocutaneous flap should be drained with large-bore suction drains. The donor site can be closed primarily, using strong absorbable sutures for the subcutaneous layer and clips or non-absorbable sutures for the skin. The tracheostomy tube shouldbe sutured rather than held by tapes, as these can cause pressure on the pedicle of the flap.

The patient should have NBM for 7 days postoperatively (10 days if the patient has had previous radiotherapy). Feeding is commenced via the nasogastric tube on the first postoperative day. The tracheostomy tube cuff can be deflated on the first or second postoperative day. Thetubecan be removed whenthe swelling has settled such that the tube can be occluded for 24h without difficulty. However, if the resection has been extensive (particularly if a significant tongue-base resection has been performed), aspiration may be a problem, andit may be better to leave thetracheostomy in place until feeding is established.

Fistula formation is more common in patients whohave had preoperative radiotherapy, especially if they are in poor general health. Poor placement of skin incisions, traumatic surgical technique and closure of mucosa and skin under tension may also contribute to fistula formation. A fistula is usually evident within 2 weeks of surgery and often becomes obvious when oral feeding is commenced. If there is some drainage from the neck but

doubt as to whether a fistula exists, a barium swallow (or more simply giving thepatientacoloureddrink, such as blackcurrant juice) will resolve the issue. When the presence of a fistula is established, then it is necessary to inspect the oropharynx to determine the site of the internal openingof the fistula and the state of the soft tissues. It is important to assess the condition of the flap used for the reconstruction, and also to be sure that there is no residual tumour present in the wound edges. If it is not possible to do this with the patient awake, an examinationunderanaestheticshould be carried out. A small fistula tract through otherwisehealthy tissues will usually close spontaneously within 6 weeks. The patientshould be keptNBM and antibiotics given if there is anyobvious soft-tissue infection aroundthe tract. If closure fails to take place asanticipated,a bariumswallowshould be performed to assess the fistula tract. If a small fistula fails to close spontaneously, or if there is a significant soft-tissue defect, the patient should be returned to theatre and the woundexplored and any necrotic soft tissue removed. It is occasionally possible to close a fistula primarily, using local tissues, but it is usually necessary to bring in healthy tissue from elsewhere to achieve closure. The most suitable choice is again usually the pedicled myocutaneous flap (pectoralis major or latissimus dorsi). They have the advantage of being reliable and easy to raise, and the pedicle of the flap affordsgoodprotectionforthecarotidartery, which is at risk of rupture in the presence of a fistula, particularly in an irradiated patient. If there is any tension when theskin of the neck is approximated over the pedicle of the flap, the skin should be left open and the exposed part of the pedicle covered with a splitthickness skin graft.

This is commonly associated with fistula formation, as described above.However,problemswiththeblood supply of the flap, leading to either ischaemia or venous engorgement, may be noted at anearlier stage. If there is doubt about theviability of the flap, the patient should be examined under anaesthetic. The neck incision can be opened to ensure that the pedicle is not twisted or compressed. If the blood supply of the flap is then improved, it can be left and the wound closed using sutures or skin grafting onto the muscle of the flap, so asnotto compress the pedicle. If the viability of the flap cannot be improved,itshould be discarded and a new flap raised and used for the closure.

"

Surgery for aligna ant Lesions of the Oropharynx

The operative technique described above is suitable for resection of a tumour involving the tonsil which has spread to invade the ascending ramus of the mandible. There are other approachesto resecting tumours in theoropharynx,as well asavariation of theabove technique in which the lateral mandibulotomy is used for access butnone of themandible is resected, and these will now be described briefly with.their indications.

The lateralmandibulotomy gives good access to the oropharynx and is aparticularly useful approach for tumours arising from the tongue base which have not spread to involve the mandible (Desanto & Thawley, 1987’).The procedure commences as described in step 1 of Procedure above.The periosteum is then elevated fromboth sides of themandible at the site of the osteotomy.This is usually just posterior to the third molar,althoughthetoothcan be removed and the osteotomy made through its socket if this provides better access. Thetwo plates to be used to close the osteotomy are then temporarily placed in position and the screw holes are drilled prior to the division of the mandible. The osteotomy is made with a saw, and the cut end of the mandible is rotated laterally. The great

Fig. 50.7 Lateral mandibulotomy with lateral pharyngotomy for access to tonguebase tumour. Note retraction of great vessels.

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vessels are retracted posteriorly and the pharynx is entered by making a vertical ‘lateral pharyngotomy’ incision. This incision can be extended inferiorly to give adequate access to the tumour (Fig. 50.7). The tumouris then excised and the reconstruction is completed. The lateralpharyngotomy incision is closed using interruptedsutures(Vicryl)andthe mandible is approximated using the two predrilled plates.

The anterior mandibulotomy approach combined with a lip-splitting incision gives wide exposure of the oral cavity and oropharynx. It is a useful approach for tumours which do not invade the mandible, particularly base-of-tongue tumourswhichextendanteriorlyinto the floor of the mouth. The upper neck incision is extended to split the lower lip in the midline (Fig. 50.3). An incision through thelip at 45” gives a better cosmetic result. The periosteum is then elevated from the mandible for 1.5 cm to either side of the planned osteotomy. This is usually made between thecentral incisors, or between the central and lateral incisors on the side of the tumour. Care should be taken not to elevate the periosteum too far laterally, as damageto the submental nerve may occur. The screw holes are drilled in the mandibleprior to makingtheosteotomy,asforthe lateral mandibulotomy. Once the osteotomy has been made, the incision is continued posteriorly intra-orally

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Chapter 50 along the floor of the mouth on the affected side to the tumour (Fig. 50.4). When the resection and repair have been completed, the intra-oral incision is closed with interrupted sutures and the osteotomy with the predrilled plates. The lip is closed with fine (5/0) interruptedsutures,withgreat care being taken to accurately approximate the vermilion border. One variation of this approach is the median translingual pharyngotomy. This is suitable for the rare situation of a small midline tongue-base tumour. After making the midline osteotomy, dissection is continued by dividing the tongue in the midline (Fig. 50.8). The tumour is then excised and the tongue closed primarily with absorbable sutures. Transhyoid pharyngotomy

Fig. 50.8 Anterior mandibulotomy with a translingual approach to a small midline tongue-base tumour.

Thetranshyoidpharyngotomy is anotherapproach which can be used to excise small tumours of the tongue base. In this approach thehyoid bone is exposed and the muscular and fascial attachments are dissected from its superior surface. The pharynx is entered through the tongue base, which is pulled anteriorly using a grasping forceps to expose the tumour (Fig. 50.9). The tumour is excised and the defect can usually be closed primarily. Care must be taken when using this approach to avoid damage to the hypoglossal nerves and lingual arteries, and to avoid cutting into the tumour when entering the pharynx.

References

Fig. 50.9 Transhyoid Pharyngotomy. The tongue base is pulled forward, exposing the tumour.

Desanto LW & Thawley SE (1987) Treatment of tumours of the oropharynx-surgical therapy. In: Thawley SE & Panje WR (eds) Comprehensive Management of Head and Neck Tumours, Vol. 1. Philadelphia, W.B. Saunders, pp. 699-755. Stafford N, Walsh-Waring GPW & Munro A (1989) Tumoursof the tonsil and retromolar trigone. In: Stafford N & Waldron J (eds) Management of Oral Cancer. Oxford, Oxford University Press, pp. 147-54. Stell PM & Nash JRG (1987) Tumours of the oropharynx. In: Kerr A (ed.) Scott-Brown’s Otolaryngology,Vol. 5. London, Butterworths, pp. 235-49.

Laryngectomy R. T H E 0 G R E G O R

The earliest reference to laryngeal cancer is by Aretaeus, in about AD 100, and 100 years later Galen described a malignant ulceration of the throat and apparently understood the nature and seriousness of laryngeal cancer. However, this knowledge was lost for a time, as there are no knownreferences to laryngeal cancer in the Western literature of the Middle Ages. In 1732 Morgagni clearly described autopsy findings in two cases of laryngeal carcinoma (Silver, 19 81). The first total laryngectomy was carried out on 30 December 1873 by Billroth (Gussenbauer, 1874). Sporadic cases were reported for the next 30 years, but the operation did not gain general acceptance until the pioneering work of Gluck in the early years of the twentieth century (Hollinger, 1975). During the period between the two world wars, widespread acceptance of the procedure did not occur, andmany leading institutions placed theirmajor emphasis onradiationtherapy, which, after 1920, began producing beneficial results (Coward,1921).The lack of enthusiasmfortotal laryngectomy as well as other radical head and neck procedures was understandable in view of the state of surgical and anaesthetic technology, and because it was the preantibiotic era. It was only in the 1950s that the operation gained areputationas effective and safe therapyforadvanced or recurrentcarcinoma of the larynx (Ogura & Bellow, 1952). The subperichondrial operation described by Crowe and Broyles (1938) gave way to the narrow-field operation, as opposed to a wide-field approach by Jackson and Babcock (1931), which was much closer tothe modern laryngectomy, althoughthe hyoid bone and cricoid cartilage were frequently not resected. In the

modernoperation, neck dissection forms an integral part of the procedure, as does removal of the hyoid and cricoid and usually the ipsilateral hemithyroid.The clearance of lymph nodes of the jugular chainsina wide-field approach only constitutes astaging procedure for lymphatic disease in the NO neck.

indications Total laryngectomy is indicated in advanced malignant disease of thelarynx, usually squamouscarcinoma. Occasionally other tumours, such as lymphomas, sarcomas, chemodectomas and tumours of salivary tissue, such as adenoid cystic Carcinoma, occur which may also require this operation. Early tumours, that is, T1 andT2,are effectively treated by radiation in most partsof the world, although partial laryngectomy, either by an endoscopic or laryngofissure approach, may be appropriate. The CO, laser has emerged in recent years as a new surgical tool in resecting early lesions. More advanced lesions, such as T3andT4 tumoursaremore effectively treated by radical surgery in the form of total laryngectomy. There may be controversy in the case of T3 laryngeal carcinomas, which, in some centres, in the absence of clinical nodal metastases, are treated by primary radiation,with surgery held as salvage treatmentforthe radiation failures. This may lead to the conservation of the larynges of about half of the patients (Terhaard et al., 1992). Certainly, in the case of T4 tumours, or those with clinically positive lymph nodal metastases, total laryngectomy is indicated. This operation is also indicated in hypopharyngeal tumours, most of which cannot be resected without also removing the larynx. These

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include tumours of the pyriform fossae, lateral and posteriorhypopharyngeal walls, postcricoid and upper oesophageal areas.

As in all of medicine, history-taking is an essential first step in the assessment of patients. Patients with glottic tumours will usually present early with hoarseness, but patientswithsupraglottictumours present laterwith pain, swallowing difficulty or neck metastases. Similarly, patients with hypopharyngeal cancerpresent later with swallowing problems, pain or neck masses. Smoking of cigarettes is an almost invariable feature, and alcohol abuse canusually be elicited and is more prominent in supraglottic and hypopharyngeal lesions. Clinical examination commences with examination of the mouth, nose and ears as well as the neck for any metastases. The presence of synchronous second primary tumours should also be borne in mind. Mirror examination usually makes the diagnosis, but, in more difficult patients, rigid or flexible telescopic examination is extremely useful. CT (Gregor et al., 1981) andMRI scanning (Castelijns et al., 1987) have become almost essential investigations in all these patients. These modalities are helpful in determining spread of the tumour within the larynx and pharynx, the presence of framework invasion (Gregor& Hammond, 1987) anddirect spread into

surrounding tissues. Also the detection of lymph nodal metastases, especially in the absence of palpable lymph nodes, is important. CT scanning usually indicates positive nodes, with contrast enhancement showing central necrosis by a hypodense area. MRI and, more recently, positron emission tomography (PET)have also added to our ability to interpret neck nodal status (Bailet et al., 1992). All patients should then be subjected to an examination under anaesthetic, where the exact progression of the tumour is assessed and a biopsy taken. At this stage, treatment planning decisions can be made. If operative intervention is planned, standard blood investigations for haemoglobin, leucocytes and electrolytes should be obtained. As these patients commonly have intercurrent disease, ECG, lung-function testing and often a physician’s opinion should be asked for. Psychological and speech therapist’s counselling is advised for these patients preoperatively. When prosthetic voice rehabilitation is planned, which is recommended, this should be explained to the patient. The fact that feeding will be via a nasogastric tube and that no speech will be possible for a least 2 weeks must be made clear.

The larynx is situated in the midline compartment of the neck, deep to the infrahyoid strap muscles. There are two layers of these muscles. The outer layer,

Fig. 51.1 View of the anterior neck, showing the position of the larynx and thyroid gland within the strap muscles.

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terior vascular pedicle. Thethyroidgland is in an inferior andanterior relation to the larynx, and the upper portions of the right and left lobes lie deep to thesternothyroid strap muscles’ attachment to theoblique lines of the thyroid cartilage. The lobes of thethyroid glands intervene between the visceral tubes of pharynx, oesophagus, larynx and trachea, and the carotid sheaths, and the isthmus lies over the second tracheal ring. The ipsilateral thyroid lobe is usually resected with the larynx (see Fig. 51.l).

Fig. 51.2 View of the neck from the right side showing the incisions for total laryngectomy with possibility of a right neck dissection. The stomal opening is shown in the inferior skin flap (see text).

sternohyoid, runs from the body of the hyoid bone to thesternalmanubrium.The deeper layer consists of sternothyroid, which inserts on the oblique line of the thyroid ala, and thyrohyoid, which arises from the oblique line and inserts on the lower border of the greater cornu of the hyoid bone (Fig. 51.1).The inferior constrictor muscles insert laterally on theoblique lines, enclose the pharynx and meet posteriorly in the median raphe. The superior laryngeal artery and vein are accompanied by the internal branch of the superior laryngeal nerve. This neurovascular pedicle enters the thyrohyoid membrane laterally. The artery arises from the superior thyroidartery, and the vein joins thecommon facial vein. The internal branchof the superior laryngeal nerve is sensory to the mucosa of the larynx above, including the vocal cords; theexternalbranch supplies the cricothyroid muscle. The intrinsic muscles of the larynx are supplied by therecurrent laryngeal nerve, which passes upwards in the groove between the oesophagus and trachea, and enters the larynx behind the cricothyroid joint. Theinferior laryngeal artery,a branch of the inferior thyroid artery, accompanies the nerve, and alateral division passes laterally and upwardsto anastomosewithabranch of thesuperior laryngeal artery. In the area of the cricothyroid membrane, deep to the strap muscles, there is a ramification and anastomosis of vessels related to the angle of the thyroid cartilage and the thyroid gland isthmus. This arterialarcade is contributed to by thesuperior and inferior blood supply of the larynx, and communicates with the intralaryngeal vessels, thus constituting an an-

The procedure is carried out under general anaesthesia. The use of perioperative broad-spectrum antibiotic (including anaerobic) cover has made a great difference to the morbidity of the operation. The patientis positioned supine on the table, with the neck extended and in an anti-Trendelenburg (head raised) position to minimise venous engorgement. The usual incision is a modification of the GluckSorenson superiorly based flap, in that a much widerbased flap is used, so that, if a neck dissection is to be performed, an extension over the clavicle is all that needs to be added, on one orboth sides (Fig. 51.2). The incision is made through skin, subcutaneous tissue and the platysma muscle, and the platysma is included in the raised skin flaps. When a neck dissection, either radical, modified or regional, is to be performed, this is done first. At least one jugular vein must be preserved. 1 The laryngeal dissection commences with the incision of the infralaryngeal strap muscles, using the knife or electrocautery, the inferior thyroid arteries are exposed and, on the side of the lesion, tied and cut. 2 Next thesuprahyoidmusculature is severed, using electrocautery. Thismanoeuvre allows considerable mobility early in the procedure (Fig. 51.3). 3 On the side of the lesion, the thyroid lobe is to be resected, and so this thyroid lobe is now mobilised from the carotid sheath, and the superior thyroid artery and middle thyroid vein are ligated and cut (Fig. 5 1.4). 4 Thethyroidisthmus is now exposed and divided, between haemostats, and oversewn with absorbable suture material. Thecontralateralthyroid lobe is now dissected off the larynx, using electrocautery because of the bleeding due to the rich anastomotic arcade mentioned above. This step is completed by dissecting the superior laryngeal artery away from the larynx under the cover of theattachment of sternothyroid to the oblique line. Thissteptherefore ideally preserves the

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Chapter 51 cautery, the attachment of the inferior constrictor muscle is severed just in front of the posterior edge of the thyroid cartilage on the opposite side to the tumour. Normally the pharynxis entered above the hyoid, which is grasped with a heavy tissue forceps. Care is taken not

Fig. 51.3 View of the neck from the right showing the initial steps in mobilising the larynx for total removal.

upper and lower thyroid pedicles (Fig. 515 ) . 5 The superior laryngeal artery and nerve can now be tied off on both sides, and the mobilisation of the hyoid bone cannow be completed, by severing theattachments of the greater and lesser cornua. The attachments of the greater horns of the thyroid cartilage are also severed at this time. 6 The larynx is now only attached by the inferior constrictor, the trachea and its mucosal attachments. The next steps are dictated by the natureof the lesion, which should be approached in such a way that wide excision of thetumour is accomplished. Whenatumour is known toinvade the tongue base, the pharynxis opened laterally, to ensure that the lesion is excised under direct vision. If there is no subglottic extension, the tracheostorne can now be fashioned. 7 The trachea is usually severed between the second and third cartilaginous rings; it is important for the posterior tracheal wall not to be mobilised off the oesophagus. The tracheostome shouldusually be fashioned in a separate opening in the lower skin flap (Fig. 51.2). At this point, the endotracheal tube (ET) is withdrawn by the anaesthesiologist and a tube is passed by the surgeon, through the skin opening and into the lower trachea. One or two anchoring sutures are made between the anterior trachea and the skin opening. The larynx can now be dissected out in a leisurely way, with maximum mobility and under excellent vision. Using electro-

Fig. 51.4 View of the neck from the right showing the stage of the thyroid isthmectomy, and mobilisation of the left thyroid lobe from the larynx and trachea. Internal jugular vein not shown, as seen in a right radical neck dissection.

Fig. 51.5 View of the neck from the front, showing the left thyroid lobe mobilised off the larynx, preserving its blood supply; the right lobe, on the side of the tumour, remains applied to the larynx. (Internal jugular veins not shown.)

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laryngeal excision inferiorly and to ‘peel’ the organ superiorly, while dissecting from below. The pharyngeal repair is the next stage, but, before it is commenced, a nasogastric tubemust be advanced down the oesophagus, unilateral a pharyngeal neurectomy should be performed, and a self-retaining voice prosthesis, such as the Provox (Hilgers & Schouwenburg, 1990) voice prosthesis, should be inserted. This will be discussed in more detailat the end of this chapterinthe section on Long-term effects of laryngectomy. Pharyngeal neurectomy

Usually at least three major branches of the pharyngeal plexus can be identified when dissecting right up to the skull base. These are severed by electrocautery, which effectively demonstrates their innervation of the pharyngeal musculature. This is usually done on the same side as the tumour and the thyroid gland lobectomy. Fig. 51.6 View of the neck fromthe left, showingthe severing of the inferior constrictor from the thyroid cartilage, the division of the trachea and further mobilisation of the hyoid bone.

to enter the pre-epiglottic space and, once the epiglottis is identified, it is grasped by an Allis tissue forceps. Using suction and scissors, the aryepiglottic folds are followed down and posteriorly, exposing the laryngeal vestibule. Once the exact extent of the tumour is seen, the constrictor fibres on the same side are also severed (Fig. 51.6). 8 The larynx is now ‘peeled’ forwards, while the surgeon carefully dissects it away. Good suction, light and assistance are essential at this stage, while the surgeon stands above thepatient’s head, facing hidher feet. Once the mucosal excision line around the tumour is complete, the mucosa of the pyriform fossa on the opposite side can be dissected loose from the larynx, and the mucosal excision line continued over the postcricoid area (if there is no tumour involvement). The posterior tracheal wall is now dissected away from the oesophagus to the point at which it has already been transected, thus completing the laryngeal extirpation (Fig. 51.7’). Although this approach may be regarded as standard, it should sometimes be modified by preoperative knowledge of the extent and localisation of the tumour. Thus, when dealing with a hypopharyngeal tumour, the opposite pyriform ‘Ossa is entered in Order to have control in excising the larynx. In supraglottic tumours, with tongue-baseinvasion, one might choose to start the

Closure

Closure can be accomplished by continuous or interrupted sutures, but shouldalways be meticulous, invert-

Fig. 51.7 The neck from the left showing the mucosal excision line; the larynx is ‘peeled’ inferiorly, while the mucosal excision is done from above, using good light and suction.

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Chapter 511

ing the mucosa. A second submucosal layer is used, and the muscle layer is loosely 'tacked' over the repair. The remaining thyroid lobe should never be sutured across the repair, since it may produce swallowing and speech difficulties in the rehabilitation of the patient. Bilateral suction-drain catheters,which should be soft, areplaced lateral to the pharynx oneach side, care being taken not to apply suction directly onthe repair. The skin is sutured intwo layers. The sutureline may be sealed with antibiotic ointment, or with povidone-iodine, and thin strips of plaster. No heavy dressings are needed, and indeed they are contraindicated because they tend to mask any haematoma formation and may obstruct the stoma. Tracheostome constructfion

The best results are obtained whenit is possible to make thestomainthe inferior skin flap, using aseparate fenestra in the skin (see Fig. 51.2). This may be round, but experience has shown that themost effective shape is crescentic. The trachea should be transected at a slight angle, making the posteriorlip more rostral. An angle of between 20" and 30" is optimal; if greater, the stoma becomes unacceptably large for the patientto effectively occlude for prosthetic speech. The suture should ensure that there is skin cover over the bare edge of the trachea, so that no cartilage is exposed. Exposed cartilage may lead to perichondritis, infection, granulations and eventually stenosis (Verschuur et al., 1996).

Postoperative management Unless the patient is to be ventilated in the immediate postoperative period, no tracheostomy tube is needed. The use of stoma tubes or buttons is controversial, but should not be needed, as the trachea hasbeen sutured to the skin. Any type of tube or cannula is only needed when there is bleeding, swelling or oedema which may occlude thestoma. The use of these tubesshould be limited as much as possible, since they may cause erosion of the mucocutaneous edges and lead ultimately to stenosis. Humidification of inspired air is of paramount importance, so that no crust formation takes place and secretions remain liquid. Suctioning by nursing staff must be monitored carefully and should be gentle, not producing erosions of the mucosa, which also promote crust formation. The patient should be encouraged to cough up thesecretions, so that they are suctioned at the stomal edge. In the early phases, it is helpful for skinprotective agents, such asTegaderm, Stomahesive or Duoderm, to be placed over the skin surrounding the

stoma. All these measures are directed at achieving firstintention mucosa to skin healing of thewound and minimising the complication of stomal stenosis.

~omplication Complications may be divided into immediate or operative, intermediate or postoperative and late. Operative

Operative complications are those of any comparable majoroperation, such as bleeding, air embolism or pneumothorax.Withcompetent surgical technique, these are very rare indeed. Postoperative

These are usually divided into general and local. General complications are again those of any major operation, such as pulmonary infection, urinary infection (in association with catheterisation)and septicaemia, cardiac or neurological. The rate of pulmonary embolism is lower in head-and-neck surgery than in chest or abdominal surgery, but theuse of low-dose subcutaneous heparin is recommended. Local complications are mainly related to bleeding or to pharyngeal repair leakage, both of which may lead towound breakdown and fistula formation. Broadspectrumantibiotic cover (includinganaerobic) and meticulous repair of the pharynx, with careful haemostasis and effective suction drainage, should prevent the complication of fistula. Chylous leakage and carotid 'blow-out' are complications of neck dissection, with or withoutpharyngeal breakdown, and will not be considered further here. Skin necrosis may occur,particularly in irradiated patients and with ill-advised incisions. Airway obstruction may cause some concern, but, as mentioned above, when the trachea is meticulously sutured to skin, preferably in a separate opening in the lower skin flap, and there is no excessive swelling or exceptional bleeding, there should be no fear of this. It is, however, very important that the patient should be nursed in an intensive, or high, care facility for the first 24-48 h. Warm moistened inspired air should be provided by a tracheostomy mask, thus preventing crust formationand obstruction. Rarely, apatientwitha short, thick or fat neck may require a postlaryngectomy cannula to avoid obstruction.This is usually only needed fora few days. Bulky dressings should be avoided since they may obstructthestomainadvert-

Total Laryngectomy ently. Cuffed tracheostomy tubes should be limited to patients who need postoperative ventilation. They do not help with the control of secretions, and may lead to excessive irritation and coughing. Most fistulae close spontaneously with careful nursing and delay in feeding the patient by mouth, but some may persist and require closure by local procedures, by repairing the innermucosa and outer skin or by local or distant flaps. In large pharyngocutaneous fistulae, the pectoralis major mycutaneous flap is of major importance. By applying split skin to the muscular surface, two epithelial layers are achieved, with the chest skin sutured to the pharyngeal mucosa.

These are: tumourrecurrence, particularly stomal recurrence, and stomal stenosis. Dysphagia and difficulties with speech rehabilitation will be considered under Long-term effects of laryngectomy. Hypothyroidism andhypoparathyroidismarealso late complications, particularly in patients who have also been irradiated. Stomal recurrence

This is a dreaded complicationsince it is associated with a very poor prognosis. Predisposing factors are related to theextent of thetumour,particularlysubglottic spread with paratracheal nodes, and the presence of a prelaryngectomy tracheostomy (Stell & van den Broek, 197’1).More recently, the validity of this contention has been questioned, suggesting that it is not the tracheostomy, but the size of the tumour that is important in nce. Nevertheless, tracheostomy remains an undesirable procedure with laryngeal cancer, whetherthepatient is to be treated by radiation or laryngectomy. For this reason ‘emergency laryngectomy’ (laryngectomy en c h a d ) has been advocated to avoid thepossibility of this complication.Alternatives to emergency laryngectomy may be to resect tumour with theCO, laser to provide an interim airway, or to perform a cricothyroidotomy (coniotomy), as the tract of this procedure canbe easily and widely resected with the larynx. Radical excision of the stoma,including an upper mediastinal dissection and pectoralis major myocutaneous flap reconstruction, offers the only chances of cure, but the operative mortality is high and 5-year survival remains poor (Biller et al., 1980). Stomal stenosis

Stomal stenosis has no accepted definition in the litera-

37 I

ture, but there is some rationale for the concept that a stoma with a cross-sectional area less than that of the glottis at rest may be considered too narrow (Gregor & Hassman, 1984). Thebest way to avoid stomal stenosis is the use of sound surgical principles with the initial construction (see above). Other factors predisposing to stenosis are those that will result in secondary healing with scar formation. Suturing under tension, infection, perichondritis and trauma, which may be produced by injudicious suctioning or the use of ill-fitting cannulas, are significant.

laryngectomy The physical and psychosocial consequences of total laryngectomy must be takenintoaccountwhen performing the operation. Good voice rehabilitation is an essential step in the rehabilitation of the patient (Hilgers & Balm, 1993). Apartfrom voice rehabilitation,the presence of a stoma, sputum production and coughing, and the need for forced expectoration all contribute to psychological distress (Hilgers et al., 1990). The need for humidification of the inspired aircan be demonstrated by the improvement of these symptoms by the use of heat-moisture exchangers (Hilgers et al., 1991).

Bailet JW,Abemayor E, Jabouw BA, Hawkins RA, H0 C & Ward PA (1992) Positron emission tomography-a new precise imaging modalityfor detection of primary head and neck tumours and assessment of cervica lymphadenopathy. Laryngoscope 102, 281-8. Biller HF, Krespi YP, Lawson W & Baek S (1980) A one-stage flap reconstruction following resection stomal for recurrence. Otolaryngol. Head Neck Surg. 88, 357-60. Castelijns JA, Kaiser MC, Valk J, Gerritsen GJ, van Hattum H H & Snow GB (1987) Magnetic resonance imaging of laryngeal cancer. J.Comp. Assist. Tomogr. 11, 134-40. Coutard H (1921) Roentgentherapy of epitheliomas of the tonsillar Am. J. region, laryngopharynx and larynx from 1920 to 1926. Roentgenol. 28, 313-31. Crowe SJ & Broyles EN (1938) Carcinoma of the larynx and total laryngectomy. Trans. Am. Laryngol. Assoc. 60, 47-68. Gregor RT & Hassman E (1984) Pulmonaryfunction testing in postlaryngectomy patients, related to stomal size. Acta Otolaryngol. (Stockh.) 97, 177-83. Gregor RT & Hammond K (1987) Framework invasion by laryngeal cancer. Am. J.Surg. 154, 452-8. Gregor RT, Lloyd DM & Michaels L (1981)Computed tomography of the larynx: a clinical and pathologic study. Head Neck 3, 28496. GussenbauerC (1874) Ueber die erste durchTh. Billroth am Menschen ausgefuhrtekehlkopf-extirpationund die anwendung eines kunstlichen kehlkopfes. Arch. Klin. Chir. 17, 343-56. Hilgers FJM & Balm AJM (1993) Long term results of vocal rehabili-

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tation after total laryngectomy with the low-resistance, indwelling ProvoxTMvoice prosthesis system. Clin, Otolaryngol. 18, 517-23. Hilgers FJM & Schouwenburg PF (1990) A new low-resistance, selfretaining prothesis (ProvoxTM) for voice rehabilitation after total laryngectomy. Laryngoscope 100, 1202-7. Hilgers FJM, Ackerstaff AH, Aaronson NK, Schouwenburg PF & van Zandwijk N (1990) Physical and psychosocial consequences of total laryngectomy. Clin. Otolaryngol. 15, 421-5. Hilgers FJM, Aaronson NK, Ackerstaff AH, Schouwenburg PF & van Zandwijk N (1991) Theinfluence of a heat and moisture exchanger (HME) onthe respiratory symptoms aftertotal laryngectomy. Clin. Otolaryngol. 16, 152-6. Hollinger PA (1975) A century of progress o f laryngectomies in the northern hemisphere. Laryngoscope 85, 322-32. Jackson C & Babcock W (1931) Laryngectomy for carcinoma of the

larynx. Surg. Clin. North Am. 11, 1207-27. Ogura JH & Bellow JA (1952) Laryngectomy and neck dissection for carcinoma o f the larynx, Laryngoscope 62, 1-52. Silver CE (1981) Surgery for Cancer of the Larynx, 1st edn. New York, Churchill Livingstone, p. 1. Stell PM & van den Broek P (1971) Stomal recurrence after laryngectomy: aetiology and management. J.Laryngol. Otol. 8 5 , 131-40. Terhaard CHJ, Hordijk GJ, van den Broek P et al. (1992) T, Laryngeal carcinoma:a retrospective study of the Dutch Headand Neck Cooperative group: study design and general results. Clin. Otolaryngol. 17, 393-402. Verschuur HP, Gregor RT, Hilgers FJM & Balm AJM (1996) The tracheostoma in relation to prosthetic voice rehabilitation. Laryngoscope 106, 111-15.

Vertical Partial Laryngect

Y

KERRY D. OLSEN

moval of one vocal cord through an external incision. No thyroidcartilage is removed in this procedure. ‘Frontolateralpartial laryngectomy’ (‘vertical partial laryngectomy’) refers to excision of aportion of the laryngeal cartilage, generally with removal of one vocal cord or aportion of theoppositecord (orboth). ‘Hemilaryngectomy’ is used to describe the removal of half of the larynx, including one side of the thyroid ala, the arytenoid and the vocal cord. The cricoid cartilage is preserved. Theanterior-commissureprocedure removes aportion of thethyroid cartilage overlying the anterior portionof each vocal cord. ‘Vertical partial laryngectomy’ is also used as an all-encompassing term that includes laryngofissure-cordectomy, hemilaryngectomy and all other open procedures performed for early glottic cancer.

Introduction Carcinoma of the larynx is the most common head and neck malignancy treated by otolaryngologists. However, the treatment of early glottic carcinoma is still a matter of controversy. The treatment options include endoscopic removal, radiation therapy and open surgical procedures. This chapter focuses on glottic tumours for which partial vertical laryngectomy is the selected treatment. Stage T1 glottic tumours comprise a spectrum of disease, i.e. not all T1 tumours are the same. Some are barely invasive and are small enough to be removed with biopsy. These tumours are grouped with lesions that involve theanterior-commissure region and that extend close to or invade the thyroid cartilage. Kirchner (1984, 1989) has clearly shown the problems with tumour invasion in theanterior-commissurearea. The appropriate treatment for anterior-commissure cancer is debatable; however, the main indication for performing a partialvertical laryngectomy is tumour involvement of the anterior-commissure area or anterior portion of the true cord. At the Mayo Clinic, open operations have accountedfor 55% of the initial treatmentfor early glottic cancers. Endoscopic removal has been used in 25% of cases and radiation therapy in 20% (DeSanto, 1987). Withearlier diagnosis, the percentage of tumours that can be treated endoscopically should increase. The terminology used for open laryngeal operations can be confusing. ‘Laryngofissure’ and ‘thyrotomy’ refer to division of thethyroid cartilage, generally in the midline, to expose the laryngeal lumen. ‘Cordectomy’ refers to the removal of a vocal cord,whichcan be performed endoscopically orthrough laryngofissure. Therefore, laryngofissure-cordectomy results in the re-

Surgical indications General

The main indicationis a large, invasive T1 carcinoma on a mobile vocal cord involving the anterior-commissure area. Other important factors include the patient’s sex, age, occupation, lifestyle, ability to travel to treatment centres and reliability of follow-up. Ultimately, the patient’s own desires must be paramount. Pathology

The histological features of the tumour and extent of invasion are important factors relevant to the performance of an open laryngeal procedure for early glottic cancer. In general, when in situ carcinomaalone is found, it is treated endoscopically and is not an indica373

tionfor an openoperation. Anterior-commissure involvement by carcinoma in situ, however, has been reported to result in conversion to invasive squamous-cell carcinoma (SCC) in 92% of cases compared with 17% of lesions limited to the midportion of the mobile vocal cords (Chiesa et al., 1991). When in situ disease in the anterior-commissure cannot be effectively ablated endoscopically, radiation therapy shouldbe considered. Also, early microinvasion of the glottic larynx can generally be managed endoscopically; it does not usually require an open operation (Crissman et al., 1988). In general, open laryngeal procedures are performed for invasive carcinoma and not for in situ disease, dysplasia or early microinvasion. Exceptions can occur because of difficulties with exposure endoscopically, tumour location orrecurrence after previous endoscopic removal. In addition, areas of invasive carcinoma that may require vertical partial laryngectomy often coexist with in situ disease on the opposite cord. This mucosal component can be removed in an open operation, with preservation of the underlying cordal structures and control by examination of frozen sections. Results of the examination of frozen sections of thetumourmust be available in order to perform any vertical partial laryngectomy operation. ca

Invasive cancer that is limited to the midcordal area, with retained cordal mobility and absence of involvement of the anterior quarter of each vocal cord, can generally be removed with an endoscopic procedure. However, treatment the of invasive anteriorcommissure cancer with endoscopic removal has been associated with a high rate of local recurrence. Laser removal of tumour in this area has also been associated witha high rate of recurrence, often necessitating laryngectomy (Krespi & Meltzer, 1989; Chiesa et al., 1991). In contrast, open operations have an associated lowrate of local recurrence for invasive anteriorcommissure tumours. An openoperation provides a wide, safe, anterior margin by going beyond the thyroid cartilage to establish oncological safety (Ossoff et al., 1985; Olsen et al., 1993). The tumour canextend from the arytenoid on one side to the anterior third of the opposite vocal cord and still be removed by a vertical partial operation. Contralateralvocal-cord involvement beyond theone-thirdarea generally requires the removal of too much cordal tissue to support an adequate voice or a larynx free from stenosis or aspiration. When there is extensive bilateral invasive disease, the preferred treatment option is generally radiation therapy.

ic

Vertical partial laryngectomies are generally used only for T1 glottic tumours. The glottis is defined as an area withextension to the midventricle and to the region from 5 mm to 1cm beneath the true cords.Small degrees of subglottic or supraglottic extension can be managed effectively with an open laryngeal procedure (DeSanto &;Vaughan, 1991). Fixation of the vocal cord implies that the tumourinvolves the intrinsic laryngeal musculature and theparaglottic space. After this occurs, the tumour has access through the paraglottic region down to the level of the cricoid cartilage. Vertical partial laryngectomy then becomes oncologically unsound unless the cricoid cartilage is removed. Removal of the bulk of the cricoid cartilage usually necessitates a permanent stoma. Therefore, stage T1 glottic cancer can be managed withvertical partial laryngectomy if the cancer extends from the arytenoid to the opposite one-third of the vocal cord, with retention of mobility of the cord.

1 Tumours that extend posteriorly to involve the bulk of the body of the arytenoid should not be treated with vertical partial laryngectomy. 2 The tumour should not involve the subglottic larynx. Extension of the tumour more than 1cm beneath the truecords is one of themajor causes for failure of vertical partial laryngectomy. 3 Involvement of the supraglottic larynx. Invasive tumour extension in the false vocal cord, i.e. transglottic tumours, should not be managed with a vertical partial operation. Involvement of the supraglottic larynx gives ready access to the rich lymphatic vessels in the supraglottic area, and tumour extension can occur rapidly in this region. Supraglottic tumours should be treatedwithhorizontaloperations, i.e. supraglottic laryngectomy, when appropriate and not with vertical procedures because vertical operations do not encompass the area in which supraglottic tumours can spread readily.

The surgical anatomy of the larynx pertinent to vertical partial laryngectomy is well known by all otolaryngologists; however, certain anatomical structures are important in the performance of the variations of vertical partial laryngectomy (Schwartz et al., 1963). The Delphian lymph node, or prelaryngeal node, is located in the fascia above the thyroid isthmus and lies

between the cricoid and thyroid cartilages. This node should be submittedforpathologicalstudy. Usually, there is only onelymph node, but two to four nodes may be grouped together. Other midline nodes located anterior to the trachea are called the ‘subdelphian nodes’. They are generally foundbeneaththeborder of the thyroidisthmus andare less constant in location. The Delphian lymph node receives lymph flow from the upper and anteriorportions of both lobes of the thyroid gland andfrom thethyroid isthmus. Italso receives efferent lymph flow from the larynx. The subepithelial space of the true cords containsfew lymph vessels, and metastasis fromtumours confined tothetrue cords is rare.However,tumourextension to theanterior commissure can spread through a small anterior lymphatic pathway that pierces the cricothyroid membrane and drains to the Delphian node. The subglottic larynx also has lymphatic vessels that pierce the cricothyroid membrane anddraininto theDelphian node. When metastasis is found in the Delphian lymph node from glottic carcinoma, the recommended treatment is ipsilateral neck dissection (Olsen et al., 1987). Accurate identification of the midline of the larynx is also important in performing laryngofissure via an external approach. The thyroid notch is often asymmetrical and so is not a reliable landmark for the midline. However, a vein in the cricothyroid membraneis immediately beneath the midpoint of the vocal cords, and its location is a fairly constant landmark for thelevel of the anterior commissure. The anterior-commissure area contains Broyle’s ligament, which is attached anteriorly to the thyroid cartilage inthe midline. In this area,there is no internal perichondrial layer and thus less protectionagainst tumour invasion. No surgical plane exists inside the larynx to separate soft tissue easily from the anterior thyroid cartilage. Bailey (1985)states that adequatesurgical excision of cancer in this area must include removal of adjacentstructures, such asthe overlying thyroid cartilage.

invasive cancer,the neck is prepared anddrapedto permit possible laryngectomy or neck dissection. The patient is placed in a slight reverse Trendelenburg position, and routine tracheostomy is performed inferior to thethyroid isthmus; general anaesthesia is continued through this site. is

Several skin incisions can be used to perform a vertical partial laryngectomy. Generally, aseparate transverse incision is made over the midportion of the thyroid ala and extendedfromonesternomastoid muscle to the other. Neck flaps are then elevated in a subplatysmal plane to the level of the hyoid bone and to beneath the cricoid cartilage. Thestrap muscles are divided in the midline and retracted.TheDelphian lymph node is then identified, removed and submitted for frozensection pathologicalstudy. At this point,the midline vein can be seen in the region of the cricothyroid membrane. The various vertical partial laryngectomy opera-

Operative techniq Preparation

The patient is brought to theoperatingroom and intubated with asmall endotracheal tube (ET),generally a 7-mm (no. 5) tube.Thelarynx is then assessed by direct laryngoscopy. A biopsy specimen of the larynx is takenand submittedfor frozen-section pathological examination. The exact extent of the tumour is visualised and confirmed pathologically. After confirmation of

Fig. 52.1 (a) Lesion (white area) appropriate for laryngofissurecordectomy operation. (b)Incision used for all open laryngeal procedures. (From Olsen, 1992. By permission of Mayo Foundation.)

Fig. 52.2 (a) Identification of Delphian node. (b) Midline cartilage incision. (From Olsen & DeSanto, 1990. By permission of Mayo Foundation.)

Fig. 52.3 (a) Division of cricothyroid membrane. (From Olsen & DeSanto, 1990. By permission of Mayo Foundation.) (b) Larynx opened at midline. (From Olsen, 1992. By permission of Mayo Foundation.)

tions can now proceed'(Fig. 52.1). An alternative to the transverse incision is a small apron incision raised at the level of the tracheostomy site or a midline vertical incision, which can be very effective for exposure and cosmesis in an older person with redundant anterior platysma1 folds.

Specific operations Laryngofissure=cordectomy

After retraction of the strap muscles and exposure of the thyroid cartilage, a paralysing agent is given by the anaesthetist. Laryngeal hooksarethen placed inthe superior portion of each thyroid ala and used to retract the larynx in a superior and lateral direction. Next, an oscillating saw is used to make a cutin the midline of the

cartilage (Fig. 52.2). The vein found in the cricothyroid membrane is a useful landmarkfordeterminingthe midline position of this incision. The surgeon then uses a headlight and divides the thyroid ala. With traction, the cartilage will separate easily without entering the laryngeal lumen. A small cut is then made in the cricothyroidmembranewitha long-handled knife (Fig. 52.3). The incision is extended superiorly. Small skin hooks are placed in each side of the incision and advanced superiorly by the surgeon and an assistant. The anterior commissure can be identified by notingthe yellow end of Broyle's ligament and by direct observation from below. The larynx is opened in the midline, dividing the anterior commissure and extending the incision into the pre-epiglottic space. The larynx is then opened like a book. Direct inspection of the tumour should ensure that the

Vertical Partial Laryrzgectomy

3 77

Fig. 52.4 (a) Dissection of thyroid perichondrium. (b) False-cord and subglottic incision. (From Olsen & DeSanto, 1990. By permission of Mayo Foundation.)

cancer does notinvolve the most anterior portiono f the vocalcord.Thetumourcanbe easily visualised. A periosteal elevator is used to dissect the intrinsic laryngeal musculature and soft tissues from the inner thyroid perichondrium. Establishment of a correct plane can be ensured by noting the smoothfeel o f the elevator against the thyroid perichondrium. If the elevator has a rough feel to it,the dissectionis too deep and haspassed beneath the thyroid perichondrium against the cartilage. Dissection in this plane can lead to perichondritis, especially in a previously irradiated larynx. With the patient still paralysed, a malleable retractor is inserted to protect the opposite normal vocal cord. With a cautery, cuts are then made through the inferior portion o f the false cord or in the ventricle and in the subglottic region (Fig. 52.4). The vocal cord is grasped at its anterior extent, and dissectionismadeprogressively back toward the vocal process of the arytenoid. The final attachment o f thevocalcordtothevocalprocess o f thearytenoid is divided with curved Panzer scissors (Fig. 52.5), andfrozen-sectionevaluation of all marginsis then obtained. Vertical partial laryngectomy (frontolateral procedure)

The most common open operation for early glottic carcinoma is performed to treat tumours that involve the anterior-commissure region. A safe anterior margin can be ensured only by removing a portion o f the thyroid cartilageadjacent to thelocation o f thecancer.The

Fig. 52.5 (a) Division of vocal process of the arytenoid. (From Olsen & DeSanto, 1990. By permission of Mayo Foundation.) (b) Defect after cordectomy. (From Olsen, 1992. By permission of Mayo Foundation.)

amount o f cartilage removed is dictated by the extent of the tumour and is almost always less than half of one hemithyroid cartilage (Fig. 52.6). As stated above, the cancer can involve one vocal cord and cross the midline to involve not more than the anterior third o f the opposite cord. The initialstage o f the operation is identical to

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Chapter 52

Fig. 52.6 (a) Lesion (white area) suitable for frontolateral partial laryngectomy (vertical partial laryngectomy). (From Olsen, 1992. By permission of Mayo Foundation.) (b) Second cartilage cut. (From Olsen & DeSanto, 1990. By permission of Mayo Foundation.)

that described for laryngofissure-cordectomy. A scalpel with a no.15 blade is used to make an incision along the superior and inferior borders of theexternalthyroid cartilage. The external perichondriumis reflected off the thyroid cartilage from the initial thyrotomy site back to approximately the halfway point on the side ipsilateral to the tumour. The perichondrial flap is often useful in later closure. The initial thyrotomy incision throughthethyroid cartilage is made approximately 1cm from the midline on the side oppositethetumour. An incision is then made in the cricothyroid membrane with a long-handled no. 15 blade. Skin hooks are placed on each side of the incision and, by using a headlight and working from below, the surgeon connects the incision in the cricothyroid membrane with the thyrotomy cut. With direct visualisation from below, cuts are made progressively through the true and false cords just beyond the level of the tumour. The amountof vocal cord removed on theopposite side is dictated by theextent of the

tumour. This will have been confirmed earlier at the time of direct laryngoscopy. The larynx is again opened like abook and thetumour is inspected. A second cartilage cut is now madeon the side of the tumour. The amount of cartilage excised depends on the size of the lesion, but it generally involves about one-third of the thyroid ala on the ipsilateral side. Again, laryngeal hooks are placed on each side of the cartilage cut and the incision site is marked with an ink pen and divided with an oscillating saw. Retraction on the cartilage permits easy separation of the cartilage without entering the soft tissues of the larynx. The anterior thyroid cartilage to be removed is now grasped with forceps. A skin hook isused to retracttheposteriorportion of the thyroidala, and thesoft tissues are bluntly elevated fromthe remaining posteriorthyroidperichondrium (Fig. 52.7). Thesoft tissues are elevated back to the level of the arytenoid. A malleable retractor is placed to protect the opposite vocal cord. With a cautery, cuts are made in the subglottis beneath the tumour and in the ventricle or through the false cord and extended up and around the free anterior thyroid cartilage. Again with cautery, the deep soft tissue is progressively thinned back toward the vocal process and, under direct vision, Panzer scissors are used to divide the final posteriorattachment of thetumour, generally throughthe vocal process of thearytenoid (Fig. 52.8). The specimen is submitted for pathological examination of frozen sections for confirmation of the margins. Separate margins may also be taken from the patient for oncological security. Anterior-commissure procedure

For tumoursconfined to the anterior-commissureregion alone, a variationof vertical partial laryngectomy can be performed in which only the anterior quarterto third of each vocal cord is removed (Fig. 52.9). The overlying thyroid cartilage is excised to ensure anterioroncological security. Identical exposure of thethyroid cartilage is performed as described above. Skin hooks are placed on each side of the thyroid cartilage and, with an oscillating saw, cartilage cuts are madeon either side of the midline. Again, the amount of cartilage excised is determined by the extent of the laryngeal cancer. The cartilage cuts are made only in the cartilage and do not enter the lumen of the larynx. The cricothyroid membrane is divided with a long-handled no. 15 blade and, under direct vision workingfrom below, the cricothyroid incision is extended up each side into the previously made cartilage cuts. This is done by progressively advancing a skin hook on either side of the incision.

VerticalPartialLaryngectomy

3 73

Fig. 52.7 (a) Separation of laryngeal musculature from the thyroid perichondrium. (b)False-cord and subglottic incision. (From Olsen & DeSanto, 1990. By permission of Mayo Foundation.)

Fig. 52.8 Posterior division of specimen. (From Olsen, 1992. By permission of Mayo Foundation.)

Under direct vision from below, cuts are made through each vocal cord just beyond thelevel of the tumour. The midline section of thyroidcartilageandeachanterior vocal cord are then removed. Frozen-section confirmationofadequate margins is thenobtainedto ensure clearance at the level of the remaining true cords and paraglottic space.

Fig. 52.9 (a) Lesion (white area) suitable for anterior-commissure procedure. (From Olsen, 1992. By permission of Mayo Foundation.) (b)Bilateral anterior-commissure cartilage cuts. (From Olsen & DeSanto, 1990. By permission of Mayo Foundation.)

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Chapter S2 ect

Hemilaryngectomy is also an open laryngeal procedure. It has not been described in this chapter from asurgical technique standpoint because it is rarely performed for early glottic carcinoma.According to the classic description, hemilaryngectomy removes half of thelarynx, including half of the thyroid cartilage and one arytenoid. The terminology used in the literature, however, can be confusing and frequently this formal extent is notmeant in descriptions of ‘hemilaryngectomy’. Hemilaryngectomies have been useful for the rare early lesions that extend back on to thebody of the arytenoid with a mobile vocal cord. Also, this operation may be useful in cases of tumours that impair mobility of the cordwithout complete fixation. For early cordaltumours, hemilaryngectomy provides an oncological margin at the far edge of the posterior thyroid cartilage, where it is least needed. Indeed, if the tumour extends to this portion of thethyroid cartilage, deep-muscle invasion and paraglottic-space invasion should have occurred and the vocal cordshould not be mobile. Therefore, hemilaryngectomy is excessivefor most early growths, and the vocal consequences aftera hemilaryngectomy are worse thanwith theotheropen procedures. In addition, laryngeal reconstruction is essential, and stenosis of the larynx and long-term use of a tracheostomy tube may follow. For the rare posterior cordal T1 tumoursthat involve the body of the arytenoid, the author preserves the superior and inferior anterior ipsilateral thyroid cartilage and removes only

the midcordal and posterior thyroid ala to achieve adequate exposure and oncological security. Preservation of these portions of the thyroid ala assist closure and avoid the need for reconstruction with muscle flaps. Closure

After laryngofissure-cordectomy, no attempt is made to reconstruct the resected tissue. The wound is allowed to heal by secondary intention, and generally a pseudocord develops that is often indistinguishable from a true cord. The main noticeable feature will be loss of cordal thickness. The thyrotomy incision is reapproximated by plating sutures in the thyroid perichondrium or through the thyroid cartilage (passing sutures through the cartilage itself in non-calcified areas or after placing small angled drillholes).The fascia overlying the strap muscles is reapproximated in the midline (Fig. 52.10). A Penrose drain is inserted, and a cuffed tracheostomytube is placed to avoidsubcutaneous emphysema. Next,the neck incision is closed in layers withinterrupted 4 0 chromic sutures deeply and 610 non-absorbable sutures in the skin. A dressing is applied. After partial vertical laryngectomy, a suture is placed to reattach the base of the epiglottis superiorly to the hyoid bone. The remaining true and false vocal cords arereattached to theexternal or internalthyroid perichondrium (Fig. 52.11). The ipsilateral false vocal cord is alsoresuturedanteriorly.This is donewith Vicryl sutures and anchored securely into the remaining thyroid cartilage. If necessary, drill holes can be placed

Fig. 52.10 (a) Reapproximation of the

thyroid cartilage. (From Olsen, 1992. By permission of Mayo Foundation.) (b)Final closure after laryngofissure-cordectomy. (From Olsen & DeSanto, 1990. By permission of Mayo Foundation.)

Vertical Partial Laryngectomy in the thyroidcartilage. If possible, sliding advancement mucosal flaps are used to cover any bare cartilage aver the arytenoid. Thiswill decrease subsequent granulation formation. The cricothyroid membrane is closed, as are the soft tissues, above the laryngeal notch. The external perichondrium is reapproximated to close the remaining portion of the larynx. Again, the strap muscles are su-

38I

tured by reapproximatingtheposterior andanterior fascia in layers. A cuffed tracheostomy tube is inserted, and the final closure proceeds as in laryngofissurecordectomy. For the anterior-commissure procedure, after the tumour is removed, the possibility for a near-normalvoice exists because the majority of each true cord has been preserved. A Montgomery laryngeal keel is then placed between the thyroid cartilage remnants and secured into position with a Prolene suture (Fig. 52.12). The tissues above and below the keel are closed with interrupted chromicsutures to secure the closure of thethyroid cartilage. This is done by closing the cricothyroid membrane and soft tissues above the thyroid notch. By plating a blue Prolene suture to secure the keel in position, it can easily be found and removed at a later date. The keel is generally removed through a small incision, with the patient given local anaesthesia, at about 4 weeks postoperatively. A cuffed tracheostomy tube is placed, and the neck incision is closed, as described above. A neck dressing is applied postoperatively.

Postoperative management

Fig. 52.11 Reattachment o f contralateral true and false cords. (From Olsen, 1992. By permission of Mayo Foundation.)

Fig. 52.12 (a) Removal o f anterior pot-tion of vocal cords and overlying cartilage. (b) Insertion of laryngeal keel. (From llsen, 1992. By permission of Mayo Foundat:ion.)

The tracheostomy tube is kept inflated for the first 2448 h postoperatively. At that time, it can generally be changed to a small no. S metal tracheostomy tube and of usually corked. When the patient can tolerate corking the tracheostomy tube for 24 h, the tubeis removed, and thetracheostomy site is allowed to heal secondarily. Patients begin speech whenthetracheostomytube is

3 82

Chapter 52

occluded, and 'no limitations are given about the use of their voice in the postoperative period. Feeding by mouth can generally begin after the tracheostomy tube is removed. Patients will do best with a soft diet. In most cases, there are no problems with aspiration. The Penrose drain is generally removed the day after the operation. Broad-spectrum antibiotics are given preoperatively and forabout 5 days postoperatively. After vertical partial laryngectomy, patients generally breathe and eat normally. Stenosis and aspiration are rare. The single exception to no formal reconstruction is hemilaryngectomy. Because half of the thyroid ala and onearytenoidare removed, problemswith laryngeal incompetence, aspiration and poor voice are common sequelae. In these cases, theauthor uses a fascialmyotransposition graft with the strap muscles to reline and surface the missing hemilarynx. After hemilaryngectomy, problems of stenosis and retained tracheotomy tubes are generally related to a narrowed glottic lumen due to the reconstructive procedures.

eo Complicationsafter vertical partial laryngectomy are infrequent. An earlier report by Neel et al. (1980) described complicationsin 26% of a series of vertical partial operations. The operative and postoperative problems included atelectasis, pneumonia,subcutaneous emphysema, wound problems, removal of granulation tissue and poor ultimate voice. Granulation tissue will be found in the healing laryngeal bed in all patients if the larynx is observed early. This generally resolves within 3-6 months. Rarely, persistent granulation tissue must be removed because of interference withthe voice or airway. Problems with infection can occur, especially if the perichondrium is removed from the underlying cartilage in additionto the perichondrium being removed from the outer surface of the cartilage. Infection is more common after the treatment of radiation failure. Hospitalisation usually averages 5 days.

Summ~ Open laryngeal proceduresarea versatile and efficacious treatment option for treating the wide spectrum of

large T1 glottictumours.Thisoperation is especially applicable whentheanterior commissure area is involved. Vertical partial laryngectomy for select and appropriate T1 glottic tumours offers excellent curative results at the cost of alteration in vocal quality. Althoughthe voiceis altered, this operation ultimately gives the highest local control rate and disease-free survival and preserves the greatest number of laryngeal voices.

References Bailey BJ (1985) Glottic carcinoma. In: Bailey BJ & Biller HF (eds) Surgery of the Larynx. Philadelphia, W.B. Saunders, p. 267. Chiesa F, TradatiN, Costa L etal. (1991) CO, laser surgery in laryngeal cancers: three year results. Tumori 77, 151-4. Crissman JD, Zarbo RJ, Drozdowicz S, Jacobs J,Ahmad K & Weaver A (1988) Carcinoma in situ and microinvasive squamous Carcinoma of the laryngeal glottis. Arch. Otolaryngol. Head Neck Surg. 114, 299-307. DeSanto LW (1987) Surgical perspective. In: Thawley SE & Panje WR (eds) Comprehensive Managementof Head and Neck Tumors, Vol. 1. Philadelphia, W.B. Saunders, pp. 1029-39. DeSanto LW & Vaughan CW (1991) Early carcinoma of the larynx. In: Silver CE (ed.) Laryngeal Cancer. New York, Thieme Medical Publishers, pp. 151-61. Kirchner JA (1984) Pathways and pitfalls in partial laryngectomy. Ann. Otol. Rhinol. Laryngol. 93, 301-5. Kirchner JA (1989) What have whole organ sections contributed to the treatment of laryngeal cancer? Ann. Otol. Rhinol. Laryngol. 98, 661-7. Krespi YP & Meltzer CJ (1989) Laser surgery for vocal cord carcinoma involving theanterior commissure. Ann. Otol. Rhinol. Laryngol. 98, 105-9. Neel HB, 111, Devine KD & DeSanto LW (1980) Laryngofissure and cordectomy for early cordal carcinoma: outcome in 182 patients. Otolaryngol. Head Neck Surg. 88, 79-84. Olsen KD (1992) Laryngofissure-cordectomy and its variations. Instr. Courses 5, 307-12. Olsen KD & DeSanto LW (1990) Partial vertical laryngectomy-indications and surgical technique. Am. J.Otolaryngol. 1 1 ,152-60. Olsen KD, DeSanto LW & Pearson BW (1987) Positive Delphian lymph node: clinical significance in laryngeal cancer. Laryngoscope 97, 1033-7. Olsen KD, Thomas JV, DeSanto LW & Suman VJ (1993) Indications and results of cordectomy for early glottic carcinoma. Otolaryngol. Head Neck Surg. 108, 277-82. Ossoff RH, Sisson GA & Shapshay SM (1985) Endoscopic management of selected early vocal cord carcinoma. Ann. Otol. Rhinol. Laryngol. 94, 560-4. Schwartz AW, Hollinshead WH & Devine KD (1963) Laryngectomy: anatomy and technique. Surg. Clin. North Am. 43, 1063-79.

Conservation surgery of the larynx in the form of horizontal partiallaryngectomy (HPL) wasfirst described by Alonso in 1947. After a shaky beginning, the technique became more popular over the ensuing decades, mainly as a result of the work of Bocca et al. (1983) and Ogura et al. (1980) as well as histological studies by Kirchner and Carter (1987). Otherworkers followed, and gradually the indications for the procedure became more accepted and widened to include more extensive lesions. Although an examination of the barriers and compartments involved show that cancer may easily spread from the supraglottis (Tucker, 1961), in certain patients local excision of the supraglottic areaby HPL has been documented as being oncologically sound(Tucker,1961; Bocca et al., 1983).

Supraglottic cancer isdefined asa lesion affecting the area above the true vocal cords, and includes the roof and lateral walls of the sinus of Morgagni,the false vocal cords,the aryepiglottic folds and the laryngeal surface of the epiglottis. Invasion of the pre-epiglottic space, the base of the tongue and the prelaryngeal strap muscles, as well asthepharynx, may occur (Gregor, 1988).

that they invade the pre-epiglottic space. It should be possible to remove the tumour while sparing the entire glottis, including both arytenoids, the muscosa over the vocal cords and thelower half and superior cornuof the thyroid cartilage on the contralateral side. 2 The pre-epiglottic space can be removed by this operation; thus early invasion is not a contraindication. 3 Indications include any lesion that can be resected allowing a generous margin in all directions except the inferior margin, where experience has shown that margins of 3 or 4mm appear to be adequate. Contraindications are fixation of the vocal cord and extension to the arytenoid and postcricoid area. Relative contraindications are involvement of the pharynx and tongue unless these are very early and limited. Some authors advocate extended HPL for these lesions and lesions that involve an arytenoid. In the description that follows, only the classical horizontal partial laryngectomy, possibly including a small amount of tongue base or the medial wall of the pyriform fossa, will be described.

lie 1 Laryngeal carcinoma of an early stage that is situated above the plane of the ventricles may be suitable for this operation.This will include T1, T2and certain T3 lesions, which are classified as such by virtue of the fact

383

Neck dissection, either uni- or bilateral is often performed at the same time as HPL. The management of squamous-cell carcinoma(SCC) of thesupraglotticlarynx requires a different from philosophy glottic tumours. Because of the tissues involved and the natural areas of spread of supraglottic tumours, the lymphatic system is involved at a much earlier phase in thedisease and thusneck-nodal metastases are more common. Furthermore,thesupraglottis may be thought of asa midline embryological structure with lymphatic drainage to both sides of the neck. It is thought thatthis is the

384

Chupter 53

reasonwhybilateral neck metastases occur so frequently (Bocca et al., 1983). Thishas led to a longstandingcontroversyas tohow the neck should be managed in supraglottic disease (Gregor et al., 1996a). When looking at supraglottic cancer in general, some authors have found no improvement in the results of treatment over four decades (Zamora et al., 1993); others have found that bilateral elective neck dissection has improved the locoregional controland even survival (Lutz et al., 1990; Weber et al., 1994). Neck dissection can be included en bloc during HPL in thesame way as during total laryngectomy.

Preoperative management The preoperative work-up should include full ENT examination and direct examinationof the larynxto determine the spread of the tumour. CTscanning should also be obtailned to assess pre-epiglottic space invasion or framework invasion. Thepulmonaryfunction of the patient is importantand lungfunction tests and a pulmonologist’s opinionshould be obtained.This is more important than the chronological age of the patient. The presence of oesophageal reflux should be investigated by fluoroscopy. Acid reflux may negatively influence the healing and rehabilitation of these patients. If present, it may sway the balance against the procedure or suggest that aggressive anti-reflux management should be instituted. Perioperative antibiotics should be used for between 48 h and 5 days and should include Gram-positive and Gram-negative cover, as well as anaerobic agents.

Operative technique Thisprocedure seeks to remove theentire epiglottis, hyoid bone, pre-epiglottic space, false cords and upper half of the thyroid cartilage. The hyoid bone may be preserved in some cases and there is evidence that reconstruction and postoperative swallowing are facilitated by this (Gregor et al., 199613). The vocal cords and arytenoids are spared. Inclsion 1 An apron flap is used. A neck dissection can be encompassed in the same incision if it is extended laterally anduptothe mastoid.The flap is raised inthe subplatysmal plane. Tracheostomy is performed at any convenient stage of the procedure. 2 The hyoid bone, if it is to be preserved, is grasped and the muscles attaching below (sternohyoid, thyrohyoid

Fig. 53.1 Perichondrium incision.

and omohyoid) aresevered using the cautery knife. This is performed above the hyoid, cutting the suprahyoid musculature, if the hyoid is to be removed. The hyoid should be sacrificed if there is anydoubtaboutthe extent of the tumour or if the pre-epiglottic space is involved. 3 Next the strap muscles are incised at the upper margin of the thyroidcartilage. The greater cornuis exposed on the involved side. On the uninvolved side, the sternohyoid, omohyoid and greater cornu are preserved alongwiththesuperior laryngeal nerve and vessels. These are important for postoperative swallowing and laryngeal competence (Fig. 53.1 ). 4 The incision along the upper border of the thyroid cartilage is carried through the perichondrium and is extended to the cornu andlateral border on the involved side, where the inferior constrictor fibres are also severed (Fig. 53.2). 5 Next the perichondrium is elevated from the thyroid cartilage inferiorly to apoint below the level of the proposed cartilage incisions. This differs in males and females; the anteriorcommissure is situated between the upper and lower halves of theanterior ridge of the cartilage in males and is somewhat higher in the female larynx. Hence the cartilage incision is made higher in the female patient. If the thyroid cartilageis heavily ossified, the cut should be made using a micro-oscillating saw to avoid fracture.

Horizontal (Supraglottic) Laryngectomy

385

Fig. 53.2 Extension of incision.

Opening into the lumen

This must be done with care in orderthat the tumour is not approached too closely; entry should be performed either from the pyriformfossa or from thevallecula. The opening is gradually continued with the tumour under direct vision (Fig. 53.3). Good light and suctionare essential. After the upper excision has been completed, an incision is made on the lower margin, which passes through the lateral extent of the ventricle, preserving the Fig. 53.4 Supraglottic tumour excised with continuous traction.

mucosa over the vocal cords and passing through the petiole anteriorly. Posteriorly the aryepiglottic fold is incised over thearytenoid, leaving this area bare of mucosa (Fig. 53.4). The mucosa of the posterior commissure is left intact to avoid interarytenoid scarring (Fig. 53.5). Some surgeons advocate a cricopharyngeal myotomy to facilitate swallowing. This is undertaken by passing a finger into the cervical oesophagus and incising the cricopharyngeal fibres laterally with aknife. Others consider this unnecessary, butthe tonicity of thisarea should be tested with the finger and, if in doubt, it is probably better to perform the myotomy. Care must be taken, however, to preserve therecurrent laryngeal nerve, which enters the larynx behind the cricothyroid joint. The myotomy is therefore made as far posteriorly as possible. Repair Fig. 53.3 Internal laryngeal incision.

This is accomplished by suturingthe defect by deep, strong, absorbable material, approximating the remnant

386

Chapter 53 with swallowing (Gregor et al., 199610).Difficulty with the airway may occur, particularly when radiation is administered postoperatively, butre-tracheostomy is usually not required. These patients must be carefully observed and, if necessary, steroids and adrenaline nebulisation should be used to reduce oedema. The help of speech therapists is essential in the postoperative rehabilitation of swallowing and speech. Local recurrence in thelarynxcan be managed by completion laryngectomy. In this case primary vocal rehabilitationwith an indwelling voice prosthesis is recommended.

Fig. 53.5 Opening into the lumen.

of thyroid cartilage to the base of tongue if the hyoid was removed or around the hyoid if it was preserved. In the case of placing sutures in the tongue base, where the hyoid is removed, Ogura et al. (1980) have made the point thatit is not desirable to bring the mucosal edge of the tongue base to oppose the mucosa of the anterior commissure. This tends to bring the food bolus directly on tothe vocal cords. The sutures are therefore placed in the raw muscle edge of the tongue, thus resulting in an overlap or ‘shelf‘ above the glottis (Ogura et al., 1980). Inferiorly, thesuturesarecarriedthroughthe perichondrium and canalso be taken through drill holes in the thyroid cartilage. The sutures are all placed insitu before attempting to close the defect. To avoid tension, all sutures are held taut by the assistant while the surgeon knots them sequentially, thus approximating the tongue base (or hyoid) to the remnant of the thyroid cartilage. The strap muscles are then approximated in the midline and sutured to thetongue base or hyoid bone above. Suction drainage should be employed.

One of the major concerns after HPL is decannulation and aspirationwithdrinking. Usually decannulation can be achieved within 3 weeks after surgery, even when a bilateral neck dissection has been performed. Aspiration, however, remains a concern and even at 6-months up to 40% of patients may still experience difficulty

Because of the prevalence of lymph node metastases in supraglottic cancer, the regional spread of the disease must be aggressively managed. This includes bilateral neck dissection where indicated. Some authors (Weber et al., 1994) have suggested routine bilateral neck dissection in all cases. A more conservative approach with regard to the nodal status, together with postoperative radiation if indicated, appears more logical (Gregor et al., 1996a).

Alonso JM(1947) Conservative surgery of cancer of thelarynx. Trans. Am. Acad. Opththalmol. Otolaryngol. 51, 633-42. Bocca E, Pignataro 0 & Oldini C (1983) Supraglottic laryngectomy: 30 years of experience. Ann. Otol. Rhinol. Laryngol. 92, 14-18. Gregor RT (1988) The preepiglottic space revisited: is it significant? Am. J.Otolaryngol. 11, 161-4, Gregor RT, Oei SS, Hilgers FJM, Hart AAM, Balm AJM & Keus RB (1996a) Management of cervical metastases in supraglottic cancer. Ann. Otol. Rhinol. Laryngol, 10.5, 845-850. Gregor RT, Oei SS, Baris G, Keus RB,Balm AJM & Hilgers FJM (1996b) Supraglottic laryngectomy with neck dissection and postoperative radiation in themanagement of supraglottic laryngeal cancer. Am. J.Otolaryngol. 17, 316-321. Kirchner JA & Carter D (1987) Intralaryngeal barriers to the spread of cancer. Acta Otolaryngol. (Stockh.) 103, 503-13. Lutz CK, Johnson JT, Wagner RN & Myers EN (1990) Supraglottic carcinoma: patterns of recurrence. Laryngoscope 99, 12-17. Ogura JH, Marks JE & Freeman RB (1980) Results of conservation surgery for cancers of the supraglottis and pyriform sinus. Laryngoscope 90, 591-600. Tucker GA (1961) Histological method for the study of the spread of cancer within the larynx.Ann. Otol. Rhinol. Laryngol.70,910-21. Weber PC, Johnson JT & Myers EN (1994) The impact of bilateral neck dissection upon pattern of recurrence and survival in supraglottic carcinoma. Arch. Otolaryngol. 120, 70-6. Zamora RL, Harvey JE, Sessions DG & Spitznagel EL (1993) Clinical staging forprimary malignancies of thesupraglotticlarynx. Laryngoscope 103, 69-77.

ecto

a

ER F. PERRY

ica

Wide submucosal disease

S

Resections of thehypopharynxare principally performed to treat malignancy, chiefly squamous-cell carcinoma (SCC). However, it may rarely be indicated for massive benign disease or aspiration/stricture formation following majortrauma. Occasionally laryngeal cancers may spread posteriorly to envelop thehypopharynx, but anteroinferior extension is more common. In contrast, the larynx is a frequent pathway for spread of SCCs from the hypopharynx.The main indication for pharyngolaryngectomy is thereforea cancer arising from the hypopharynx. SCCs of the hypopharynx have a number of unusual features which predispose to a poor prognosis. es

Seventy per centof SCCs have palpable nodal disease on presentation. Of those with clinically negative necks, a further 60% are estimated to have microscopic nodal involvement on presentation. Tumours of the hypopharynxoften present with large nodaldeposits from very small, ‘silent’, primary lesions.

This is a particular problem withlesions of the posterior hypopharyngeal wall. It is not uncommon for a lesion 1cm across to have more than 3 cm submucosal spread in every direction. Cancers in the lower hypopharynx and upper oesophagus tend to spread inferiorly. Hence a minimum of 5 cm caudal clearance is required when resecting lesions in the upper oesophagus, while a 2cm margin is needed for piriform fossa lesions. With rare, small, posterior-wall lesions, biopsies of the mucosa 1 , 2 and 3cm from the margins of macroscopic disease in superior, inferior and lateral directions accurately size the lesion and its submucosal spread, in order to plan theappropriate surgical approach. Not every patient requires total a pharyngolaryngectomy for hypopharyngeal cancers. Sometimes laryngeal-sparing procedures are appropriate, provided there is 2cm clearance of macroscopic disease in all directions. Relative radio resistance

Almost allstudieslooking at surgery versus radiotherapy show improved survival with surgical excision (Eisback & Krause, 1977; Persky & Daly, 1981; El Badawi et al., 1982).Most centres use combinedmodality therapy of surgery with pre- or postoperative radiotherapy. A number of institutions have questioned whether postoperative radiotherapy adds any extra survival to that of the adequate excision, especially bearing in mind the high incidence of second primary lesions that may be more radiosensitive. For very small lesions, where laryngeal conservation surgery may be safely performed,the author prefers surgery withpostoperativeradiotherapy to cover the

The superior hypopharynx is capacious, so that lesions may grow to be very large before producing symptoms. Presenting symptoms are commonly odynophagia due to ulceration,obstructive dysphagia from bulky tumours, hoarseness due to laryngeal involvement or a lump in the neck from nodal metastases or direct tumour spread.

387

3 88

Chapter 54

primary’s propensityforsubmucosal and lymphatic spread and microscopic lymph node involvement. When thelarynxcannot be saved, surgery withpostoperative radiotherapy is offered. Sometimes a small anterosuperior hypopharyngeal lesion may be adequately encompassed by a slightly extended laryngectomy; however, the results of pharyngolaryngectomy with jejunal interposition in the author’s institution are excellent, making this the treatment of choice for the larger lesion (Smith et al., 1992). Some authors(Harrison,1970,1981;Harrison & Thompson,1986) point to the tendency of hypopharyngeal cancer to spread submucosally and to form ‘skip lesions’ further down the oesophagus.They therefore feel that adequate clearance can only be obtained by full pharyngolaryngo-oesophagectomy if the tumour is low in the hypopharynx. However, recurrence in the oesophagus has not proved to be problem a with jejunal interposition(Gluckman et al., 1987). author’s The institution prefers to reserve pharyngolaryngo-oesophagectomy for patients with elongated oesophageal lesions. The results (Smith et al., 1992) justify the assertion that the ‘gold-standard’ approach to most cases of hypopharyngeal SCC is pharyngolaryngectomy with jejunal interposition, which is the operation described in detail below. However, partial hypopharyngectomy, partial laryngectomy, extended laryngectomy and pharyngolaryngooesophagectomy all have their places in themanagement of these tumours. r”

Full assessment of the extent of the involvement of the larynx and hypopharynx is made under general anaesthetic, and the areas of involvement are drawn accurately at the time of the original biopsy. Palpation of neck nodes while thepatient is anaesthetised and relaxed is performed, remembering that ‘midneck nodes’ may represent direct tumour extension. A full panendoscopy is then performed to exclude a synchronous second primary, paying special attention to the oesophagus. A CT scan of the neck and uppermediastinum is performed in order to assess tumour spread within the larynx and hypopharynx and to look for direct spread (T4)into theneck tissues. CT assists in the assessment of nodal spread. Lower hypopharyngeal lesions spread via paratracheal nodes to the mediastinum; hence low tumours necessitate a mediastinal dissection. However, frank CTinvolvement of mediastinal structures is generally regarded as a contraindication to surgery. Upper

oesophageal lesions spread to the hilum of the lung, the coeliac nodes and the liver; thus the upper abdomen and liver arealso assessed by CT scan before surgery in patients with lowlesions of the hypopharynx and upper oesophagus. Aclotting screen and liver-function tests are performed and 4 units (2L) of blood is cross-matched. (A pharyngolaryngectomy may lose 500ml of blood, as maythefrequently needed radical neck dissection.) Mostpatients donot need atransfusionduringthe procedure; however, the patient needs to have a haemoglobin of at least logldl postoperativelyforoptimal healing to occur. The author generally invites a dietitian to consult the patient. The patient is given a high-calorie/protein dietary supplement with the addition of vitamin B complex, vitamin C and folic acid 20 mglday. At least 2 days preoperatively, 20mg of vitamin K and 5000 units of vitamin B,, are given parenterally. The extra demandsof healing in somebody with real or potential deficiencies are covered safely and cheaply by this regimen. Lastly, before the surgical reconstruction is decided upon,any previous abdominal surgical history is assessed by the involved general surgeon to decide suitability for jejunal conduit resection. Previous extensive upper abdominal surgery or peritonitis may make harvesting difficult.

Relevant anatomy Thehypopharynx is divided into subsites and staged according to the combined UICC/AJCC 1987 classification (Fig. 54.1). It runs from the level of the hyoid bone/ pharyngoepiglottic fold to theupperborder of the cricopharyngeus. The pyriform fossa is shaped like an inverted pyramidal cone, with its ill-defined apex at the level of the upper border of the cricoid. The postcricoid area is a complete ring of foregut tissue corresponding to the levels of the cricoid cartilagesuperiorly and inferiorly. The posterior wall runs from the arbitrary level of the hyoid bone to theupperborder of the cricoid. The marginal area between hypopharynx and larynx is oncologically included in the hypopharynx, as tumours in thisarea have thelatepresentation,bad prognosis and tendency towardscaudalextension of hypopharyngeal lesions. Hypopharyngeal cancers do invade the larynx and frequently fix the vocal cord by invasion of the cricoarytenoid joint and the recurrent laryngeal nerve and by direct extension into the paraglottic space lying unprotected medially (Figs 54.2 and 54.3).

Pharyngola~yngectomyandPharyngolaryngo-oesophagectomy 3 89 placed vertically) and a head ring stabilises the patient’s head and neck. Povidone-iodine preparation (or alcoholic chlorhexidine if iodine-sensitive) is applied from mouthto pubis. The body is drapedto expose the prepared areas. Incision (Fig. 54.4)

In an average to long neck (Fig. 54.4a), ahorizontal incision with a lateral ‘T’ is performed if there is to be a radical neck dissection. The vertical incision is thrown intoa lazy ‘S’ to minimise webbing. A 3.5 x 3.5cm stomal hole is made which is slightly bigger than the trachea, in order to pull the stoma open with healing/ scar retraction. A patient with short a thick neck is usually approached using a Gluck-Sorensen incision (Fig. 54. 4b). This U-shaped incision is not extended too far cephalad (otherwise the inferior portion of the flap may slough) and is made broad-based. A lateral ‘T’ running at right angles from this extended ‘U’ on one side can allow access for a radicalneck dissection. The lateral ‘T’

Fig. 54.1 Subsites.

Operative technique Preparation

1 Thisoperation is always performedunder general anaesthetic (CA). Occasionally, awakebronchoscopeguided intubations are necessary for safe induction of anaesthesia. 2 Prophylactic antibiotic cover forpotentialaerobic/ B is commenced. Theauthorcuranaerobicpathogens rently uses ticarcillin/clavulanic acid 3 g, three times a day for 3 days. Antibiotics cease after 3 days provided the patient is afebrile and hidher chest is clear on X-ray and auscultation. 3 The patient is positioned supine on a warming mattress with the sandbag horizontally beneath the shouldersforextension (the patienttends to roll off one

rent laryngeal

Fig. 54.2 Piriform fossa lesions readily invade cricoarytenoid joints, recurrent laryngeal nerve and paraglottic space.

Fig. 54.3 Lymphatic drainage of hypopharynx.

Right angled junction2cm behind carotid

~

artery

Lateral ‘T’ at right angles positioned behind carotid

Apron extension of Gluck-Sorensen incision

J

Fig. 54.4 Potential incisions.

must always be positioned behind thecarotidartery in incision (Fig. 5 4 . 4 ~ ) t oallow access intotheposterior case there is breakdown of the ‘T’ junction tips. Another inferior neck area in order to remove the contents of the way of doingaradical neck dissection is toputan posterior triangle of the neck withoutalateral ‘T’. ‘apron extension’ onthe side of the Gluck-Sorensen

~baryngolaryngeGtomyand Pharyn~olaryngo-oesopbageGtomy 331 Procedure in stages

1 The skin incision is marked and points are tattooed with methylene blue for ease of closure. 2 Injection of vasoconstrictor. The author uses 20ml of a solution of 1m1of l :1000 adrenaline in 100m1 saline (1in 100 000 adrenaline), or half this concentration (0.5m1 adrenaline in 1OOml saline) if a long incision (e.g. with radical neck dissection) is required. (This solution has apH of 7, compared with apH of 4.8 when xylocaine with adrenaline solution is used, and adrenaline is more vasoactive at a pH of 7.) 3 The incision is carried through the platysma, and flaps are raised in a subplatysmal plane to expose to the suprasternal notch inferiorly and 2cm over the sternomastoids laterally. Superiorly the flap is raised to be 2cm above the hyoid bone. The flaps are obviously taken wider on the side of radical neck dissection if needed. Silk stay sutures hold open the flaps. 4 The larynx and hypopharynx are mobilised laterally from the carotid sheath structures. The superior layngeal neurovascular bundle is isolated at the distal end of thegreatercornu of the hyoid bone. Major arteries and veins are tied individually, but smaller vessels are tied off in groups for speed. The middle thyroid veins are ligated. Theposterior wall of thepharynx is separatedfromthepre-vertebral fascia by blunt dissection. 5 The strap muscles are divided low in the neck and the thyroid isthmusis divided. If the lesion is high in the hypopharynx, both lobes of the thyroid should be separated from the trachea,using coagulating diathermy for speed when dividing through the multiple small vessels running between the thyroid gland and trachealcricoid. The inferior thyroid artery's supply to the parathyroid glands is preserved if possible. (There is a high incidence of later hypothyroidism in irradiated patients who have had one lobe of the thyroid surgically removed.) For lower pyriform fossa and posterior-wall tumours and all postcricoid lesions, thethyroidgland and parathyroids on the side of involvement are resected, and often both sides are taken. If the patient required a tracheostomy due to airway obstruction in a prior procedure, thethyroidgland is routinely Completely removed along with the tracheostomy tractand overlying skin. When the thyroid gland is completely removed and theparathyroids have not been preserved, thenthe parathyroidsshould be identified fromthe specimen, sliced into thin sections and reimplanted into the preserved sternomastoid or a similar muscle. The parathyroid glands are pale brown and are situated in the inferior half of the posterior margin of the thyroid.

Unlike fat lobules, they bruise to a purple-brown colour withhandling, and sink whendroppedintonormal saline. When in doubt, especially if there is a possibility of the nodular tissue being an enlarged lymph node, a slice of the nodule is sent for frozen section to confirm that it is parathyroid tissue before reimplanting. 6 The trachea is entered at a sufficient level to encompass the malignancy but not so low as to compromise attachment of the stoma to the skin of the suprasternal notch. Usually thetrachea is entered by ahorizontal incision, extended to encompass 40% of the tracheal circumference, and an armouredendotrachael tube (ET) is inserted to replace the original oroendotracheal tube, which is removed Completely from the patient by the anaesthetist. The cuff of the new tube is inflated just enough to keep blood out of the airway-too high a pressure will damage the mucosa and will commonly cause the tube toslip up or down continually and get in the way of the surgeon. A silk suture with a tie-around secures the tube to the chest skin at the right level to maintain equal lung ventilation. Stay sutures of nonbraided material are placed in the walls of the trachea and oesophagus below theintended inferior excision line tostop these structures being later 'lost' in the mediastinum. Usually stay sutures are 210 chromic catgut on a tapered needle, with the needle left on to be later used as deep anchoring sutures from the tracheal wall to the undersurface of the stomal skin flaps. 7 The hyoid bone is grasped with an Allis forceps, as is done when performing a total laryngectomy (Fig. 54.5). The geniohyoid and genioglossus muscles are separated from the body of the hyoid bone, and the middle constrictor and hyoglossus are separated from the greater cornu, using pencil diathermy on a low cutting and, as required, low coagulation setting. Scissors are used to free the medial attachments of the greater cornua. Care must be taken to stay close to the lesser cornua when separating tongue muscles- the hypoglossal nerves can be less than 1cm above them, lying on the hyoglossus, and may be damaged when freeing the hyoid bone. 8 The hyoepiglottic sheet ligament is followed by the diathermy needle into the vallecula on the opposite side to the cancer. The mucosa is entered and the cut is taken through the affected side with an adequate 2cm margin superiorly. The posterior surface of the pharynx should have been previously separated off thepre-vertebral fascia by blunt dissection, and thesuperior incision is continued with scissors to include the posterior wall in line withthe hyoid bone, or above if there is oropharyngeal spread. 9 The inferior tracheal incision isbevelled upwards to leave an obliquesuperior end to thetrachea.The

Fig. 54.5 Superior and lateral mobilisation of the larynx and hypopharynx.

posterior tracheal wall and trachealis muscle are separated for 1.5cm from the anterior oesophageal wall. 10 The oesophagus is divided at the appropriate level below the cricopharyngeus. At least a 2cm margin is required for pyriform fossa lesions, with up to 5cmfor cricopharyngealhpper oesophageal tumours. 11 In patients where ahorizontalskin incision with separate stoma is done, the tracheal stump is sutured into the skin stoma (Fig. 54.6). Any tension should be carried by three to five deep 2/0 chromic catgut stay sutures, now used to anchor the trachea up under the stomal skin flaps. The skin-mucosa suturesare of a vertical mattress type, which donot go through tracheal mucosa except posteriorly, where the tracheal cartilage rings are deficient. The sutures should be 68mm apart.Theauthor uses a4/0 blue dissolving monofilament (Maxon orPIX) suture ona small cutting needle. Mucosa and skin should appose with a loose overlap. 12 If primary voice restoration is to be done, a fistula tract from the back wall of the trachea to the oesophagus is made and a size 14 catheter inserted (Fig. 54.7). This catheter’s passage through common the tracheal/oesophageal wall should be hidden in fibromuscular tissue. Thelength of the pharyngealoesophageal defect is then measured accurately. The defect is usually between 6 and 8 cm when thetissues are slightly on the stretch. 13 At this point the otolaryngologist takes lunch and afternon tea while theabdominaland microvascular

-~

Fig. 54.6 Securing the stoma.

Fig. 54.7 A primary voice puncture may be fashioned between the stoma and the butt of the oesophagus. The catheter should not be visible from inside the wound. Close over it with sutured tissue if necessary.

surgeons do their best! The abdominal surgeon should be aware that the removal of the larynx prevents adequate coughing andthat the patient’s coughing attempts postoperatively will put greater strain on hidher abdominal suture line than is usual. Jejunum is harvested with the longest, straightest vas-

Pbary~~ol~rynge~tomy and ,Pbaryngolaryngo-oesophagectomy

39 3

Fig. 54.9 Jejunum segment sutured in under slight tension. Fig. 54.8 Jejunum segment with long vascular arcades.

cular arcade possible (Fig. 54.8). The proposed transplant segment is accurately measured (also whenslightly on the stretch}and thendivided off, but left to lie warm, moist and closeted withintheabdomenuntilthe microvascular surgeon hasisolated and prepared hidher intended neck vessels. The enteric vessels are left attached to this isolated segment of jejunum and an endto-end anastomosis rejoins the intestine’s continuity. The vessels commonly used by the microvascular surgeon are the superior thyroid, inferior thyroid and transverse cervical vessels, depending on the size match and availability. The veins available can include an end-toside anastomosis to the internal jugular vein (IJV) or end-to-endanastomosiswiththeexternal jugular or transverse cervical vessels. As the IJVis a high-flow vessel, the suction effect produced by the more rapid passage of blood theoretically draws venous blood from thetransplanted vein more effectively, lessening the chance of it obstructing. It is best not to use anterior jugular veins (AJVs), as they usually have low flow rates. The jejunum is inserted into the neck, with its caudal end placed inferiorly and cephalic end superiorly; that is, be sure it is not antiperistaltic (Fig. 54.9). Peristalsis often continues to occur in the transplanted bowel. As the small bowel’s contractions occur slowly (three per minute), peristalsis has little part to play in the rapid

transit of food during the second stage of swallowing. However, if the jejunum is placed in an antiperistaltic direction, the patientmay experience a feeling of MUCUS welling up into the throat. Serosa protectsthetransplanted jejunum from taking up the surrounding blood supply, so that division of the transplanted bowel’s feeding artery and vein, even if years later, may result in late sloughing of the graft-a problem not encountered in myocutaneous transfer. The abdominal surgeon then anastomoses the transplanted and newly revascularised jejunum, being careful not to pull apart the microvascular anastomosis. Closure/drainage/dressings

A large-bore nasogastric tubeis inserted, even if there is aprimary voice-puncture catheterin place, as this is required in the postlaparotomy patient. Two3 mm suction drains areinserted, but they are kept away from the transplant’s vascular arcade. A 6mm suction drain is placed inferoposteriorly if a radical neck dissection was performed, and the neck is closed in two layers. The deep layer of dissolving sutures (usually 310 chromic catgut)holdsthe flaps together and is theimportant layer of closure. The skin’s layer of closure is for accuracy of apposition and tokeep the wounds airtight. The author uses running continuous 4/0 nylon for the skin, with interrupted sutures in any T-junctions. Interrupted

394

Chapter S4

skin closure is best for the whole length of the incisions if there has been preoperative radiotherapy. No dressings are placed over the wounds. An antibiotic-impregnatedointment is smeared over the wound to keep bacteria out, to stop a crust of blood from forming over the wound and to keep the nursing staff contented. A cuffed tracheostomytube is introduced and the flanges sutured in place to the skin (tape ties around the neck may compromise the microvascular arcade).

Postoperative management The tracheostomy tube’s cuff is kept inflated until the patient is. fully awake and is not oozing. It can then be changed for an uncuffed or laryngectomy tube.The tracheal stoma requires normal tracheostomy care, humidification and suction. The nasogastric tubeis left on free drainage and the patient is kept nil by mouth until bowel sounds start and flatus is passed, usually about the third day. Dextrose 500ml is run into the nasogastric tube over 4 h, which is then blocked off to see if the patient becomes nauseated. If it is well tolerated, half-stre~gth and then full-strength total liquid replacement diet (e.g. Isocal, Ensure, Osmolyte) is instituted. If there is no sign of pharyngocutaneous fistula, the patient starts a liquid and then solid diet after l 0 days, provided a barium swallow shows no leaks at the anastomoses. The patient’s free jejunal segment is inspected hourly for the first 12 h after surgery and then every 2 h for a further 36 h, every 4 h for2 days and thentwice daily for 4 days. Any change in thecolour of the jejunum is reported to the microvascular surgeon immediately and he/she inspects it. The haemoglobin must be keptabove10g/dl.The blood pressure should be kept above 100 mmHgsystolic from the start of the microvascular transfer to keep the free flap perfused. The free calcium/phosphate levels are estimated soon after surgery and 8 and 16h later,especially if both sides of the thyroid are removed. The author does not give calcium gluconate supplements unless the free calcium level (corrected for albumin)falls below 1.7Oiu. There is often a small transient fall in calcium and too early an introduction of supplements may suppress the patient’s own ability to adjusthidher calcium. Thyroxine replacement needs to be started within a coupleof weeks of total thyroid removal.

Complications Complications specific to this procedure include the following: 1 Loss of jejunal segment-replace with another segment. 2 Pharyngocutaneous fistula -maintainnasogastric alimentation. 3 Paralytic ileus-parenteral alimentation may need to be instituted if bowel sounds are delayed. 4 DuodenaUbiliary injury-use only an experienced abdominal surgeon. These patients rarely survive major abdominal complications. 5 Wound haematoma-the placement of suction drains may be compromised by the need to keep the drains away from the microvascular arcade. If a haematoma needs evacuation, be aware of the position of the vascular anastomoses and stay away from it if possible. Be sure themicrovascular surgeon is aware of what you are doing and is available to come in quickly if the vessels or their anastomoses are damaged.

Alternative procedures Extended total laryngectomies are the frequently used treatment of marginal and mid to high piriform fossa lesions in many institutions (Fig. 54.10). Indeed in the author’s own institution, a localised marginal or medi-

Fig. 54.10 Extended laryngectomy.

P b a ~ y n ~ ~ l ~ ~ ~ n and g e c Pba~y~golary~go-oeso~bagectomy tomy 39 5 ally placed piriform fossa lesion is frequently treated with this procedure. If the tumour is more laterally or posteriorly placed within the pharynx, a2cm margin of excision may leave only a thin bridge of the residual pharyngeal mucosa. It may then need to be closed tightly around nasogastric a tube or a pedicled myocutaneous flap must be swung into close the defect. Stricture formation is common if these manoeuvres are employed. It is the author’s contention that extended laryngectomy is only indicated forthe high anterior piriform fossa lesions (morethan3 cm abovethe cricopharyngeus)withoutposterior-wallextension of the incision when an adequate margin is obtained. The submucosal spread of 2cm that these lesions frequently exhibit is best encompassed by the radical removal allowablewith free jejunal replacement. Theauthor’s insititution has an operative mortality of 2% for this procedure, compared with 8-15% for total pharyngolaryngo-oesophagectomy withstomach pullup (Smith et al., 1992). When skilled microvascular surgery is unavailable, the author prefers pharyngolaryngo-oesophagectomy withgastricpull-upfortumoursapproaching closer than 3cm from the cricopharyngeus and for the more circumferential high lesions. Pha~ngo~aryngo-oesophagectomy The otolaryngologist’s role in totalpharyngolaryngooesophagectomy (TPLO) with stomach pull-up is little different to hidher role in pharyngolaryngectomy with jejunal conduit except for a few points. 1 The stomach is mobilised on the tenuous blood supply of the right gastroepiploic artery. Trying to stretch thestomachabovethe hyoid bone level places great tension on the anastomosis line. This operation is most suitable for lower lesions. 2 The abdominal/thoracic surgeon involved must choose between a two-stage (abdomenand neck) or three-stage (abdomen, neck and chest) procedure. Most authors suggest that thetwo-stageprocedure is best. However, the best results the author has seen for this operation were procedures performed by a ‘three-stage’ thoracic surgeon. 3 The stomach requires drainage a procedure (pyloromyotomy or pyloroplasty), as the operation cuts the vagal nerves. 4 The otolaryngology (neck) procedure is the same as for total pharyngolaryngectomy except that the hypopharynx must not be separated from the oesophagus. Rather,theotolaryngologist helps to bring the stomach upto the neck by bluntly dissecting the anterior

and posterior surfaces of the oesophagus at the appropriate time, to allow full mobilisation. The vascular supply of the oesophagus comes in laterally, and these vessels are best left alone until the actualelevation of the stomach to the neck. 5 A primary voice puncture is not usually successful, due to the capaciousness of the stomach. 6 The stomach may be slower to start working again, compared with the small intestine. Gastric stasis may occur despite bowel sounds being present. 7 Special problems of acid reflux into the mouth and ‘dumping’ may be sequelae of this form of surgery.

Suggestions for further reading For a description of partial hypopharyngectomy with laryngeal sparing, see Hawley and Pane (198’7). McNeil (1981) detailed five patientstreated by larynx-sparing procedures with a high rate of relapse and problems with aspiration. The authorhas a current series of 12 such patients, allalive and disease-free for at least 3 years, except for one patientwho presented at 62 monthswithasolitarycerebral metastasis, still with locoregional control.Only very small tumours,with multiple biopsy-proved lack of appreciable submucosal spread, are suitable for laryngeal-sparing procedures.

References Eisback KJ & Krause CJ (1977) Carcinoma of the pyriform sinus: comparison a of treatment modalities. Laryngoscope 87, 1904-9. El Badawi SA et al. (1982) Squamous cell carcinoma of the pyriform sinus. Laryngoscope 92, 357-64, Gluckman Jet al. (1987) Partial vs. total oesophagetomy foradvanced carcinoma of the hypopharynx. Arch. Otol. Head Neck Surg. 113 (l),69-72. Harrison DFN (1970)Pathology of hypopharyngeal cancer in relation to surgical management. J.Laryngol. Otol. 84, 349-67, Harrison DFN (1981)Surgical repair of hypopharyngeal and cervical oesophageal cancer. Ann. Otol. 90, 372. Harrison DFN & Thompson A (1986) Pharyngolaryngooesophagectorny with pharyngogastric anastomosis for cancer of the hypopharynx: review of 101 operations. Head Neck Surg. 8 (6),417-28. Hawley SE & Pane W (1987) Comprehensive Management of Head and Neck Tumours. Philadelphia, W.B. Saunders, pp. 783-93. Hermanek P & Sobin LH (1987) TNM Classification of Malignant Tumours (4th edn). Berlin, Springer-Verlag. McNeil R (1981)Surgical management of carcinoma of the posterior pharyngeal wall. Head Neck Surg. 3, 389. Persky M & Daly J (1981) Combined therapy vs. curative radiation in the treatment of pyriform sinus carcinoma. Otol. Head Neck Surg. 89, 87-91. Smith IM etal. (1992) Triple therapy for advanced squamous cell cancer of the head and neck. Aust. NZ J.Surg. 373-81.

Surgical Voice Restor NIGEL R. BLEACH AND ANDREW J.G. BATCH

Secondary Since tracheo-oesophageal puncture (TEP) was first described by Blom and Singer in 1980, it has become the most widely used technique for surgical voice restoration (SVR). It may be performed either at the time of laryngectomy (primary) or in patients who have previously undergone laryngectomy without voice restoration (secondary). There are two main categories of prosthetic devices, which actas valves withinthe surgical fistula. Nonindwelling prostheses are smaller and can be removed, cleaned and replaced by the patient at varying intervals asrequired (e.g.Blom-Singer prosthesis). Indwelling prostheses are larger and more robust, and stay in situ until device failure requires replacement by the surgeon (e.g. Provox). Thischapter describes the surgical techniques and principles involved in both primary and secondary SVR. Specific details relevant toboth Blom-Singer and Provox prostheses are included.

1 Patients who have failed to achieve satisfactory oesophageal speech after laryngectomy, despite adequate speech therapy. 2 Patients who have very poor-quality speech, or no voice, following more extensive resections (pharyngolaryngectomy and myocutaneous flap repair, or laryngopharyngo-oesophagectomy(LPO) with gastric transposition or free jejunum reconstruction). 3 Patients who find electrolarynx speech unacceptable (robotic quality, slow rate, poor intelligibility) or standard oesophageal speech inadequate (low volume, short phrases, staccato delivery) for daily communication. 4 Patients with good oesophageal speech who require excellent communication skills and fluent clear speech, e.g. teachers, broadcasters, clergy, etc.

indications

2 Patientswitha

Primary

Patients undergoing laryngectomy, including those requiring partial pharyngectomy with flap reconstruction, or total pharyngeal replacement with free jejunum or gastric transposition, may be considered for synchronous TEP and subsequent fitting of an indwelling voice prosthesis. This allows the patientto leave hospital with a functional voice, but does preclude careful assessment for SVR, and this may subsequently reduce the overall success rate. Emotional and social factors may prove to be particularly adverse, leading to late failures.

Contraindications Primary 3. There are no absolute contraindications to SVR.

T3 or T4 obstructing laryngeal tumour, extensive subglotticextension or peritracheal nodal involvement are athigh risk of stomal recurrence, and a primary TEP should probably be avoided. 3 Patients who require full-dose radiotherapy (RT)(5070Gy preoperative or plannedpostoperative)are at greater risk of fistula formation and woundbreakdown. In general, however, the presence of a well-constructed surgical fistula stented by a nasogastric tube should not interfere with woundhealing. If wound breakdown and/ or salivary fistula occurs, then stoma-gastric feeding via the tracheo-oesophageal (TE) fistula tube is well tolerated by the patient. Insertion of a prosthesis should be

SurgicalVoiceRestoration delayed until wound healing is achieved, or electively deferred in any patient at high risk of delayed healing. 4 Postoperative RT in a patient with a primary TEP may cause considerable peristomal reaction (tenderness, oedema, serous ooze and crusting),This makes accurate sizing and fitting of a Blom-Singer prosthesis difficult, and stomal occlusion for voicing becomes painful. Temporary stentingof the fistula with a catheterand delayed fitting of the prosthesis after completion of RT (or secondary SVR) may therefore be preferable. An indwelling Provox prosthesis fitted primarily should not need changing during RT, but voicing may not be possible initially, due to local reaction as above. Secondary and general

Most patients are ableto gain benefit from SVR using a voice prosthesis. Contraindications are relative, rather than absolute, and vary in significance and relevance in different patients.Factors to consider include the following: 1 drug abuse/alcoholism; 2 extreme age, frailty, senile dementia; 3 impaired eyesight, e.g. cataract, glaucoma, myopia; 4 impaired dexterity or incoordination, e.g. severe arthritis, Parkinson’s disease, CVA, etc; 5 coexistent chest disease with chronic cough,excessive sputum, dyspnoea at rest; 6 poor support from spouse, family, other relatives. A combination of two or three of the above adverse factors may, in practice, make succesful SVR impossible. However, with a given patient, trial and error are often required before a final decision to abandon TE fistula speech is made.Manualdexterityand visual acuity are more relevant to patients required to change non-indwelling prostheses, forwhomapermanently indwelling valve may be more appropriate.

Preoperative management Patient counselling

Full discussion withtheoperatingsurgeon, speech therapist, ENT nursing staff and successfully rehabilitated patients (both oesophageal and prosthetic speakers) is importantto allow informed decisionmaking. This may include the use of instructional videos, booklets, etc. and alsofamiliarisationwith equipment, e.g. voice prostheses, stoma valves, electrolarynxes.

3 97

Primary tracheo-oesophageal puncture

Full preoperative investigations prior to major surgery (as standard for laryngectomy/laryngopharyngectomy-see Chapters 51 and 54), plus endoscopic and radiological staging of the primary tumour, assessment of neck-node involvement and exclusion of distant metastases, are required. Secondary tracheo=oesophageal

1 Define the reason for failure of oesophageal speech, using acombination of radiology (preferably videofluoroscopy) and air-insufflation testing via a transnasal catheter to simulate phonation. This allows identification of patients with pharyngeal strictures or hypertoniclspastic pharyngeal function who fail to produce oesophageal speech oradequate voice on air insufflation. These patients usually require pharyngeal myotomy to allowgood voice production following TEP (Cheesman et al., 1986; Baugh et al., 1987; McIvor et al., 1990). 2 Patients who fail insufflation testing preoperatively, or whofail to produce fluent speech with a low-pressure prosthesis, may be retested after pharyngeal-plexus blockade, using local anaesthetic (LA) infiltration. Marcaine (10%) is injected intotheparapharyngeal region bilaterally while palpating (and hence protecting) thecarotid vessels. The needle passes medial to the fingertips and straight back onto thepre-vertebral fascia. After 10-20min, insufflation testing is repeated withthepharyngealconstrictorstemporarily relaxed, simulating myotomy. A good voice suggests that division of constricting pharyngo-oesophageal (PE)muscles is liable to be effective. 3 The neck and stomashould be assessed. A deeply recessed stoma prevents adequate stoma occlusion for voicing; this is readily corrected by dividing prominent sternomastoidtendons, which often ‘bow-string’ on either side of the stoma. A very small stoma may require stomaplasty to allow adequate space for the voice prosthesis. Excision of an overhanging crescentic lip of cartilage and fibrous tissue, together with a midline inferior or superior cartilage splitting incision and V-Y advancement flap is effective, as are bilateral Z-plasties. Either procedure is conveniently performed at the time of TEP and myotomy.

398

Chapter 55

As for laryngectomy (see Chapter 51). (Fig. 55.1) Followinglaryngectomy, RT andneckdissection,or flap repair o f the pharynx, the anatomy o f the neck is altered. 1 The pharynx lies immediately subcutaneously in the midline above the tracheostome. 2 The common carotid artery (CCA) and internal jugumay be densely adherent to the side of the lar vein (IJV) pharynx, and the carotid may also be subcutaneous on the side o f a previous neck dissection. 3 Normal tissue planes are distorted or obliterated by fibrosis, and landmarks are few. The pharynx may be more readily identified if distended by a large-bore (32FG) gastrictube,which gives afirm, palpablelandmark in the midline. The pulsatile common carotid laterally and the plane of thepre-vertebralfascia posteromedially areother valuable landmarks in the previously operated neck. Careful sharp dissection and blunt finger dissection to open tissue planes must be used in combination.

Fig. 55.2 Primary tracheo-oesophageal puncture.

cture

Pre~aratio~

The procedure is performed undergeneral anaesthetic (GA)asan integral part o f laryngectomy,andwith appropriateantibioticprophylaxis.TheTEP is performed following resection of the larynx, but prior to the closure o f the pharynx. Procedure

1

1

tendons lateral to stoma

I I

/

reopened on left side of neck]

f

,

---__ or buried in fascia

. .

.. . . .

. . . . . .

.~" "

Fig. 55.1 Secondary voice restoration-anatomy of myotomy approach.

1 Duringmobilisation o f the larynx,theconstrictor muscles should becarefullydissected and preserved, withoutcompromisingtumourclearance, to allow an adequate PE segment to be constructed. 2 Thepartywall between the tracheaand upper oesophagus should not be dissected below the level at whichthetrachea is resected to deliver the resected larynx.However,ifthetracheaandoesophagusare widely separated, then the party wall is reinforced with abuttresssuture (310 Vicrylmattress) to stabilise the region and prevent an area o f dehiscence and potential abscess formation (Hamaker et al., 1985). 3 A large, curved, artery forceps is passed into the lumen of the upper oesophagus and angled so that the tips

I

Surgical Voice Restoration

3 99

Fig. 55.3 Primary tracheo-oesophageal puncture-Provox technique.

indenttheposteriortracheal mucosa inthe midline, approximately 1cm inferior to the cut margin of the trachea. A S--lOmm transverse incision is then made on to the tips of the forceps (a vertical incision may disrupt the posterior tracheal wall) (Fig. 55.2). 4 A 14FG Ryle’s tube is introduced into the open tips of theforcep anddrawnthrough the incision into thepharynx. Thetube is then reversed and passed inferiorly, using non-toothed forceps and digital pressure, to be used postoperatively as a feeding tube. 5 For inserting the Provox prosthesis, a specially designed trochar and cannula, plus pharyngeal protector, are available. The latter is a short bevelled tube which is inserted into the upper oesophagus down to the level of the stoma. The sharp, pointed trochar and cannula are then used to puncture the party wall 1cm below the transected tracheal margin (Fig. 55.3). 6 In a routine laryngectomy, without preoperative irradiationor flap reconstruction,theProvox prosthesis

may be inserted at the time of surgery, as first described by Hilgers and Schouwenburg (1990). The introducing guide-wire is passed throughthecannulaintothe pharynx,a valveis attached by its ‘string’ and then pulled through retrogradely into the fistula (Fig. 55.4). Valve seating is helped by combined gentle traction on the tracheal flange of the valve with a fine artery forceps and asynchronousrotating movement. Postoperative feeding is then via a standard nasogastric tube. 7 In patients at high risk of woundbreakdown,the technique of primary TEP with stenting of the fistula and deferred fitting of the prosthesis is employed, as for the Blom-Singer prosthesis. In such cases, an artery forceps can be guided through the lumen of the Provox cannula as itis slowly withdrawn anda 12-14 FG Ryle’s tube passed through the fistula, as previously described. 8 The avoidance of a tight, hypertonic PE segment is vital to the success of SVR. In many cases, the upper oesophageal region feels tight when the index finger of

ployed. However, a tight vertical or T-shaped closure may predispose to stricture, especially when postoperative RT is planned. To produce a relaxed, widely patent pharynx,horizontal closure (as in pyloroplasty) may be preferrable. Thelateral margins of thetriangular pharyngeal defect may be gently distractedwithstay sutures, and with neck flexion (and occasionally mobilisation of a superior, tongue-base flap) horizontal closure is usually possible. Inverting 310 Vicryl sutures are used (interruptedorcontinuous Connell),with loose closure of the preserved inferior constrictors and tongue-base muscles as a second reinforcing layer (Fig. 55.5). St

Fig. 55.4 Primary tracheo-oesophageal puncture-Provox

technique.

the surgeonis gently inserted into thelumen. If this is so, then the circular upper-oesophageal muscle fibres should be divided down tothe submucosa to release any constriction.This myotomy shouldextendfromthe level of the TEP inferiorly, up to the level of the pharyngeal closure superiorly. Alternatively, dissection and then division of branches of the pharyngeal plexus to denervate the muscle may be performed (Singer et al., 1986). These measures should prevent a hypertonic PE segment developing postoperatively. Pharyngeal closure

This is performed as for routinelaryngectomy, but again it is vital to prevent stricture or hypertonicity if SVR is to be successful. If sufficient pharyngeal mucosa is present, then a T-shaped or vertical closure can be em-

1 Keep the patient nil by mouth (NBM) for 7-10 days and feed via the stoma-gastricRyle’s tube; then progressively reintroduce fluids, soft diet and normal diet as tolerated. 2 Once normal feeding is established, the fistula may be sized, using a Blom-Singer voice-prosthesis sizer, and an appropriate voice prosthesis is fitted (16FG BlomSinger duckbill or low-pressure prosthesis, sizes 1.43.6 cm). Alternatively, the fistula may be progresively dilated and the new long-term indwelling Blom-Singer prosthesis (20FG with special introducer and soluble gelatin insertion cap) may be fitted. 3 If aProvox prosthesis has been inserted at laryngectomy, valve cleaning (using a moist cytology brush) should commence on the first postoperative day, to prevent crusting or distortion of the valve flap. Voicing is not allowed until the wounds have healed and normal oral feeding has been reinstituted. 4 If fitting of theProvox valve has been deferred, thenpostoperativemanagement is the same asin 1 above. However, the Provox valve comes in only three sizes (6, 8 and 10mm lengths, 22 FG diameter). At first insertion, almost all patients require the standard 8mm size. 5 After fitting of anappropriate prosthesis, speech rehabilitation by an experienced speech therapist commences. An adhesive external tracheostomal valve may also be fitted, which obviates the need for finger occlusion of the stoma on exhalation when speaking. 6 If postlaryngectomy complications occur (e.g. wound infectiodbreakdown, salivary fistula, chest infection), then prosthesis fitting is deferred and the fistula is stented with a catheter. Similarly, RT may delay speech rehabilitation because of peristomal soreness, crusting and oedema.

Surgical VoiceRestoration

40 I

Fig. 55.5 Horizontal pharyngeal closure.

Complications

Complications of primary TEP arethose of laryngectomy, plus those related to the additional fistula and prosthesis, and general complications following major surgery (e.g. pneumonia, wound infection, neck haematoma, deep vein thrombosis (DVT), etc.). Specific complications include the following: 1 tracheostomal stenosis; 2 salivary fistula; 3 fistula granulation and/or closure; 4 salivary leakage through or around prosthesis; 5 aspiration of prosthesis (not permanently indwelling prostheses). ec

Preparation

Anaesthesia Theoperation is performedunder GA, using an armouredJ-shaped laryngectomy anaesthetictube (e.g. Rusch Laryngoflex). This tube can be taped to thechest in the midline to lie away from the operative field, and may be intermittently removed (after preoxygenation) to allow access to the stoma.

Antibiotic prophyla~is Prophylactic cover is advisable when pharyngeal myotomy is performedas an adjunct to simple TEP,

in order to protectagainstinadvertent breach of the pharyngeal mucosa with salivary contamination. Metronidazole and acephalosporin (e.g. cefuroxime) or Augmentin (amoxicilli~clavulanate) areacceptable options.

Position The patient is positioned supine with the head extended on a flexed neck, as for oesophagoscopy. Procedure

1 An illuminated bronchoscope or oesophagoscope is passed into the oropharynx and thenadvanced past the tongue base into the upper oesophagus. Any narrow or strictured area is gently dilated with bougies, and the scope is passed down to the level of the tracheostome. 2 The scope is rotated through 180" so that the bevel is facing anteriorly to transilluminate the posterior wall of thetrachea.The bevel will thenalsoprotectthe pharynx from the scalpel blade and/or trochar used to perform the TEP (Fig. 55.6). 3 Occasionally, after previous RT and/orcomplex pharyngeal reconstruction, itmay be difficult to pass the rigid scope downto the level of thetracheostome. A flexible paediatric gastroscope (e.g. Olympus XP20-diameter 6.6mm)can be passed under direct vision, a flexible guide-wire introducedthroughthe scope, the scope withdrawn and the pharynx then dilatedwith complete safety, using perforateddilators

Fig. 55.6 Transillumination of stoma.

threaded over the guide-wire. Thistechnique allows subsequent rigid instrumentation in almost all cases (A. Batch, pers. comm.). 4 A transverse incision is made into the posterior tracheal wall in the area illuminated by the bevelled tip of the endoscope, which is maintained firmly against theparty wall, using the left hand.The blade will pass through to the underlying metallic lumen of the

scope. The incision lies approximately 1cm below the mucocutaneous junction in the midline (Fig. 55.7). 5 A flexible Teflon trochar and attached 14FG Ryle’s tube (A.D. Cheesman, CharingCrossHospital, pers. comm.) is then passed throughthe incision intothe lumen of the oesophagoscope and, by advancingthe trochar andsimultaneously withdrawing the endoscope, the trochar and tube are delivered through the mouth (Fig. 55.8). 6 Alternatively, the Blom-Singer TEP set may be employed. This comprises a small, curved trochar with a Teflon sleeve, which is inserted in a similar fashion to make the initial TEP. The trocharis then removed and a guide-wire, attached to atapered silicone catheter is passed via the sleeve into the oesophagoscope. Traction on the wire and gentle dilatation of the puncture with the tip of a fine, curved artery forceps allows thesilicone catheter to be drawn up the oesophagoscope and out through the mouth (Figs 55.9-55.11). 7 A further technique employs a modified pair of abdominal forceps (TE forceps-Down’s Surgical), which areintroducedintothepharynxunder direct vision, alongside a pharyngoscope. The forceps is then advanced to the level of the stoma and the tips are angled to indent the posterior tracheal wall, allowing secondary TEP to be performed in a similar fashion to primary TEP (Rhys-Evans, 1991). 8 Whichever technique is employed, thecatheter

Fig. 55.7 Placement of tracheooesophageal puncture.

Surgical ‘Voice Restoration

403

further down the oesophagus under direct vision. This can be combinedwith slow tractiononthecatheter externally at thestoma in order to pass thecatheter inferiorly-paticularly when the catheter forms a tight loop at the level of the stoma. 9 Thecatheter is secured to the skin with adhesive tape, and spigoted to prevent reflux of gastric fluid. 10 Fistula sizing and fitting of an appropriate prosthesis

Fig. 55.8 Advancement of trochar.

Fig. 55.10 Inserting guide-wire.

Fig. 55.9 Tracheo-oesophageal puncture using trochar and Teflon sleeve.

stenting the TIE fistula must then be reversed and passed down the oesophagus (in a similar fashion to passing a nasogastric tube) by using an anaesthetic laryngoscope and Magill forceps. A pharyngoscope and straight oesophageal grasping forceps may then be used to advance the presenting loop or ‘knuckle’ of the catheter

Fig. 55.11 Traction on guide-wire draws catheter superiorly.

404

Fig. 55.12 Tracheo-oesophageal puncture.

supplied andtomaketheTEPapproximately1cm belowtheposteriortracheocutaneousjunction.The trochar passes intothe bevelled mouth of theoesophagoscope, as previously described, and an introducer is then fed through the cannula and delivered through the mouth as the scope is withdrawn. If preferred, the introducer is rigid enough to be passed up the pharynx after withdrawing the scope. An 8 m m Provox valve is then attachedto the fixation point at the end of theintroducer by its ‘string’, and the valve is pulled down through the pharynx until the string emerges through the fistula. The cannula in the fistula is thenwithdrawn. Do not puli hard on thestring at this pointin an attempt to seat the valve; this will damage the valve or fistula, or both.

Introducer passed through trocar and up pharyngoscope

Fig. 55.13 Trochar inserted into pharyngoscope.

Fig. 55.15 Valve withdrawn into pharynx.

Fig. 55.14 Prosthesis attached to guide string.

can proceed after 24-72 h, depending on thepatient and the speech therapist. 11 T o insert an indwelling Provox valve(Figs 55.1255.151, it is advisable to use the trochar and cannula

Fig. 55.16 Final positioning of prosthesis.

Surgical Voice Restoration

40 5

care not to enter the subcutaneous pharynx. 2 The incision (Fig. 55.17) should be made on the side opposite to a previous neck dissection, as the sternomastoid muscle is a useful landmark and also protects the carotid and IJV. Similarly, the side on which the thyroidlobehas been preserved at laryngectomy (if known) should be avoided, as thevascular and adherent thyroid remnant may complicate the approach.

Procedure

Fig. 55.1’7 Pharyngeal myotomy-incision.

12 Thetracheal flange of the valve should be gently grasped withmosquito forceps as it appears through the fistula. The valveis seated by combinedtraction and rotation until it flicks into place (Fig. 55.16). The string is then cut to free the introducer, and the valve is orientated upright in the fistula. Voicing should start immediately the patient returns to the ward from theatre. Pharyngeal myotomy

This may be necessary as an adjunct to secondary TEP, inorder to relieve hypertonic or spastic pharyngeal muscle function, which would impede or prevent successful SVR..It is appropriate to voice rehabilitation using either prosthesis type (non-indwelling or indwelling).

l Careful elevation of skin and platysma1 flaps allows identification and dissection of the anterior border of sternomastoid. 2 Cautious sharp dissection, alternating with frequent deep palpation, will identify thepharynx medially (stentedwitha 32FG tube) and the pulsatile carotid laterally. Note that the carotid sheath and IJV may be closely adherent tothe lateral pharynx and/orencased in fibrosis, particularly in the irradiated neck. 3 Sharp dissection should open a plane medial to the carotid (see Fig. 55.1), which may then be developed with blunt swabor finger dissection to enter theplane of the pre-vertebral fascia retropharyngeally. This is usually an unscarred area and a further landmark. 4 Rotation of the pharynx by the assistant exposes the posterior surface, and the tube within the lumen is simultaneously pushed towards the operator. This provides resistance to incise on to whenperformingthe myotomy (Fig. 55.18). The tight circular muscles of the pharynx and upper oesophagus are divided with a no.

Preparation

1 Following secondary TEP as above, a large-diameter (32FG) gastric tube is passed into the upper oesophagus, to act asa rigid stent in the lumen and to aid in the identification of the pharynx in the operated and irradiated neck. 2 The neck is extendedwiththepatient supine, the shoulders raised with a sandbag and the head supported ina head ring. The skin is preparedwithasuitable antiseptic (e.g. aqueous chlorhexidine) and the patient draped with towels to exclude the mouth from the operative field. Antibiotic prophylaxis is given. Incision

1 The previous Gluck-Sorensen laryngectomy incision is reopened from below the angle of the mandible superiorly to the supra-stomal area in the midline, taking

Fig. 55.18 Pharyngeal myotomy

406

Chapter 55

10 blade down to, but not through, the mucosa, from the tongue base to thelevel of the stoma.Some surgeons use operating loupes or the microscope to ensure complete division of all constricting fibres. 5 The upper and lower limits of the myotomy are conveniently marked with Ligaclips, which can be identified subsequently during radiological investigation. Closure

1 A suction drain is placed in the parapharyngeal region to prevent haematoma, or to drain saliva should any fistula develop. 2 The wound is closed in layers, using 310 Vicryl, 410 nylon and Steristrips to support the skin.

and rarely affect subsequent voice acquisition (Scott et al., 1993).

l Minor wound infection. 2 Haematoma formation. 3 Aspiration of prosthesis. The more serious complications are related to difficulties in endoscopy andlor inexpert tracheal puncture. 1 Oesophageal perforation. 2 Parapharyngeal abscess. 3 Mediastinitis. More commonly, a small salivary leak develops, which is managed conservatively by continued suction drainage, tube feeding and antibiotics, and speech rehabilitation is not adversely affected (Scott et al., 1993).

References Postoperative management

1 Prophylactic antibiotics are continued for 24 h (three doses) but may be reintroduced if haematoma or salivary fistula develops. 2 A regular antiemetic (e.g. prochlorperazine or metaclopramide) should be given for thefirst 24-48 h to prevent vomiting and rupture of the weak pharyngeal mucosa. 3 The suction drain is removed after 24-48 h. 4 The patient should be kept NBM for 2-S days and feeding maintained via the stoma-gastric catheter. Diet is then reintroduced progressively, from fluids, through soft diet to full diet as tolerated. 5 Sutures are removed after 5-7 days (7-10 days in an irradiated neck). 6 The fistula issized andanappropriate prosthesis is fitted after removal of sutures and once normal diet is being tolerated. Speech rehabilitation then commences. Complications These are usually minor, affect less than 20% of patients

Baugh RF, Lewin JS & Baker SR (1987) Preoperative assessment of tracheoesophageal speech. Laryngoscope 97, 461-6. Cheesman AD, Knight J, McIvorJ & PerryA (1986)Tracheooesophagealpuncturespeech: an assessmenttechniqueforfailed oesophageal speakers. J.Laryngol. Otol. 100, 191-9. Hamaker RC, Singer MI, BlomED & Daniels HA (1985) Primary voice restoration at laryngectomy. Arch. Otolaryngol. 111, 182-6. Hilgers FJM & Schouwenburg PF (1990) A new low-resistance self retainingprosthesis(Provox)for voice rehabilitationaftertotal laryngectomy Laryngoscope 100, 1202-7, McIvor J, Evans PF, Perry A & Cheesman AD (1990) Radiological assessment of post-laryngectomy speech. Clin. Radiol. 41, 312-16. Rhys-Evans P (1991) Tracheo-oesophageal puncture without tears: the forceps technique. J.Laryngol. Otol. 105, 748-9. Scott PMJ, Bleach NR, Perry AR & Cheesman AD (1993) Complications of pharyngeal myotomy for alaryngeal voice rehabilitation. J.Laryngol. Otol. 107, 430-3. Pharyngealplexus Singer MI, BlomED & HamakerRC(1986) neurectomy for alaryngeal speech rehabilitation. Laryngoscope 96, 50-3.


PHILIP J. ROBINSON

Introduction Open biopsy of a suspicious neck node, or of a mass in the head and neck, remains an essential diagnostic manoeuvrebutshould be deferred, absolutely, until an exhaustive diagnostic work-up has been completed in an effort to detect the primary lesion. All patients presenting with a head and neck mass should undergo a full ENT assessment. In many cases a careful history will elicit symptoms related to a primary site within the upper aerodigestive tract. In asymptomatic patients presenting with a neck mass, the initial clinical ENT examination, alone, will detect 65% of the primaries (Martin & Romieu, 1952). Overall, a primary site can eventually be found in all but 10-15 % of patients presenting with a neck mass after an exhaustive work-up and careful follow-up over many years. The advent of increasingly reliable fine-needle aspiration cytology (FNAC) has greatly reduced the necessity foropen biopsy of neck masses. FNAC will usually define the problem (tumour versus in~ammation) and identify cell type and tissue of origin. In a report of 500 head and neck lesions the diagnostic accuracy of FNAC was 94.5% (Young et al., 1981). This technique is also virtually free of tumour seeding (Sinner & Zajicek, 1976). Open biopsy of a cervical lymphnodecontaining squamous-cell carcinoma (SCC) has not been shown to affect survival time, but it may delay appropriate treatment of the undetected primary and it is associated with certain complications, including fungation, wound necrosis, local recurrence and distant metastases (McGuirt & McCabe, 197’8; Gooder & Palmer, 1984). Furthermore scarring makes subsequent assessment of the neck more difficult (Shaw, 1970).

The differential diagnosis of cervical lymphadenopathy includes benign lymphoid hyperplasia, lymphoma, metastatic carcinoma, mycobacterial infection, toxoplasmosis and otherviral, bacterial and fungal infections (particularlyinimmunocompromisedpatients). The differential diagnosis also includes thyroid tumours, salivary-gland tumours, carotid-body tumour, branchial cyst and neurogenic tumours.

Indications Open biopsy should be considered only after an exhaustive diagnostic work-up (see below), including clinical examination, radiological studies, panendoscopy and FNAC, has failed to reveal a diagnosis.

1 Failure of diagnostic work-up toestablish a diagnosis.

2 Cytology suggestive of lymphoma, where histological architecture is still necessary for classification and treatment planning. In this situationopen biopsy can be coordinated with bone-marrow aspirationand trephine. 3 Children: cervical lymphadenopathy is very common in children. However, an enlarging neck node, symptoms and signs of systemic disease orabnormal test results (see below) are indications for open biopsy. Occasionally, parental anxiety is such that itis necessary to remove the offending lymph node. 4 HIV/AIDS patients: cervical lymphadenopathy is present in about20% of patientswith AIDS/AIDSrelated complex (Davis et al., 1988). Open biopsy is only indicated in thosepatientswherethenode is tender or enlarging and where theFNAChas been unhelpful. It is not indicated in the HIV or AIDS patient 409

410

Chapter S6

withnon-tender or non-enlarging nodes who have persistent generalised lymphadenopathy. FNAC will enablea diagnosis to be madeinmost cases with enlarging or tender nodes, enabling specific treatment such antituberculous as chemotherapy to be commenced. 5 Tuberculosis: fine-needle aspiration with samples sent to cytology and microbiology combined with a Mantoux skin test will usually allow the diagnosis of mycobacterial adenitis to be madewithout recourse to open biopsy (Davis et al., 1993). However, where there is any doubt about the diagnosis, open biopsy will provide material for histology and further microbiology. Excision of the lymph node may be necessary to treat atypical mycobacterial infection (Mycobacterium avium i~tracell~lare), which is frequently resistant to Chemotherapy.

only at right angles to the nerve and notin theline of the nerve. Supraclavicular nodes may indicate metastatic spread from outside the head and neck and therefore a thorough examination of breasts, bronchus, gastrointestinal tract and kidneys is required. In all cases a search is made for any other sites of lymphadenopathy and for hepato- or splenomegaly.

Preoperative managemen

In every case a full blood count with differential and erythrocyte sedimentation rate (ESR) is requested.

All patients presenting with a mass in the headand neck should undergo a full ENT assessment. History

A careful evaluation of symptoms referable to the upper aerodigestive tract, especially hoarseness, dysphagia, pain, otalgia, nasal obstructionand bleeding, is undertaken. Systemic symptoms, such as nightsweats, malaise and weight loss, are sought. A past history of heavy smoking and alcohol intakeis significant. Possible contact withTB and HIV risks should be borne in mind. Examination

A full ENT examination,takingparticularcare to examinethepostnasal space, oral cavity, posterior third of the tongue, tonsil, larynx, pharynx and thyroid. This examination is supplemented by fibre-optic rhinolaryngoscopy. The position of the node is a guide to the likely site of the primary. The size, positionandcharacter of thenode(s) are recorded and N staging established. A hard, fixed mass is suggestive of SCC and single or multiple rubbery nodes are more suggestive of a Hodgkin’s lymphoma. Pulsation within the mass should alert one to the possibility of a carotid-body tumour and is an indication for further investigation with an arteriogram or a magneticresonance arteriogram. A vagal schwannoma may present in a similar way to an enlarged lymph node but is fixed to the underlying nerve and is therefore mobile

Fine-needle aspiration cytology

Aspiration samples are taken in every case, except in young children, and sent for cytology and to microbiology; the possibility of acid-fast bacilli must be mentioned on the request form. Blood tests

Mantoux skin test

In any case where there is suspicion of tuberculosis.

1 Chest X-ray. 2 Sinus X-ray. 3 Barium swallow is indicated where there is suspicion that the node represents a metastasis from a primary withinthehead and neck. There is alsoa significant incidence of synchronous primary tumours within the upper oesophagus. 4 CT is very useful both in evaluating the neck nodes and in searching for the primary site. If performed, it should always be done before any biopsies are taken. The following CT signs suggest that a cervical node is likely to be positive for tumour: (a) greater than 1.5cm diameter; (b) non-enhancing or heterogeneous nodes; (c) ill-defined or irregular border; (d) groups of three or more nodes, 0.6-1.5 cm, with ill-defined or juxtaposed borders. The following CT signs suggest that the node is more likely to be negative for tumour: (a) less than 1.5 cm diameter; (b) discrete; (c) sharp margins; (d) virgin fascial planes around the carotid artery.

Lymph-nodeBiopsy in theHeadandNeck

Endoscopy

If the above management has failed to reveal a primary site and/or to make a diagnosis, panendoscopy is indicated. This should be done by the surgeon who will be responsible for the further management and should include direct laryngoscopy, direct pharyngoscopy, rigid oesophagoscopy, bronchoscopy and examination under anaesthetic (EUA) of thepostnasal space, oral cavity and oropharynx. Biopsies are taken from any suspicious areas and, in the absence of an obvious primary, random biopsies are taken from the fossa of Rosenmuller, the posterior wall of the postnasal space, the posterior third of the tongue after careful palpation and the pyriform fossa, and the ipsilateral tonsil is removed for serial sectioning by the histologist. Management strategies

The management strategy used will depend on whether the planned further treatment for an SCC is radiotherapy or a radical neck dissection. 1 Panendoscopy and proceed to open biopsy of the cervical node, under the same anaesthetic, if there is no sign of a primary tumour. Thisstrategy is appropriate if, when histology reveals an SCC within the lymph node, further treatment would be radiotherapy alone to the neck and potential primary sites. If multiple nodes are present, it would be usual to plan a radical neck dissection, followed by radiotherapy to the potential primary sites and, where indicated, to the neck as well. 2 Panendoscopy andawait results of therandom biopsies. If these results are negative, the patient would undergo a further anaesthetic and open biopsy of the cervical lymph nodewith frozen-section histology; if this shows SCC one would proceed to a radical neck dissection underthe same anaesthetic. Frozen section allows diagnosis of cell type in all but 1.2% of cases, but much moreinformation is available aftera paraffin section is done with tumour surface markers and electron microscopy (Remsen et al., 1984). The relevant merits of the subsequent managementstrategies and the use of radiotherapy are beyond the scope of this chapter and readers are referred for further readingto Liepzig et al. (1981) andJesse et al. (197’3). Management of cervical lymphadenopathy in children

Cervical lymphadenopathy is very common in children and usually associated withupperrespiratorytract

411

infections (URTIs). However,it is not uncommon to see a child with a persistently enlarged lymph node with anxious parents and GP. The child should undergo afull clinical assessment with particular regard to systemic symptoms such as weight loss, night sweats, malaise and examination for other lymphadenopathy and hepatosplenomegaly. A full blood count and differential, ESR and chest X-ray should be done and a Mantoux test where there is any suspicion of mycobacterial infection. FNAC isvery helpful if age permits. The child is reviewed after 2 weeks with the results and re-examination by the same clinician. Open biopsy is indicated if there is any suspicion, e.g. rapid enlargement orabnormal test results; otherwiseit is usually satisfactory to reassure the parents and to arrange a review in 1 month, again by the same clinician.

Relevant anatomy The lymphatic drainage of the head and neck is into two levels: first a deep group, which forms the common drainage pathway, and second an intermediate group or superficial layer, which drains into the deep group. It is the deep group which is usually involved when a patient presents with a node in the neck. This group lies along the great vessels from skull base to clavicle and is covered by the sternomastoid muscle for much of its length. However, -the more superior nodes may present in the anterior triangle of the neck (e.g. jugulodigastric node) and the lower deep nodes may present behind the muscle in theposterior triangle. Thelocation of cervical lymph-node groups most frequently involved by metastases from different primary sites within the head and neck is shown in Fig. 56.1. The deep group of lymph nodes lies beneath the deep layer of cervical fascia and therefore it is necessary to divide skin, subcutaneous tissue, platysma, superficial cervical fascia and finally the deep layer of cervical fascia to reach the involved nodes. In lymph-node biopsy, the deeper structures of the neck, such as the great vessels, are rarely encountered, but a detailed knowledge of the anatomy is still necessary. However, it is the more superficial structures, such asthemarginalmandibular nerve and the accessory nerve, which are at particular risk.

Marginal mandibular nerve

The marginal mandibular branchof the facial nerve is at risk with any dissection in the submandibular region. The nerve leaves theparotidglandandruns in the

412.

Chapter S6

Fig. 56.1 Location of cervical lymph-node groups most frequently involved by metastases from named primary sites. (adapted from Scott Brown’s Otolaryngology, 1987, Kerr AG (ed.). With the permission of Butterworth-Heinemann.)

superficial layer of thedeep cervical fascia fromthe angle of the mandible to the mandibular notch, usually about 1cm below the mandibular body in a gentle arc (Fig. 56.2). The nerve is always superficial to the facial of the vessels and is always abovethelowerborder mandible, anterior to the facial vessels (Stern, 1992). Careful elevation of the skin flap in this region in a plane immediately below platysma will leave the superficial layer of deep fascia intact.Careful dissection of this layer of fascia with dissecting haemostats, as used in tracingthe nerve inaparotidectomy, will reveal the nerve. A facial nerve stimulator will help in finding the nerve, which canthen be isolated or avoided as necessary. ss

Fig. 56.2 Location of marginal mandibular nerve (adapted from Stern, 1992).

er

The spinal accessory nerve is at risk with any dissection in the posterior triangle. The nerve lies within the superficial layer of deep cervical fascia and so great care must be takenin elevating any skin flaps in the posterior triangle. The nerve is located by first identifying the position of Erb’s point, a point halfway between the mastoid process and the clavicle on the posterior border of the sternomastoid, wherea bundle of cervical cutaneous nerves emerge. An imaginary line is dravvn,from this point to thethyroidnotch (Fig. 56.3). The accessory nerve will emerge fromtheposteriorborder of the sternomastoid muscle within 2cm above this line and will courseacrosstheposterior triangle to enterthe anterior border of trapezius within 2cm below it. Care-

ful dissection within these boundaries in the superficial layer of deep cervical fascia with fine haemostats, aided by a nerve stimulator, will identify the nerve (Becker & Parell, 1979).

Operative technique The operative procedure should be carried out by the surgeon who will have responsibility forthefurther, p:qssibly surgical, management of thepatient.It is Aot a procedure that should be left to the most junior surgepnl

Lymph-node Biopsy in the Head and Neck

413

excised and the incision incorporated into a subsequent neck dissection. Where possible it should lie over the node and inthe lines of relaxed skintension. For a submandibular node, it should be at least 3cm below the mandibular margin to avoid the marginal mandibularbranch of the facial nerve. For a posterior-fossa node, it should be remembered that the accessory nerve courses fairly superficially and can be cut inadvertently in the first incision. rocedure

Fig. 56.3 Course of accessory nerve. (adapted from Becker GD and Parell GJ (1979) Technique of preserving the spinal accessory nerve during radical neck dissection. Laryngoscope 89, 827-3 1.)

Preparation

Preoperatively fully informed consent is obtained. The procedure is usually doneundera general anaestheticwithendotrachealintubation,butcan be done under local anaesthetic (LA) with sedation if the patient is unfit for a general anaesthetic (GA). If it is planned to use a nerve stimulator, LA is avoided and the anaesthetist should be asked not to paralyse the patient. Infiltration with 1:200000 adrenaline can reduce the bleeding, but the infiltration itself can distort the tissue planes and make it more difficult to find a small node. The patient is placed supine on the operating table. The neck is extended and a sandbag placed under the ipsilateralshoulder.Theplanned incision should be marked before the head is rotated. The head of the table is elevated to reduce bleeding. The skin is prepared in the standard fashion and the patient is draped. lncision

Careful planning is required to ensure that any incision will not compromise any future neck dissection. Readers are referred to Chapter 62 for neck-dissection incisions. The incision should be placed so that the scar can be

1 Skin incision, carried down through the skin, subcutaneous tissue and platysma. 2 Elevation of skin flaps, including platysma. In the submandibular region, the elevation of the flap should be precisely at the interface of platysma and the underlying fatty tissue. Judicial use of hand-held a electrocautery unit will reduce the bleeding and aid early identification of nerves. 3 Identification of the marginal mandibular nerve in the submandibular region. If the node is close to the course of the nerve, it is wise to identify the nerve in order to avoid inadvertent damage. The nerve runs within the superficial layer of the deep cervical fascia, lateral to the facial vessels (Fig. 56.2). Careful dissection of this fascia from over the submandibular gland, using fine dissecting haemostats in a similar fashion to tracing the nerves in a parotidectomy and supplemented by a facial nerve stimulator, will allow direct visualisation of the nerve so that it may be dissected free. Alternatively, the fascia may be divided at a level below the submandibular gland and elevated as a flap with the nerve within it, but thiscarries a higher risk of inadvertent damage. 4 Identification of the accessory nerve in the posterior triangle. If thenode is intheposterior triangle, it is frequently adjacent to the nerve. A detailed knowledge of the course of the nerve is required (Fig. 56.3), and identification and avoidanceare recommended. The nerve is found coursing across the posterior triangle in the superficial layer of the deep cervical fascia, often in a very superficial position and occasionally even adherent to skin. Erb’s point is identified, mid-way between the mastoid process and the clavicle, where the cutaneous cervical nerves emerge from the posterior border of thesternomastoid muscle. Careful dissection in the superficial layer of deep fascia of the posterior triangle will enable identification of the nerve, which can then be dissected free of the node. 5 The dissection is deepened to the deep cervical fascia, which is divided. For access to the jugular chain of lymph nodes, this is easily done along the anterior bor-

4-14

Chapter 56

der of sternomastoid muscle. Frequently, the node lies under the belly of the sternomastoid muscle and retraction is required to dissect the node free. Occasionally, it is necessary to split the fibres of sternomastoid, but this is less satisfactory. 6 Identification of the position of important structures in the neck. The pulsation of the carotid artery is noted andthe jugular vein identified, as well asanyother significant structures, such as cranial nerves. 7 Identification of the node. The mass is carefully palpated to confirm the diagnosis of lymphadenopathy and to exclude such masses as a carotid-body tumour, vagal schwannoma or branchiogenic remnants. If a carotidbody tumour is suspected, theprocedureshould be abandoned without a biopsy and the patient should be further investigated with arteriography. 8 Isolation of the node. The tissue around the node is carefully dissected free to enable an excisional biopsy where possible. When the node is part of a matted mass of nodes or where it is adherent to an important structure,it may be necessary to perform an incisional biopsy. 9 Removal of the lymph node. 10 Haemostasis is secured. Diathermy should only be used under direct vision, since it is possible to damage neighbouring structures with injudicious use. Closure and drainage

1 A vacuum drain may be placed if there is concern about oozing. If the cavity is small and dry, no drain is required. 2 The wound is closed in layers: the deep structures with 2/0 Vicryl, the platysma with plain 2/0 catgut or undyed Vicryl and the skin with staples or 310 Prolene. 3 The wound is sprayed with a protective spray, such as Opsite spray. No dressing is usually necessary.

Postoperative mana~ement 1 Routine postanaesthetic management. 2 Discuss findings and implications with the patient. 3 Day case or overnight hospital stay only. 4 Removal of clips or skin sutures at 5-7 days.

Complication intraoperative

l Haemorrhage from damage to great vessels. Ligation of the internal jugular vein may be required. 2 Carotid sinus reflex during dissection around carotid bifurcation. The anaesthetist should be warned when

dissecting in this area. Lignocaine injected into the tissues can reduce the reflex. 3 Air embolism from inadvertently opening the internal jugular vein or other large vein in the neck. A sucking sound is heard and there may be a machinery-type heart murmur with hypotension and arrhythmias. Treatment consists of quickly rolling the patient into theleft lateral decubitus position with head down. Aspiration of air from the heart or even thoracotomy may be required. 4 Pneumothorax, if dissecting low in the neck. If significant, this may require a chest drain. 5 Nerve damage. Particularly the marginal mandibular and accessory nerves but other cranialnerves, e.g. vagus and hypoglossal, are also at risk. Very rarely the brachial plexus, sympathetic chainor phrenic nerves can be damaged. Postoperative

1 Haematoma.

2 Wound infection. 3 Chylous fistula, if the thoracic duct is damaged.

Becker GD & Parell GJ (1979) Technique of preserving the spinal accessory nerve during radical neck dissection. Laryngoscope 89, 827-31. Davis JM, Chadburn A & Mouradian JA (1988) Lymph node biopsy in patients with human immunodeficiency virus infections. Arch. Surg. 123, 1349-52. Davis Prinsley JP, PR & Robinson PJ (1993) Cervical lymphadenopathy due to mycobacterial infection: a diagnostic protocol. J.Laryngol. Otol. 107, 614-17. Gooder P & Palmer M (1984)Cervical lymph node biopsy-a studyof its morbidity. J.Laryngol. Otol. 98, 1031-40. Jesse RH, Perez CA & Fletcher GH (1973) Cervicallymphnode metastasis: unknown primary cancer. Cancer 31, 854-9. Liepzig B, Winter ML & Hokansen JA (1981)Cervical nodal metastasis of unknown origin. Laryngoscope 91, 593-7. McGuirt WF& McCabe BF (1978)Significance of node biopsy before definitive treatmentof cervical metastatic carcinoma.Laryngoscope 78,594-7. Martin H & Romieu C (1952) The diagnostic significance of a lump in the neck. Postgrad. Med. J.11, 491-501. Remsen KA, Lucente FA & Biller HG (1984) Reliability of frozen section diagnosis in head and neck neoplasms. Larnygoscope 84, 519-24. Shaw HJ (1970) Metastatic carcinoma in cervical lymph nodes with occult primary tumour. J.Laryngol. Otol. 84, 249-65. Sinner WN & Zajicek J (1976)Implantation metastasis after percutaneous transthoracic needle biopsy. Acta Radiol. Dzagn. 17, 473-80. Stern SJ (1992) Precise localization of the marginal mandibular nerve during neck dissection. Head Neck 14 (4),328-31. YoungJEM,Archibald SD & Shier KJ (1981) Needleaspiration cytologybiopsyinheadand neck masses. Am. J. Surg. 142, 484-9.

S

Surgery is indicated for recurrent or persistent inflammatory conditions, e.g. recurrent sialadenitis, chronic sialadenitis, mucocele andranula(mucous extravasationcyst),submandibularductobstruction (traumaticor calculus) and neoplasia (benign and malignant). Surgery is contraindicated during acute inflammatory episodes.

Sialadenitis is diagnosed on historywithfeatures of recurrent, painful swelling of the submandibular gland, which may be exacerbated by eating. Calculus obstruction commonly results in a persistent swelling of the gland,withintermittentpainful episodes. Wharton’s duct calculi are often visible or palpable on bimanual examination. Intraglandular calculi are difficult to feel but are usually apparent on plain X-rays of the region. Mucous extravasation cysts have a classical appearance when they occur in the floor of the mouth, i.e. ranula (Latin diminutive meaning ‘small frog’; tbis is a reference to the cyst’s similarity to a frog’s soft underbelly). The ranula has a bluish, cystic appearance and usually fills the floor of themouthlateraltothe Submandibular duct. These cysts rnay extend through or behind the mylohyoid muscle into theneck, i.e. plunging ranula (Joseph & Davidge-Pitts, 1985). These may extend to any level in the neck up to the clavicle. Communication with the oral componentrnay be demonstrated by applying pressure to the neck, which results in bulging within the floor of the mouth. These cysts transilluminate brilliantly. A history of trauma to the

.

sublingual-gland area rnay be elicited, although this is uncommon. Smaller mucoceles of theminor salivary glands usually occur inareas where trauma is more likely; hence most are found on the lower lip mucosa. They may occur in anyarea where minor salivary glands occur. Tumours of the Submandibular and minor salivary glands are usually painless swellings present for months or years. Pain associated with neoplasia of these glands is suggestive of adenoid cystic carcinoma, with its propensity for nerve involvement. Most salivary gland tumours donot involve adjacent nerves except in advanced, malignant disease. CT scans are useful in assessing neoplastic conditions of these glands. Extent of the tumour, particularlyin the palate or parapharyngeal space should be assessed. Neck-gland involvement may be noted on the scan. MRI scans yield similar information, although theuse of both investigations is unnecessary in these conditions. Sialography is of little help in the assessment of these conditions. Fine-needle aspiration cytology is useful in differentiating benign frommalignanttumours of the Submandibular gland. Thisinformation is important asthe surgical approach differs. In cases wherethe cytology is equivocal or not available, intraoperative frozen section is of value, although pathological assessment rnay be difficult. Minor salivary-gland tumours involving oral mucosa are usually amenable to incisional biopsy for management planning.

Surgery of the submandibular gland places the marginal

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mandibular nerve, hypoglossal nerve and lingual nerve at risk. Themostconstantanatomicalrelationship of the marginal nerve is the mandibularnotch. The nerve crosses over on to the mandible at this point and runs forward. Itleaves the parotid gland at variable distances below the angle of the mandible, usually 1-2cm, and courses anteriorly below the border of the mandible to thearea of themandibularnotch and facial vessels (Stern, 1992) (Fig. 57.1). The hypoglossal and lingual nerves run alongthe floor of the gland. The hypoglossal runs inferior to the lingual nerve, from posteroinferior a position to anterosuperior.The lingual nerve is wider and loops down from a posterosuperior position. Traction on the submandibular gland pulls the lingual nerve inferiorly via its submandibular ganglion attachments. Thesubmandibular gland surroundstheposterior border of the mylohyoid muscle, which is easily identifiedby the direction of its fibres. These run obliquely from the hyoid anteroinferiorly to the mandible posterosuperiorly. The final point of note is the relationship between the submandibular duct and lingual nerve. The duct is ‘double-crossed’ by the nerve. Posteriorly the nerve loops down, crossing superficial/lateral to the duct; it courses anteriorly below and then deeplmedial to the duct. This relationship is particularly important during intraoral surgery for ranula and plunging ranula.

ec

ue

1 Most surgery is performed under general anaesthesia. The exceptions include small oral mucosal mucoceles and excisional biopsy of small (less than 1cm) mucosal tumours or incisional biopsy of larger mucosal lesions. 2 Prophylactic antibioticsarerequiredfor surgery to lesions involving the oralmucosa. They are notrequired submandibular-gland for surgery, although the submandibularductshould be ligated. Ampicillin or amoxil with flagyl is a reasonable choice. 3 Patient positioning. Submandibular gland surgery is performed with the patient supine, neck slightly flexed on the shoulders with support beneath the shoulders; the head is extended on the neck and turned away from the side of surgery. A similar position is useful forpalatal lesions. A Boyle-Davis gag or dental props are helpful.

Fig. 57.1 Marginal mandibular nerve. The nerve may be found anywhere within the shaded area.

Incision

Submandibular-gland surgery

Benign lesions may be approached by a curvilinear incision placed withinaskin crease below the gland. It should extend from the posterior margin of the gland to a point 1-2cm beyond the anterior border and include the platysma. The crease is usually below the inferior border of the gland and is thus further away, from the mandibular border (2cm or twofingers’ breadths) than is usually recommended. This is cosmetically acceptable and also avoidsdamage to themarginalmandibular nerve. Formalignantconditionsthe incision is prolonged posteriorlytowardsthemastoid and inferiorly along the border of the trapezius muscle. This results in a safe and cosmetically acceptable flap for neck dissection withsubmandibular-gland malignancy (Dissanayaka, 1990). An alternative incision for combined gland and neck dissection is to takea limbinferiorly from the horizontal incision over the sternocleidomastoid into the posterior triangle, curving on to the clavicle. Neck incisions are infiltrated with Por 8 (vasopressin) 1:40 or a bupivacaine-adrenaline mixture. Procedure

Submandibular gland: benign conditions

1 Superior skin flap is raised. Either of two approaches may be used. (a) The incision is continued onto the inferior border of the submandibular gland. Glandular tissue is identified. A gauze swab is placed on a finger and

ry of the S u b ~ ~ n d i b uand l ~ rMinor Salivary Glands the flap is bluntly dissected away from the gland up to the inferior border of the mandible. This protects the marginal mandibular nerve, which now lies on the undersurface of the flap. Silk retraction sutures are placed inthe platysma muscle and sutured to drapes. (b) Alternatively the flap is raised by sharp dissection immediately on theundersurface of the platysma muscle. This tissue plane is immediately abovethe marginal mandibular nerve, so extreme care is necessary near andanteriorto themandibularnotch, where the nerve courses abovethemandible.The nerve is then identified at the notch and dissected free. Cautery should be used with extreme caution. 2 The gland is grasped and retracted posteriorly. The anterior margin is dissected free fromthe mylohyoid muscle (identified by obliqueanteroposterior fibres). Theposteriorborder of this muscle is identified and retracted anteriorly with blunt a retractor, e.g. Langenbeck. The floor of the submandibular gland is exposed by this manoeuvre. 3 Importantstructuresare identified onthe floor, namely the hypoglossal nerve inferiorly and lingual nerve withsubmandibular ganglion superiorly (Fig. 57.2). 4 The gland is dissected away from these structures by blunt dissection (finger and peanut swab). The gland is freed from the submandibular ganglion after its attachments are cauterised. 5 The facial artery and vein may be ligated at the posterior margin of the gland and below the mandibular

417

notch. Alternatively, these vessels may be preserved and dissected away from the gland, with cautery and ligation of branches to the gland. 6 The submandibularduct is ligated and transected. Absorbable sutures (Vicryl) are satisfactory. Malignant conditions of the sub~andibulargland

The approach differs in that wide margins are required, although preservation of the marginal nerve is important where no clinical involvement is present. Wide dissection of thesubmandibular triangle is performed, including the floor of thesubmandibular gland. (The patient must be informed preoperatively of possible resection of hypoglossal and lingual nerves if involved by tumour.) Modified radical neck dissection (functional) (Joseph et al., 1985) or modified regional dissection is indicated in malignant conditions of the submandibular gland (Weber et al., 1990). Intraoral minor salivary glands

Tumoursare excised with wide margins, including periosteum. Bony palateshould be preserved where possible. Adenoid cystic carcinoma of the oralcavity is particularly liable to wide submucosalspread.Tumour-free margins are very important and frozen-section control should be utilised to achieve this. However, massive resections of the maxilla for adenoid cystic and other salivary-gland carcinomas have not improved the prognosis significantly. Combined radiotherapyis extremely important in the management of salivary gland malignancies and should be considered in all cases, with thepossible exception of low-grade mucoepidermoid carcinoma.

CIosure/drainage/dressings

Fig. 57.2 Submandibular floor (left side). Mylohyoid muscle retracted anterosuperiorly. Anterior limit of gland retracted posteroinferiorly. Lingual nerve pulled into position below mandible by attachment to submandibular gland and ganglion. Lingual veins run the along floor with hypoglossal nerve.

1 The submandibular gland incision is closed in layers with 4 0 Vicryl sutures. 2 A small suction drain, e.g. 1/8 inch (3mm) Portovac, is inserted. 3 Closure of the platysma layer is importantand is responsible for the strength of the wound closure. 4 Skin is closed with subcuticular 4/0 plain catgut or skin clips. S Absorbing dressings areapplied and covered with adhesive tape or dressings. 6 Oral mucosal woundsare closed withinterrupted absorbable Sutures, e*g*VicrYl. Plain and chromicgut should not be used.

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Chapter 57

7 Palatal mucosal defects may be dressed withan acriflavine pack sutured in position. Graftsand flaps are not required to cover mucosal defects of the hardpalate. Defects greater than 50% of the hard palatemucosa will heal spontaneously. Where required local palatal flaps or grafts are useful. 8 Maxilla defects may be managed with prosthetics or pedicled, e.g. temporalis and free flaps.

Postoperative management Submandibular-gland surgery

Benign conditions

The drainis usually removed the day following surgery. Patients may commence eating immediately. They are discharged fromhospital onoral analgesics 1 day postsurgery. Marginal mandibular together with hypoglossal nerve function should be noted. The patient should be examined 2 weeks postsurgery for satisfactory healing. Malignant conditions

Hospital stay is usually slightly longer as a result of the neck dissection. If oral mucosa was not involved, eating may commence the next day. Drains are removed when secretions fall below 50 mu24 h. Patientsare mobilised on day 1 and may be discharged soon afterwards. Radiotherapy should begin as soon as woundhealing has occurred, i.e. approximately 2 weeks postsurgery. Intraoral lesions

Large palatal lesions are dressed with acriflavine, which remains in position for 10-14 days. Following removal, oralmouthwashes (normal saline) should be used frequently and oral Daktarin gel is useful.

Complications important most Thecomplication following submandibular-gland surgery is damage to the marginal mandibular nerve. This results in paralysis of the depressor anguli oris and labii inferioris. Flattening and inversion of the lower lip with loss of animation on smiling follow. This complication should not occur in surgery for benign lesions. Where surgery is performed for malignant conditions, the patient should be prepared for

possible resection of the nerve, although this is rarely indicated. Retraction on the flap by metal retractors may lead to neuropraxia and care should be taken if retraction is required. Hypoglossal and lingual nerve damage less is common. Further complications are rarely encountered.

Alternative procedure Mucous extravasation cysts

Small cysts of the oral mucosa and lips may be excised with the involved gland, which is usually very small and not identifiable. Ranula and plunging ranulas are successfully treated by drainage and excision of the sublingual gland. The submandibulargland is rarely involved and excision is not required (Joseph & Davidge-Pitts, 1985). Procedure

1 The submandibular duct is identified and a lacrimal probe inserted. The incision is made lateral to the duct, running anteroposteriorly, following infiltration of the mucosa with lignocaine 1% with adrenaline. The ranula is opened and drained, including any cervical plunging component, through the mouth. 2 Tissue lateral to theprobe is excised by blunt dissection (peanutswab) fromanteriortoposterior, where the lingual nerve is identified looping under the ductfromposterolateral to anteromedial. The tissue cleared by this method includes the involved sublingual gland. 3 Closure is achieved with interrupted Vicryl sutures (410 round-bodied needle). Drains are not required. Marsupialisationhas been recommended forranulas. This results in an unacceptably high recurrence rate (Joseph & Davidge-Pitts, 1985). The intra-oralremoval of the sublingual gland is a simple procedure and should be thetreatment of choice forranula and plunging ranula. Patients who have had previous surgery may require a cervical or submandibular approach. Large inoperabletumours of theminor salivary glands may respond to treatment with neutrons where this is available. Favourable results have been reported (Stannard, 1993). Incision biopsy of submandibular-glandtumours is not recommended. As malignant tumours of this area tend to have a poorer prognosis, fine-needle aspiration

Surgery of the Submandibular and Minor cytology or intraoperative frozen section should be used for correct planning.

1 Marsupialisation of ranulas is simple and quick but should be avoided because it is not successful. 2 Do not dissect plunging ranulas. They should be drained via the mouth andthe sublingual gland removed intra-orally. 3 The marginal mandibular nerve may loop down to the inferior border of the submandibular glandor it may remain above the mandible. Numerous branches to the platysma may be conhsed with the marginal branch. The marginal mandibular nerve may be very small. In view of these features regard all nerves in the area as the marginal mandibular nerve until proved otherwise.

Salivary Glands

419

References Dissanayaka L (1990) A modified single flap for neck dissection in oral cancer. Head Neck 12, 74-6. Joseph CA & Davidge-Pitts KJ (1985) Mucous extravasation cysts of the head and neck. South Afr. J.Surg. 23, 95-7. Joseph CA, Gregor RT & Davidge-Pitts KJ (1985) The role of functional neck dissection in advanced tumours of the upper aerodigestive tract. South Afr. J.Surg. 23, 83-7. Stannard C (1993) Neutron therapy imposes local control of salivary gland tumours. Presented at the Combined National Annual Spring Meeting of the South African Society of Otorhinolaryngology and theSouth African Headand Neck Oncology Society, Somerset West, South Africa, 18-22 October 1993. Stern SJ (1992) Precise localisation of the marginal mandibular nerve during neck dissection. Head Neck 14, 328-31. Weber RS,Byers RM, Petit B, Wolf P, Ang K & Luna M (1990) Submandibular gland tumours:adverse histologic factors and therapeutic implications. Arch. 'Otol. HeadNeck Surg. 116, 10.5560.

Excision of Thyroglossa cysts D. CARETH J O H N

thyroglossal duct. Fine needle aspiration cytology may aid diagnosis in equivocal or atypically sited lesions. Surgery is indicated for neck lumps which are clinically thyroglossal cysts for diagnostic confirmation, if they are cosmetically unacceptable or if theyare complicated by recurrent infection or inflammation. Acutely infected cysts should be treated byIV antibiotics, and incision and drainage avoided whenever possible, as scarring or fistula formation may occur. Definitive surgery is then performed once the acute infection has settled.

Preoperative management History and examination

Thyroglossal cysts may present at any age, butmost present before the age of 20as a firm (sometimes fluctuant) lump of variable size, which moves on swallowing and tongue protrusion, andwhich appears to be attached to the hyoid bone. Typically the lump is fixed deeply, but the overlying skin is freely mobile. The lump is situated in, or close to, the midline and may become acutely inflamed. The sex incidence is equal. The differential diagnoses include apyramidalthyroid lobe, a midline thyroidadenoma, midline lymph nodes and dermoid cysts. Unusually the cyst may be very lateral (mimicking a branchial cyst) or very high (mimicking a tongue tumour). Investigations

Athyroidisotopescan (99mTc)andloran ultrasound scan will ensure thatother thyroid tissue is present, confirm the diagnosis and demonstrate any associated

Relevant anatomy Early in fetal life the thyroid gland arises in the floor of thepharynx between two midline swellings, the tuberculum impar anteriorly and the copula posteriorly. It descends to its adult position, through tissues which will later form the tongue musculatureand hyoid bone. During descent it remains connected to the pharynx by the thyroglossal tract or duct (controversy remains as to whether a true duct with a lumen exists, and it will be referred to as a tract hereafter). The tract atrophies and its point of origin at the tongue base persists as the foramen caecum. A thyroglossal cyst is said to be a remnant of this tract, and such a cyst can thus occur anywhere between the foramen caecum and the final position of thethyroidgland (Fig. 58.1).The hyoid bone develops later and the tract usually comes to lie behind the bone, but may pass superficial to it or through it. The caudal portionof the tractmay persist as apyramidallobe of thyroid. A s thetract does not naturally communicate with the skin surface, a fistula originating from it is a secondary feature, representing surgical drainage, incomplete removal or infection and discharge.

Operative technique (Sistrunk’s procedure) (Sistrunk, 1928) Preparation

Anaesthesia General anaesthetic (GA) with nasotracheal intubation.

Excision of Thyroglossal Cysts

Fig. 58.1 The site incidence of thyroglossal cysts (from Maran, 1987).

Prophylactic antibiotics

Not normally indicated, unless the operation results in accidental opening of the mucosa of the laryndpharynx or tongue. Then a broad-spectrum antibiotic (including anaerobic cover) would be indicated. Patient positioning

421

3 Dissection of the tract (or the cyst) from the hyoid should not be attempted, but rather the central segment of the hyoid bone, which is associated with the tract, should be removed with the specimen. Using sharp dissection, the top and bottom of the hyoid bone are freed from their muscle attachments at two points either side of the midline, taking care not to injure the thyrohyoid membrane (Fig. 58.2). The bone may require stabilising with Allis forceps, and is then divided in these two places (Fig. 58.3),allowing the central part (about 12cm) between the lesser horns to be removed in continuity with thecyst. Medial to the lesser horns there is no danger of damaging the hypoglossal nerves. 4 Ideally a core of tongue musculature (including portions of mylohyoid, geniohyoid and genioglossus) containing the tract should then be removed, with theaid of cutting diathermy. It is important to realise that above the hyoid the tract passes backwards at 45" towards the foramen caecum. A finger in the mouth, pressing the tongue base forwards and upwards into the wound, is a useful manoeuvre to aid such dissection (Fig. 58.4), although the surgeon should be aware of the risk of introducing oral bacteria into the wound in this technique. In his original description Sistrunk stated that 'in temporarily disregarding the duct and coring out the tissues through which it passes, lies one of the secrets of cure, as the ductis so small and delicate that it is almost invariably broken ...if efforts are madeto dissect it out alone'. Alternatively, downward traction on the central portion of the hyoid bone with Allis forceps may define a conical tract of muscle and duct, which may be dissected and then ligated and divided.

Supine with the neck extended by a sandbag under the shoulders and the head supported in a head ring. incision

A horizontal skin crease at theupper margin of the cyst, so that the tract can more easily be followed upwards. If a fistula is present, then a horizontal incision should be made at that level, including the fistula in a skin ellipse. Procedure in stages

1 The incision is carried through platysma, and flaps are raised superiorly and inferiorly. The anteriorjugular veins (AJVs) are ligated and divided. 2 The cyst is identified by separating the strap muscles in the midline. The cyst is then mobilised, and in low cysts a tract can usually be identified passing upwards, intimately associated with the hyoid bone.

Fig. 58.2 The relation of the thyroglossal tract to the hyoid bone and the thyrohyoid membrane (from Allard RHB (1982) The thyroglossal cyst. Head Neck Surg. 5 , 134-46. 0 1982, reprinted by permission of John Wiley & Sons, Inc.).

monofilament sutures and Steristrips usually produce an excellent cosmetic result.

The neck should be watched for swelling. The drain is removed whendrainage ceases on aboutthe second postoperative day.

Fig. 58.3 Excision of cyst, tract and a core of suprahyoid musculature (from Hibbert, 1983 Rob ei- Smith's Operative Surgery. With permission of Chapman and Hall.).

Fig. 58.4 Excision of core of suprahyoid musculature aided by a finger over the foramen caecum. Note the 4.5" angle at which the tract passes backwards above the hyoid. (From Brown & Judd, 1961.)

The wound is closed in layers and a suction drain inserted with its exitinthe lower flap. Subcuticular

l Bleeding in combinationwitha blocked draincan result in neck swelling and airway obstruction (reopening the wound on the wardmay be life-saving). 2 Inadequate removal of the tract may result in recurrence, sometimes with afistula. This is probably because of extension of the tract tothe tongue base, and because of the presence of multiple tracts (Mickel & Calcaterra, 1983).The recurrence rate varies between different series, but is probably lower than 8% inthe classic Sistrunk operation, and as high as 85% if the middle part of the hyoid bone is not removed (Allard, 1982). Recurrence is usually apparent within afew months, but may take many years. Treatment is simple if Sistrunk's operationhasnot been performed-the body of the hyoid and a core of musculature are removed. If recurrence follows a Sistrunk procedure, the removal of cyst and tract may involve an anterior block dissection from thyroid isthmus to foramen caecum (Mickel & Calcaterra, 1983). 3 Rarely a mass which is clinically a thyroglossal cyst proves to be composed solely of ectopic thyroid tissue, and may represent the only thyroid tissue present. Removal thus results in hypothyroidism. It is said that 65'75% of patients with lingual thyroids have no other thyroid tissue. This presumablyrepresents complete failure of the gland to descend. Poor scar in a cosmetically unacceptable site.

Perhaps not all thyroglossal cysts require surgery. Of 17'5 patients at the Mayo Clinic who were not operated on for various reasons, follow-up of between 8 and 22 years showed that only 22% eventually came to operation(Brown & Judd, 1961). However, removal does allow histological confirmation of what would otherwise be an undiagnosed neck mass. Thyroid carcinomas (usually papillary)in ectopic thyroid tissue are rare, but well recognised. Some authors recommend that the incision be placed

Excision below the lump, asthis is cosmetically more acceptable. Ifthe cyst is very low in theneck, then adequateremoval of the tractwill require two parallel incisions, one at the level of the cyst and the other higher in the neck, with the cyst (and attached tract) being passed beneath the intervening bridge of skin.

References Allard RHB (1982) The thyroglossal cyst. Head Neck Surg. 5, 13446.

of

ThyroglossalCysts

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Brown PM &;;‘Judd ES (1961) Thyroglossal duct cysts and sinuses: results of radical (Sistrunk) operation. Am. J.Surg. 102, 494-501. Hibbert J (1983) Thyroglossal duct cyst. In: Dudley H and Carter D Operative Surgery, 4th edn. London, (eds) Rob 6 Smitb’s Butterworths, p. 406. Maran AGD (1987) Benign diseases of the neck. In: Stell PM (ed.) Scott-Brown’s Otolaryngology, 5th edn.London,Butterworths, V01 5, pp. 283-6. Mickel RA & Calcaterrra TC(1983) Management of recurrent thyroglossal duct cysts. Arch. Otolaryngol. 109, 34-6. Sistrunk W (1928) Technique of removal of cyst and sinuses of the thyroglossal duct. Surg. Gynecol. Obstet. 46, 109-12.

Branchial cysts and sinuses should normally be removed once the diagnosis has been made, especially in adults, where the cyst can be mistaken for a malignant lymph node with cystic degeneration. They present most commonly in early adult life, either as a simple mass in the neck or as an infected mass, but acyst can present at any age. Branchial sinuses almost invariably present in infancy unless an infected branchial cyst is allowed to rupture externally to become a sinus. Branchial fistulae will normally present in infancy or childhood, with a point of discharge in the neck. It is not necessary to remove the uncomplicated branchialsinus or fistula, but discharge fromthetract will make it desirable in early childhood.

Branchial cysts, sinuses and fistulae should not be excised when they are infected, asthe risk of leaving remnant tissue will be greatly increased, as will the risk of wound infection.

Any mass that is clinically abranchial cyst and that presents without infection should be subjected to fineneedle aspiration biopsy. This will confirm the cystic nature of the mass and enable the cyst contents to be sent for cytological examination to look for the rare case of a malignant lesion presenting as a cyst. Usually, after aspiration the mass will return within a week or so, but

occasionally it will disappear for a much longer period, Assuming the mass returns and cytology studies do not suggest malignancy, no further special investigation is needed. An infected branchial cyst should be treated initially with IV broad-spectrum antibiotics, after aspiration of the contents for bacteriological investigation. Occasionally the cyst will not return after successful treatment, but usually a cyst remains and should then be removed without any further special investigation.

These need no special investigation, but careful examination of the oropharynx shouldbe undertaken to look for an internal opening of a fistula around the anterior faucial pillar. Branchial-arch abnormalities can be associated with other familial developmental abnormalities, particularly of the middle and innerear and kidney (branchio-otorenal syndrome). These abnormalities should be excluded if there is a family history of branchial-arch pathology.

Branchial cysts usually arise from remnants of the second branchial arch or cleft (Fig. 59.1). Such cysts will usually present anterior to the sternomastoid muscle at about the level of the junction of the upper third and lower two-thirds. Cysts presenting higher than this may have originated from the first cleft, and lower than this from the third or lower clefts. The relevance of this is that first-arch cysts may have complicated deep tracts connected to the external auditory meatus(EAN) atthe bone-cartilage junction and closely related to the facial

Branchial Cysts, Sinuses and Fistulae

425

P r o ~ ~ ~ l a cantibiotics/steroi~ tic cover

In the uncomplicated case antibiotics and steroids are not necessary. Patient ~ositioning

The patient should be placed supine on the operating table, using extra shoulder support to slightly extend the neck, which should be rotated to the side opposite the lesion. A small amount of head-uptilt will aid haemostasis. The skin may be infiltrated with a vasoconstrictor if desired, but this is not essential.

Fig. 59.1 Representation of developmental branchial arches, clefts

Forbranchial cysts inthe mid to lower part of the neck, a skin crease incision about &"cm long over the lump is used. To avoid themarginalmandibular branch of the facial nerve, incisions should always be morethan 3cm below the angle andramus of the mandible. An incision in line withtheanterior border of sternomastoid will give better exposure of any deeper connections of the cyst, but postoperative scarring will be more likely than with a skin-crease incision, and hence should be avoided. For cysts in the upper part of the neck, which might originatefromthe first branchial arch, standard a parotidectomy incision

and pharyngeal pouches.

nerve (Fig. 59.2). The lower-arch cysts rarely have deep connections, but may have tracts intimately related to thecarotid-arterybifurcation. Sinuses or a cyst may occasionally open into the pharynx through one of the pharyngeal pouches, usually the first, which develops into the tonsil.

Anaesthesia

Branchial cysts, sinuses and fistulae should always, if possible, be excised under general anaesthesia. Althougha simple cyst with no deep connections might be easily excised under local anaesthesia, deep connections, with which it would be very difficult to deal under local anaesthesia, can never be excluded preoperatively.

Fig. 59.2 Representation of first-arch branchial cyst with track extending in close proximity to the facial nerve to the external auditory meatus.

-

426

Chapter 59

Fig. 59.3 Representation of dissection of a branchial cyst with deep tract extending between carotid bifurcation to the pharynx.

should be made, in order to expose the facial nerve if necessary. For branchial sinuses and fistulae, the initial incision should be an ellipse around the external opening. Further short transverse incisions up the neck may be required (see below) to follow the deep tract. Procedure

cyst is lessened withthe use of scissors and ‘blunt’ dissection. 4 If the deeper parts of the cyst are difficult to identify and dissect, gentle manipulation with a finger may free itupfurther. Alternatively, the cyst may be decompressed a little by aspirating some of its contents, using a thin-gauge needle, but this often results inrupture rather than controlled decompression, and should only be used as a last resort. 5 Most cysts will be easily removed in this manner, but in all cases a tract should be sought that might extend deeper into the neck. The route of such a tract would theoretically depend on its embryological origins, but will most commonly be found extending between the internal and external carotid arteries (Fig. 59.3),or up to the bony-cartilaginous junction of the EAM in the case of a first-arch cyst. The cyst should always be sent for histological examination to exclude the very rare branchogenic carcinoma or other malignancy.

Branchial sinus and fistula The inital elliptical incision is deepened to identify the sinus or fistula tract, and this is followed as high into the neck as possible towards the carotid bifurcation. If access becomes restricted, a further skincrease incision should be made higher in the neck to expose the tracthigher up. The tractshould be followed, if necessary, to its internalopeninginthe case of a fistula.

Branchial cyst

1 The initial incision is deepened through platysma to expose the sternomastoid muscle, and the skin flaps are raised in a subplatysmal plane. 2 A self-retaining retractorto keep the skin edges with platysma well partedshould be inserted. The cyst may become apparentstraightaway,butoften sternomastoid the will need to be retracted posterolaterally. In the case of afirst-branchial-arch cyst, it may not be so superficial and formal identification of the facial nerve should be made, as in a superficial parotidectomy. 3 Oncethe cyst is exposed, the superficial tissue surroundingitcan be separatedfromthe cyst fairly easily, using blunt-ended curved iris scissors. Care should be taken in the deeper part of the dissection, where the contentsof the carotid sheathwill be exposed, as may the accessory nerve if the dissection extends intotheposteriortriangle of the neck. Although some surgeons always recommend using a scalpel for dissection, the author feels that the risk of rupturing the

Closure/larainage/dressings After removal of the cyst and any tract, a suction drain should be inserted, the platysma closed with an absorbable suture and theskin closed in a manner of personal preference. Thewound is best covered witha clear, plastic, self-adhesive dressing material.

Postoperative management The drain can usually be removed the following day, with the patient being discharged later that day. Any remaining non-absorbable sutures or clips may be removed about the fifth postoperative day.

Complications If the cyst is high in the neck, the marginal mandibular nerve may be damaged, or even the facial nerve truhk in the case of a first-arch tract which extends to the EAM. With due care, injury to the major vessels should not

BranchialCysts,Sinuses occur. In looking for or dissecting out a deep tract, the hypoglossal nerve may be damagedas it passes under the occipital artery, the facial nerve may be damaged if the tract is extending to the EAM, and the accessory

and Fistulae

427

nerve is at risk in dissection extending posteriorly in the neck. If meticulous care is not taken to remove allthe cyst, sinus or fistula tract, recurrence is likely.

OLAS P. McIVO

History e

1 Primary thyroidal: differentiated thyroid carcinoma, medullary carcinoma,intrathyroidalanaplastic carcinoma (rare). 2 Secondary involvement: as part of surgical treatment for carcinoma of the larynx, hypopharynx, cervical trachea and oesophagus. 3 Ectopic parathyroid adenoma.

Multinodular goitre extending or arising retrosternally.

1 Solitary toxic nodule. 2 Graves’ disease.

Patients at higher risk of malignancy inasolitary nodule include children, the elderly, men, those who have previously undergone low-dose irradiation to the neck and patients with a family history of thyroidcarcinoma. Pain and increase in size of a long-standing nodule maybe due to recent haemorrhage but may also indicate malignancy. Hoarseness may indicate recurrent-laryngeal-nerve invasion. Gradual onset of dysphagia andstridorare more likely to be due to multinodular disease or thyroiditis, while rapid onset is usually due to anaplastic carcinoma. Hypertension, flushing and diarrhoea may indicate systemic features of medullary carcinoma. A compressive goitre may cause dyspnoea when lying flat or when elevating the arms above the head, while dysphagia is less common. Examination

This includes palpation of the neck to assess the thyroid gland and the jugular and paratracheal nodes, as well as assessment of vocal cord mobility.

For cosmesis.

Blood tests

Thyroid-function tests and serum calcium, phosphate and albumin are performed preoperatively.

1 Extrathyroidal anaplastic carcinoma of thyroid. 2 Thyroid lymphoma,

C hest X-ray

Onlythework-upforthesolitarynodule compressive goitre will be addressed.

and

This may detect pulmonary metastases, retrosternal extension and tracheal deviatiodcompression.

Thyroid nodule

Thyroid Surgery

429

C T scan. This is useful when retrosternal extrathyroidal extension is suspected.

or

Fine-needle aspiration cytology

Compressive goitre

This is the single most useful test. A skilled cytopathologist can distinguish between non-neoplastic and neoplastic lesions with a high degree of accuracy. The distinction between a benign and malignant follicular neoplasm is not reliable because capsular and vascular invasion, the hallmarks of malignancy, cannot be assessed cytologically. However,papillary carcinoma,themostcommon differentiated tumour,has characteristic nuclear features (intranuclear cytoplasmic inclusions and grooving) that may provide the diagnosis. Furthermore, whole papillae may be aspirated. Surgery is indicated when the aspirate shows malignant cells (papillary carcinoma, medullary carcinoma) or when there are features of a follicular neoplasm. Nodules producing non-neoplastic cytology in lowrisk patients can be observed and reaspirated at a later date. In high-risk patients the decision for surgery will depend on the clinician’s index of suspicion.

1 Respiratoryfunction tests with flow-volume loops may give an idea of the degree of airways compression, but these are surprisingly insensitive for many patients. 2 CT scan is again useful if there is significant retrosternal extension seen on the chest X-ray.

Imaging This is often unnecessary after an adequate cytological exammation. Ultrasound. Thereare no ultrasonographicfeatures that can reliably distinguish between benign and malignant lesions. Furthermore this modality is very userdependent. Ultrasound can determine whether a nodule is truly solitary or part of a multinodular gland, but the latter finding does not exclude malignancy. It can distinguish cystic lesions from solid, but few cysts are simple cysts. Most are complex withsolid components and represent degenerating solid lesions. Ultrasound’s real value in this situation is to guide the fine-needle aspiration of the solid component. Furthermore, it can be used to monitor the size of a lesion over a period of time. Scintigraphy. Isotope scanning determines the activity of the lesion in relation to the surrounding gland, butin the author’s opinion gives little added information to that obtained by cytology, with the exceptionof the hot nodule, which is very rarely malignant. The majority of cold lesions are benign, butapproximately 20%are malignant. Cold nodulesmust be aspirated for cytological examination.

The thyroid gland consists of two lobes and anisthmus, and weighs approximately 25g in the adult. It straddles the cervical trachea, with the isthmus at the level of the third and fourth tracheal rings and the superior pole overlying the cricoid cartilage and cricothyroid muscle. It is enveloped by a fine capsule, from which septa pass into the gland to separate the lobules. The pretracheal fascia also envelops the gland to form the ‘surgical capsule’. Dissection beneath this capsule and on the true capsule comprises the ‘capsular dissection’. The gland is adherent to the trachea by the surgical capsule, and in addition is suspended to thelateral surfaces of the cricoid cartilage, cricothyroid joint and upper tracheal rings by a thickening of the capsule known as Berry’s ligament. The recurrent laryngeal nerve on each side usually lies in thetracheo-oesophageal(TE) groove but may lie outside the groove, particularly on the right side. Each nerve passes up in loose areolar tissue posteromedial to the lobe and is variably but intimately related to the inferior thyroid artery or its branches, which run from lateral to medial whenthegland is retractedduring surgery. The nerve then usually passes behind but may pass between the fibres of Berry’s ligament to enter the larynx behind the cricothyroid joint (see Figs 60.3, 60.5 and 60.7). There is always a small branch of the inferior thyroid artery and small veins that course along Berry’s ligament, whichcanmake dissection of the nerve through the ligament hazardous. In approximately 1% of cases the right nerve is non-recurrent and is closely related to the inferior pole of the thyroid gland, as it passes lateral to medial directly from vagus nerve to larynx. The parathyroid glands aresmall (1X 3 X 6mm), soft and ovoid, and lie adjacent to the thyroid gland,usually within the surgical capsule. They are most easily recognised by their characteristic caramel colour but are often camouflaged by associated adipose tissue. Thetotal number of glands may vary between two and six or

430

Chapter 60

more, but there are usually an upper gland and a lower gland on each side. The upper gland is the more constant of the two and usually lies posterior to the nerve on the posterior surface of the superior pole, near the level of the cricothyroid joint. The inferior gland usually lies on the posterior surface of theinferior pole and anterior to the recurrent laryngeal nerve (see Figs 60.560.7), although it may not uncommonly be in the thymus and out of the surgical field. The external laryngeal nerve arises from the superior laryngeal nerve at the thyrohyoid membrane and passes down beneath the lateral border of the sternothyroid muscle and on the middle constrictor to run along the lateral surface of the cricothyroid muscle, which it supplies. In about 15% of thyroid lobes, the nerve is below the level of the superior pole and athigh risk of surgical damage. Thethyroidgland is supplied fromabove by the paired superior thyroid arteries and posterolaterally by the paired inferior thyroid arteries. The parathyroid glands are supplied by branches of the inferior thyroid artery.

Operative technique Thyroid lobectomy will be described. Total thyroidectomy requires a repeat of this procedure on the opposite side. Preparaltion

Anaesthesia

mandible above to the clavicles below. Mark outa skincrease incision two fingers’ breadths above theclavicles, extendingapproximatelyfrommidsternomastoid to midsternomastoid. Procedure in stages

Flap elevation

Elevate the skin flaps to the level of the thyroid notch superiorly and tothe suprasternal notchinferiorly in the subplatysmal plane. Suture the flaps to the skin. Separation of strap muscles

Completely separate first the sternohyoid and then the sternothyroid muscles in the midline, using monopolar pencil diathermy (Fig. 60.1). Use finger dissection to gently separate the strap muscles from the underlying lobe to be dissected. Do not performthis onthe contralateral side, so as to provide a virgin field should subsequent surgery be necessary on thatlobe. The straps should be elevated to expose boththesuperiorand inferior poles of the lobe. The assistant retracts the strap muscles throughout the remainder of the procedure for exposure to facilitate dissection. Occasionally, for large goitres, the strap muscles may need to be divided to provide access. Exposure of the trachea and mobilisation of inferior pole

Use blunt dissection witha

Lahey swab(‘peanut’ or

General anaesthesia via anasotrachealtubebrought over the patient’s forehead.Theanaesthetist is positioned near the feet of the patient so that the operative team have access to both sides of the head. Prophylactic antibiotics

TV antibiotics are given at induction only. Patient positioning

The patientis positioned supine, the neck extended by a pillow under the shoulders. The head is positioned in the midline on a small head ring. The bed is angled in the reverse Trendelenburg position. Incision

Prepare the skin and drape to expose the neck from the

Fig. 60.1 Division of the deep cervical fascia and separation of the scrap muscles in the midline with unipolar pencil diathermy.

Thyroid Surgery

43 I

obilisation of the superior pole

Your assistant must retract the strap muscles laterally and superiorly. Use onehandto retractthe lobe inferomedially with a swab while, with the other hand, dissecting the fascia off the superior pole with a Lahey swab. The superior thyroid artery and vein should be clearly seen. Dissect medial to the vessels to preserve the external laryngeal nerve and then ligate and divide the vessels close to the gland (Fig. 60.4). Identi~cation ofthe superior parathyroid gland

Withthe lobe retracted to theopposite side, gently dissect the fascia from the undersurface of the superior pole with a Lahey swab. The superior parathyroidgland usually lies at the level of the cricothyroid junction (see Relevant anatomy) (Fig. '60.5).

Fig. 60.2 Dissection of the inferior pole to display the trachea and inferior thyroid veins. A Lahey swab is an ideal dissection tool for this.

'pusher') to identify thetrachea below theisthmus and continue this dissection to mobilise the inferior pole (Fig. 60.2). Clear the loose fascia from the inferior thyroid veins for accurate identification, and ligate and divide them. Similar dissection laterally allowsligation and division of the middle thyroid vein.

Preservation of t e parathyroid glands and the recurrent laryngeal nerve

Use bipolar diathermy and small forceps to dissect and reflect the inferior gland on its vascular pedicle posteriorly from the thyroid lobe (Figs 60.5 and 60.6). Similarly, reflect the superior gland posteriorly from the thyroid,but always visualise therecurrent nerve. A

Identification of the inferior parat

The assistantshould use a large swabtoretract the lobe awayfromtheoperator(forceps placed on the lobe tend to cause bleeding and should be avoided). Use a Lahey swabto gently breakthe loose fascia on the undersurface of thegland in an endeavour to find the inferior parathyroid (see Relevant anatomy). Identification of the recurrent laryngeal nerve

Your assistant must provide good retraction. Dissect in the TIE region with a Lahey swab by sweeping in the direction of the nerve (Fig. 60.3). If the fascia is resistant, use a mosquito forceps to break it, by spreading the forceps in the direction of the nerve. Fig. 60.3 Identification of the inferior parathyroid gland (forceps) and the recurrent laryngeal nerve. A Lahey swab is swept in the direction of the nerve.

43 2

Chapter 60 thermy before division. Once the nerve is seen passing behind the cricothyroid joint, the remaining ligamentous attachments to the gland can be divided, using either ascalpel or bipolar diathermy. Stay on thecapsule of the gland and medial to the cricothyroid joint. Dissection of lobe from trachea and division of isthmus

Use a scalpel to dissect the lobe from the trachea across the midline and resect it atits junction with the opposite lobe to avoid a palpable lump in the midline. Oversew the stump (Fig. 60.8) and inspect the specimen for the presence of parathyroid glands. If any are present, consider dicing the tissue into 1mm sections and reimplanting them into small pockets made in the sternomastoid. In thesituation of thyroidectomyfor differentiated thyroid cancer, always obtain a frozen section on the tissue to be reimplanted, to avoid implanting tumour.

Fig. 60.4 Dissection of the superior pole. The superior thyroid artery and vein are cleared of fascia and a plane is developed between them and the cricothyroid muscle and external laryngeal nerve.

Obtain haemostasis and insert a suction drain through the skin in the midline inferiorly, placing it in the thyroid bed butawayfromtherecurrent laryngeal

mosquito forceps passed along the course of the nerve facilitates dissection. Note: if the parathyroid glands have not been adequately identified, then a dissection beneath the envelopingpretracheal fascia and thetrue capsule of the gland, the so-called ‘capsular dissection’, is essential to minimise the risk of their being present on the operative specimen. While it is not acalamity to lose the parathyroids from oneside of the neck, the surgeonwho has done this unnecessarily creates an even greater challenge for him/herself if the other side needs subsequent dissection. Separation or division of Berry’s ligament

Once the parathyroid glandshave been reflected, pass a mosquito forceps along the line of the nerve to identify its relationship to Berry’s ligament. Usually a capsular dissection will allow the gland to be cleared from the ligament with full protection of the nerve. If the ligament needs to be divided, insert the forceps along the path of the nerve and gently open them. Under direct vision, divide the ligament (Fig. 60.7’). Any small bloodvessels should be carefully cauterised with bipolar dia-

Fig. 60.5 Dissection of the parathyroid glands. The glands are reflected off the thyroid gland with preservation of their pedicles. A mosquito forceps develops a plane of cleavage and the intervening tissue is cut.

Thyroid Surgery

Fig. 60.6 Bipolar diathermy dissection of the inferior parathyroid gland. Dissection begins on the edge distal to the vascular pedicle.

433

aftertotal thyroidectomy, which putsbothrecurrent laryngeal nerves at risk. Monitor wound drainage, particularly over the first 12h. The wound must also be observed, as heavy bleeding can be too much for a suction drain. Staff must be aware of the need to release both superficial and deep sutures and to evacuate the haematoma immediately in the event of impending airway obstruction. Whentherehas been bilateral dissection, even if one side wasdone previously, calcium status must be monitored for the first 2-3 days. The management of hypocalcaemia is discussed under Complications. After partial thyroidectomy, thyroid functionis tested a month after operation to determine whether any supplementation is required. Patients who have undergone total thyroidectomy can begin thyroid supplements in the first week. However, patients who have had total thyroidectomy for differentiated thyroid cancer are not started on thyroid supplements untilafter an isotope scan, between 4 and 6 weeks postoperatively. This is to ensure that thyroid-stimulating hormone (TSH) levels are high in order to increase the uptake of isotope by residual thyroid tissue and metastases.

Complications Operative Damage to recurrent laryngeal nerve

This is usually because of failure to adequately identify

Fig. 60.7 Division of Berry's ligament. A mosquito forceps is passed along the nerve and opened, allowing safe incisionof the ligament.

nerve. Reapproximate the strap muscles over the drain from superior to inferior so that the drain exits from the thyroid bed inferiorly. Close the subcutaneous layer with 310 Vicryl and the skin with 4/0 nylon sutures.

Postoperative management In recovery, note whether the patient has a normal voice and cough. The airway must be assessed, particularly

Fig. 60.8 Operative bed. The lobe and entire isthmus have been resected.

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Chapter 60

the nerve. Always consider the possibility of the right nerve being non-recurrent.Thewoundshould be reexplored if there is the possibility of a tie having been placed on thenerve. If the nerve was identified throughout the dissection, then it is likely that it is neuropraxic and steroids may hasten recovery. Damage to external laryngeal nerve

This may be from failure to develop a plane between superior-pole vessels and the cricothyroid muscle. The vessels should be clearly identified and cleared of fascia before ligation. Resection of parathyroid glands

This is only clinically relevant if the patient has had bilateral dissection, either simultaneously or metachronously. It is not advisable to divide the inferior thyroid artery lateral to the TE groove, as the parathyroids are supplied by this artery. It is better to divide the terminal branches distal to the glands. Damage to other structures

When dissecting a large multinodular gland, the pleura, oesophagus and membranous trachea are all at risk. A capsular dissection in these areas is necessary.

Early

Airway obstruction-this may be due to haematoma, bilateral recurrent laryngeal nerve palsy, tracheomalacia or laryngospasm from hypocalcaemia. Late

1 Unrecognised hypothyroidism.

2 Hypercalcaemia from vitamin D intoxication. 3 Recurrence of pathology.

Management of bypocalcaem~a It is the author’spolicy not to treat hypocalcaemia in the early phase until it is symptomatic.Whensymptoms occur(paraesthesiae, twitching, positive Trousseau’s and Chvostek’s signs), then 30ml of calcium gluconate in 300ml of dextrose saline is administeredintravenously slowly over 3 h. Blood is taken immediately before the infusion to check the calcium statusand

possibly to alter the amount of calcium that is given, althoughthe result will not be available untilafter starting the infusion. Caution must be exercised with patients on digoxin, who should be monitoredwith telemetry in an intensive-care setting. If thepatient again becomes symptomaticinthe first few days, furtherintravenous calcium gluconate is given, and also calcium Sandoz is commenced at 3g orally per day. Vitamin D supplements are usually also required promote to gastrointestinal calcium absorption. Calcitriol(la,25-dihydroxyvitaminD3)is started at1pg twice daily. Blood tests are usually required 12-hourly while the dose of calcitriol is adjusted. When theserum calcium reaches about the middle of the normal range, the daily dose of calcitriol is reduced by 0.5 pg increments, provided the calcium levels stay at the lower end of the normal range, to avoid hypercalcaemia. If hypercalcaemia occurs, calcium and calcitriol should be stopped and thepatient closely monitored to determine whether supplements arenecessary. After discharge, weekly blood levels of calcium, phosphate and creatinine are required until the condition stabilises. Ultimately the patient will continue to need blood tests at least 3-monthly.Measurement of urinary calcium is not necessary when using calcitriol. Despite its long half-life, thyroxine should be started immediately in the hypocalcaemic patient in order to avoid hypothyroidism, which impairs bone turnover.

There is considerable debateregardingtheextent of thyroid surgery for differentiated thyroid carcinomaand multinodular goitre. At issue are the reported rates of hypoparathyroidisminparticular,butalsorecurrentlaryngeal-nerve palsy, fortotalthyroidectomycompared with lesser procedures. After lobectomy, provided theopposite side has not been previously dissected, hypoparathyroidism does not occur and only one recurrent laryngeal nerve has been putat risk. For total thyroidectomy, rates of hypoparathyroidism are determined by the experience and skill of the individual surgeon. While experienced surgeons report incidences less than 2%, total thyroidectomy cannot be advocated for the occasional surgeon. Hypoparathyroidism is not simply managed but requires frequent monitoring and fine-tuning of medications. For differentiated thyroidcarcinoma,the choice of procedure is determined by the patient’s prognostic factors.The best prognosticindicators include the following: 1 age less than 40 years (male) or 45 years (female);

Tbyroid Surgery 2 tumour less size 4cm; than 3 follicular

carcinoma with minor capsular thyroidectomy

involvement; 4 extrathyroidal no extension; pears to 5 no systemic metastases. Poorer progostic indicators include the following: 1 age greater than 4.0 years (male) or 45 years (female); 2 tumour size greater than 4 cm; capsular with 3 follicular carcinoma major involvement; 4 extrathyroidal extension; 5 systemic metastases. There appears to be no difference in postoperative survival between lobectomy andtotal thyroidectomy in patients with good prognostic indicators. Proponentsof total thyroidectomy argue that recurrence is lower with the complete procedure. The author’s practice is to perform total thyroidectomy provided at least two parathyroids are identified and preserved. In the poorer prognostic group, recurrence is higher after less-than-total procedures. Also, most deaths from differentiated thyroidcarcinoma occur inthe first 5 years and from local recurrence. These patients are best served by removal of the whole gland. Total thyroidectomy facilitates postoperative radioiodine therapy-there is no delay while the residual lobe is being ablated-and the detection of systemic metastases

435

facilitated. A compromise between total and lobectomy is subtotal thyroidectomy (lobe plus isthmus plus most lobe), of other which apconfer the same local control advantage total as thyroidectomy, provided radioiodine given is postoperatively. Subtotal thyroidectomy has the advantage of posing less hazard to the parathyroid glands and usually puts only one nerve at risk.

is

Further reading Cohn KH, Backdahl M, Forsslund G et al. (1984) Biologic considerations and operative strategy in papillary thyroid carcinoma: argumentsagainsttheroutineperformance of total thyroidectomy. Surgery 96, 957-68. Harvey HK (1990) Diagnosis and management of the thyroid nodule: an overview. Otolaryngol. Clin. North Am. 23, 303-37. Sarnaan NA, Maheshwari YK, Nader S et al. (1983) Impact of therapy for differentiated Carcinoma of the thyroid: an analysis of 706 cases. J.Clin. Endocrinol. Metab. 56, 1131-8. Sarnaan NA, Schultz PN, Hickey RC etal. (1992) The results of various modalities of treatment of well differentiated thyroid carcinoma: a retrospective review of 1599 patients. J.Clin. Endocrinol. Metab. 75, 714-20. Shah JP, Loree TR, Dharker D, Strong EW, Begg C & Vlamis V (1992) Prognostic factors in differentiated carcinoma of the thyroid gland. Am. J.Surg. 164, 658. Shah JP, Loree TR, Dharker D & Strong EW (1993) Lobectomy versus total thyroidectomy for differentiated carcinoma of the thyroid: a matched-pair analysis. Am. J.Surg. 166, 331.

e Paroti

land

OHN C . WATKINSON

The following operationscan be performed on the parotid gland: 1 open biopsy; 2, superficial conservative parotidectomy; 3 total conservative parotidectomy; 4 total radical parotidectomy; 5 extended total parotidectomy; G in-continuity neck dissection. Each has its indications and contraindications and these are listed below.

vascular malformations and other miscellaneous swellings, such as lipomas. Most benign neoplasms are situated lateral to the facial nerve in the superficial part of the gland and, as such, are amenable to superficial conservative parotidectomy. Operationsto remove neoplasms fromthe cheek, mandible or infratemporal fossa, when facial-nerve preservation is mandatory, may also require a superficial parotidectomy as an integral part of the operation. Contraindications

Most parotid swellings will have had a fine-needle aspiration cytology (FNAC). In certain circumstances, when the diagnosis is unclear or the swelling is atypical, an open biopsy may be required. This shouldbe avoided, if possible, in all but the most difficult cases. When necessary, it should be done within 4weeks of, or as an entree to, the main procedure. The biopsy track should subsequently be excised.

The most common indications for superficial parotidectomy involve slowly growing and discrete intraparotid swellings which do not infiltrate the adjacentglandparenchyma. Most of these swellings are benign neoplasms, of which 80% include the pleomorphic adenoma and a small number of Warthin’s tumours. The remainder include small malignant neoplasms (4cm or less), cysts, intraparotid lymph nodes,

Any large malignant neoplasm (greater than 4 cm) should be removed (where possible) by total conservative parotidectomy. Recurrent pleomorphic adenomas, recurrent malignant neoplasms and congenital first-arch abnormalities are best dealt with by total conservative parotidectomy. Preoperative management

Special features of the history indicating malignancy include rapid swelling, pain and facial twitching. Examination should include the facial nerve and oral cavity, alongwithbothparotid and neck regions. Informed consent shouldbe offered regarding facial-nerve damage and excision and selective neck dissection. FNAC is usually indicated. CT and MRI are useful to assess large benign swellings, to distinguish between deep-lobe parotid swellings and parapharyngeal masses, and to stage malignant tumours regarding resectability and relationship to vital structures, as well as for radiotherapy planning.

Surgery of the Purotid Gland Surgical anatom

The key essential to conservative parotid surgery is total preservation of the facial nerve and its branches, so that a detailed knowledge of its anatomy is mandatory. The commonest method of identification is to find the nerve just after it has emerged fromthe skull base at the stylomastoid foramen (Fig. 6 1.1). The following markers may be used: 1 Themost reliable is thetympanomastoid groove, formed by the anterior partof the mastoid and the edge of the bony external auditory meatus (EAM). The facial nerve bisects the apex of this groove 5mm below the bony meatal edge. It then passes forwards, downwards and laterally, where it is immediately above the upper border of the posterior belly of the digastric and lateral and slightly posterior to the base of the styloid process. 2 A less reliable method is the arrow-shaped configuration of the cartilaginous meatus (Conley's pointer). The nerve lies approximately 1cm deep and inferior to the tip of the pointer. 3 Branches of the nerve can be found peripherally and traced proximally. Usually themarginalmandibular branch is identified where it crosses the posterior facial vein at the tail of the gland, and it can then be traced proximally to the lower division. This, in the author's opinion, is labour-intensive and, where difficulty arises in nerve identification (suchas large malignant tu-

43';7

mours), the best*way tofind the facial nerve is by opening the mastoid. The greater auricular nerve lies on the deep cervical fascia, which invests the sternomastoid muscle and inclines upwardsto cross the superficial aspect of the parotidgland.Itcan be used (incollaborationwith other branches of the cervical plexus)for free cable grafts infacial-nerve reconstruction. The posteriorfacial vein traverses the deep lobe of the gland from above downwards, lying immediately medial to the branches of the facial nerve. The external carotid artery (ECA) lies deep to the vein and is not normally seen in a superficial parotidectomy. Both vessels are excised, however, ih operations to remove the gland in total. Operative tee

Preparation

1 Anaesthesia. Premedication is given at least 1h before the operation and is the choice of the anaesthetist. The operation is performed under general anaesthesia with spontaneous respiration and without using muscle relaxants, in order to facilitate stimulation of the facial nerve. Controlled hypotension is useful, since it reduces blood loss and allows quicker dissection of the nerve. Depending on the extent of the procedure, hair may be shaved behind the ear or from the top of the preauricular crease. 2 Prophylatic antibiotics are not usually necessary. 3 Position of patient. The patient is placed in the supine position with a sandbag placed under the shoulders to slightly extend the neck and the head is turned away from the surgeon. The table is elevated to 15" toreduce venous congestion and arterial pressure. The homolateral eye and corner of mouth are left visible, being covered with a plastic drape. 4 If a nerve monitor such as the Magstim is to be used, the electrodes should be positioned at this point. Incision

Fig. 61.1 The surgical anatomy of the facial nerve.

This commences superiorly in front of the ear in the preauricular crease. At the lower border of the ear, it curves under the lobule of the ear to gain access to the lower border of themastoid process, andthen runs downwards and forwards on the sternomastoid muscle to finish inferiorly in the neck, using a skin crease 2cm below the lower border of the mandible (Fig. 61.2). The incision is made down on to the parotid fascia and through the platysma in the neck down to the level of, but not through, the deep cervical fascia.

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Chapter 61

Fig. 61.2 The incision for parotidectomy.

The deep investing cervical fascia is divided where it blends with the parotid fascia on the anterior border of sternomastoid. Superiorly, the gland is separated from themastoid process and thecartilaginousmeatus by blunt dissection (Fig. 6 1.4). 3 The sulcus that now exists is deepened to expose the posterior belly of the digastric, which is thentraced upwards. With an assistant pulling the parotid gland forwards and upwards, an attempt is made to identify the main trunk of the facial nerve. 4 Using the landmarks mentioned above, a haemostat is used to spread the fibrous tissue to search for the nerve in the groove formed by the bony meatus and the mastoid process. If there is any doubt, any structure should be stimulated, using the nerve stimulator. This is undoubtedly helpful butshould not replace sound anatomical knowledge, since this techniquecan fail to stimulatethe nerve or can excite itfroma distance. From this point onwards, bipolar diathermy should be used (Fig. 61.5). 5 Once the nerve has been confidently identified, the haemostat is inserted along the superficial axis of the

Fig. 61.3 The anterior flap, consisting of skin and subcutaneous tissue along with platysma inferiorly, is raised using the knife and retracted forwards. The plane of dissection is ‘under the platysma in the neck, over the platysma on the face’.

Procedure in stages 1. The anterior flap is raised, remembering to stay under the platysma in the neck and over the platysma on the face. The flap is held forward by silk stay suturesand the ear lobule retracted back by a similar thread (Fig. 61.3). 2 The greater auricular nerve is identified and divided.

Fig. 61.4 At this point, an attempt is made to find the main trunk of the facial nerve. The sulcus between the parotid gland and the external meatus and the mastoid process is deepened so that the edge of the bony meatus can be identified. The fibrous bands bridging the sulcus are quite dense and contain one or more veins which can cause troublesome bleeding. Using a mosquito haemostat to dissect these bands in the sulcus, the facial nerve is identified by blunt dissection in the tympanomastoid groove formed by the bony meatus and the mastoid process.

Surgery of theParotidGland

Fig. 61.5 The haemostat is inserted along the upper division of-the nerve, its blades opened and the haemostat lifted so that glandular tissue is then incised upwards and backwards with a knife or scissors to divide the posterior border of the gland. This process is then repeated using the haemostat, remembering the words ‘insert, lift, open and cut’.

Fig. 61.6 Using the same technique along the inferior division of the nerve, the lower half of the posterior border and the inferior border of the gland can be freed to allow the superficial lobe to be pedicled anteriorly.

439

main nerve trunk to establish a plane and to identify the bifurcation. Depending on the site of the tumour, dissection can now begin in either a superior or an inferior direction. The haemostat is slid over the upper (or lower) division and the blades opened. 6 The instrument is then raised and glandular tissue incised with a no.15 blade by cutting on tothe posterior blade of the haemostat. This technique -insert, spread, lift, cut -is then repeated to excise the superficial lobe by including the tumour with a normal cuff of parotid tissue and preserving the branches of the facial nerve. The superficial lobe is usually pedicled anteriorly but may be pedicled either inferiorly or superiorly, depending on the site of the tumour (Fig. 61.6). ’7 Dissection may be facilitated by the use of an operating microscope or loupes. Small bleeding vessels should be tied off with fine catgut or Vicryl. If the parotid duct is identified, it can be divided and ligated. At the end of the procedure, the facial nerve must be

Fig. 61.7 The buccal branches are traced forwards and the pedicle of the superficial lobe is eventually cut. Often the retromandibular vein (which lies vertically deep to the branch of the facial nerve) is seen at this point as it emerges from the tail of the remaining gland just posterior to the mandibular branch of the nerve. At this point in the dissection, the parotid duct is often encountered and may be ligated. In the process of following the mandibular branch of the nerve forwards and downwards, the lower limit of platysma can now be divided. It is important not to undermine platysma too much early in the dissection, as the mandibular branch may well be inadvertently cut as this stage.

tionaryand,as such, requires re-exploration of the wound and the appropriate vessels to be ligated. aematoma

This can occur due to the large dead space. It is usually prevented by the use of suction drainage and a pressure bandage. Small haematomasare best left alonebut larger ones require evacuation. Anaesthesia and facial weakness

Fig. 61.8 The wound is closed in two layers and the suction drainage is inserted. Platysma is closed with an absorbable stitch and the skin closed with either interrupted nylon or clips.

stimulated to confirm that the nerve is in continuity(Fig. 61.7). 8 When dealing withhaemangiomas and lymphangiomas, the technique should be modified. These tumours often infiltrate surrounding structures (particularly skin), so the anterior skin flap should be made as thin as possible.

At the end of the operation, the wound is closed in two layers. The platysma is closed by inserting an absorbable suture and the wound is drained with a vacuum drain brought out posteriorly nearthe hairline to hide the scar. The skin is closed with clips or interrupted Ethilon and the woundmay be covered with a pressure bandage for 24h (Fig. 61.8).

Division of the greater auricular nerve results in anaesthesia of the preauricular region and the lower half of thepinna.This usually settles in time asthepatient accommodates to the deficiency but can occasionally be lessened by attempting to preserve the posterior branches of the nerve. In routine superficial parotidectomy, the incidence of facial-nerve weakness is usually low (less then 15%) and the weakness is most often temporary. Resolutionis the norm as long as nerve continuity is maintained. Fistula formation

This is fortunately rare and is probably due to excessive saliva production in the remaining deep lobe. If the duct has not been ligated and production persists, then lowdosage radiotherapy is a therapeutic option.

Gustatory sweating on the side of the face at mealtimes can occur in up to 20% of patients. There is often a delay in onset of several months. Prevention is with the application of an antiperspirant. Occasionally tympanic neurectomy is worthwhile. Keloid scar

Occasionally this is aproblem; conventional manner. The pressure bandage is removed the next day, the drain can usually be removed after 48 h and stitches can usually be taken out at 5-7 days.

This is uncommon but when it occurs it is usually reac-

it is managed in the

This operationremoves the superficial and deep lobes of the parotid gland, with preservationof the facial nerve. It is indicated in benign neoplasms affecting the deep lobe, recurrent pleomorphic adenomas and large (greater than 4 cm) malignant tumours. It is also indicated in recurrent, severe parotid enlargement due to sialectasis, chronicsuppurativeparotitis secondary to

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poral artery and maxillary artery to allow the deep lobe to be removed from its bed. Occasionally the ECA lies deep to the deep lobe and can be spared (Fig. 61.10).

As for superficial parotidectomy except the incidence of temporary and permanent facial weakness is higher.

Fig. 61.9 By retracting the upper division of the facial nerve upwards and the lower division likewise downwards using a nerve hook, the deep lobe of the parotid gland may be dissected away from the posterior border of the ascending ramus of the mandible and from the temporomandibular joint.

This operation is most commonly performed for highgrade carcinomas of the parotid gland, which usually invade the facial nerve and cannot safely be removed without sacrificing it. It is sometimes performed in recurrent operations for pleomorphic adenomas and lowgrade carcinomas where, due to technical reasons, the nerve cannot be saved. Total radical parotidectomy is also an initial integral step when performing subtotal petrosectomy. The operation is contraindicated in lymphomas and for benign lesions which mimic carcinoma by enveloping the nerve. Sarcoidosis, tuberculosis, cat-scratch disease, HIV and benign lymphoepithelial lesions should also be excluded.

calculi or ductal stenosis and first-arch branchial abnormalities. Total conservative parotidectomy is contraindicated for neoplasms that grossly involve the facial nerve. Preoperative and anaesthesia

As for superficial parotidectomy. Operation

A superficial parotidectomy is performed and usually the superficial lobe is pedicled inferiorly between the cervical and mandibular branches of the facial nerve. Alternatively, the deep lobe may be removed as a separate specimen. The facial nerve is mobilised using fine scissors and is elevated witha nerve hook (Fig. 61.9). The deep lobe is mobilised from the styloid process, the ascending ramus of the mandible and the temporomandibular joint (TMJ) with either small scissors or a pledget. The ECA and posterior facial vein are ligated inferiorly; the upper end of the posterior facial vein is ligated superiorly along with the superficial tem-

Fig. 61.10 The external carotid artery is divided at the lower border of the gland above the posterior belly of digastric and stylohyoid muscles and superio& where it becomes the superficial temporal artery. The accompanying veins are also ligated.

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Chapter 61 Postoperative care

A tarsorrhaphy will probably be required if the whole nerve is sacrificed. In cases of complete facial paralysis, where nerve grafting is not performed or is unsuccessful, facial slings, pedicled muscle transposition or free muscle transfer may be required.

Extended radical parotidectomy

Fig. 61.11 The parotidectomy incision may be extended using a utility neck incision to facilitate a neck disection.

Preoperative preparation

The patient should be shaved as required and consent obtained to sacrifice the facial nerve. In all cases, a diagnosis of cancer must be obtained before the nerve is removed. This should be by previous biopsy (see earlier) or frozen section. Operation

The skin incision is as for superficial parotidectomy but withupwardextension in thetemporal hairline and lower extension in aneck crease, as required. An extension inferiorly may be necessary to carry out radical neck dissection (Fig. 6 1.11). A total parotidectomy is performed with sacrifice of the facial nerve. The nerve should only be removed whenmacroscopic invasion by tumour is confirmed. Access to the nerve to facilitate preservationcan be improved by mastoid exploration and/or neck dissection. Clearance of tumour within the nerve should be confirmed by frozen section in cases of adenoid cystic carcinoma.Thedistal branches of the facial nerve aremarkedwith silk, and primary cable grafting is performed using branches of the cervical plexus or the sural nerve. Freeze-thawed muscle is an acceptable alternative.

Radical parotidectomy may be extended to include contiguous structures such as the ascending ramus of the mandible (and occasionally the TMJ), the zygomatic arch, the temporalisand sternomastoid muscle (anterior part), as well as the lower part of the medial pterygoid muscle, the bony and cartilaginous meatus and the mastoid process. This operation is usually done in conjunction with a radical neck dissection. Skin may be involved and can be included when total conservative parotidectomy is carried out for recurrent benign and low grade malignant tumours. Most cases can be reconstructed by shaping the excision as an ellipse which follows the incision and then performing a mini-face-lift. Larger defects can be filled using pedicled myocutaneous flaps (pectoralismajor or latissimus dorsi) or free flap transfer.

Neck dissection Elective neck dissection for the NO neck may be indicated in high-grade mucoepidermoid and squamous-cell carcinoma(SCC),as well asadenocarcinomas of the parotidgland. In such cases all five levels should be dissected (in theory, a modified radical neck dissection type 3). However, since the operation is usually performedwithaparotidectomy(extended neck dissection), removal of thesternomastoid muscle actually facilitates identification of the facial nerve, so that speed and ease of operation often dictate that it is more convenient to carry out a modified radical neck dissection type 1. Thisoperationcanalso be performedwhen access isrequired for the reconstructionof defects which require pedicled myocutanous pectoralis major or latissimus dorsi flaps. With low-grade tumours, neck-node sampling can be carried out in level 1 with frozen-section control. Positive disease facilitates proceeding to neck dissection, as described above. Palpable nodes should be treated by extended modified or radical neck dissection.

"Stlrgeryof the ParotidGland

Further reading Kaplan MJ & Johns ME (1993) Malignant neoplasms of the salivary glands. In: Cummings CW, Fredrickson JM,Harker LA, Krause CJ & Schuller DE (eds) Otolaryngology -Head and Neck Surgery,Vol. 2, 2nd edn. St. Louis, Mosby Year Book.

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Suen JY & Snyderman N L (1993) Benign neoplasms of the salivary glands. In: Cummings CW, Fredrickson JM, Harker LA, Krause CJ & Schuller DE (eds) Otolaryngology-Head and Neck Surgery, Vol. 2 , 2nd edn. St. Louis, Mosby Year Book.

A N D R E W C. U R Q U H A R T

Because of the recent modifications of various neck dissections, as well as the often somewhat confusing terminology to describe them, the American Academy Committee for Head and Neck Surgery and Oncology adoptedthe following classification (Robbins et al., 1991): 1 radical neck dissection; 2 modified radical neck dissection; 3 selective neck dissection; 4 extended radical neck dissection. A radicalneckdissection consists of removal of all lymph-nodegroups (levels 1-5) and all threenonlymphatic structures (spinal accessory nerve, sternocleidomastoid muscle and IJV). A modified radical neck dissectionconsists of removal of all lymph-node groups (levels 1-5) with preservation of one or morenon-lymphaticstructures. A type 1 modified radical neck dissection preserves thespinal accessory nerve, a type 2thespinal accessory nerve and the IJV and a type 3 the spinal accessory nerve, the IJV and thesternocleidomastoid muscle. The type 3 modified radical neck dissection describes the functional neck dissection. Selectiveneckdissections consist of preservation of oneor morelymph-nodegroups and all threenonlymphaticstructures.Therearefour different named types depending on the lymph-node groups removed: supraomohyoid (levels l-3), posterolateral (levels 2-5, postauricular and suboccipital nodes), lateral (levels 24) and anterior (level 6). An extendedradicalneckdissection consists of removal of all of the structures resected in a radical neck dissection andoneor moreadditionallymph-node groups or non-lymphatic structures or both.

Local control of cancer of the head and neck has improved over the lastfew decades, partly dueto appropriatemanagement of the neck. Cervical metastasis is associated with apoor prognosis (Spiro et al., 197’4)and extracapsular spread is an even stronger indicator of a very poor prognosis (Johnson et al., 1981,1985). Extracapsular spread is diagnosed histologically by the neck dissection specimen being meticulously examined by a pathologist. The Sloan Kettering Memorialgroup(Shah et al., 1981) described six levels of cervical lymph nodes routinely removed in neck dissection procedures (Fig. 62.1). Level 1 Submental and submandibular group of nodes Level 2 Upper deep cervical group of lymph nodes around the internal jugular vein (IJV). Boundaries extend from the skull base to the carotid bifurcation (surgical landmark)or hyoid bone (clinical landmark) Level 3 Lymph nodes around the middle third of the cervical part of the IJV. Boundaries extend from the carotid bifurcation superiorly to the omohyoid muscle (surgical landmark)or cricothyroid notch (clinical landmark) inferiorly Level 4 Lymph nodes around the lower third of the cervical part of the IJV extendingfromthe omohyoid muscle to the clavicle Level 5 Lymph nodes in the posterior triangle, located along the lower half of the spinal accessory nerve and the transverse cervical artery Level 6 Lymph nodes of theanteriorcompartment, located around the midline visceral structures of the neck 444

RadicalandConservativeNeckDissections

445

squamous-cell carcinoma (SCC) of upper the aerodigestive tract. 2 Carcinoma of the thyroid gland with palpable lymph nodes in the lateral compartment of the neck.

1 SCC of the oral cavity (T2 to T4) with no palpable lymph nodes. 2 Single, palpable, mobile node in level 1or 2 from SCC of the oral cavity, lip or skin of the midportion of the face. 3 Together with parotidectomy in patients with Merkel-cell carcinoma and certainmelanomas of the cheek and zygomatic region.

Fig. 62.1 Levels of cervical lymph nodes.

The surgical treatment of the neck may include any of the above neck dissections. In the past, a radical neck dissection was done in the presence of cervical metastasis, with a wait-and-see policy regarding the uninvolved neck. It is apparent now that the information provided through the pathological assessment of the neck dissection specimen may provide valuable information regarding patient counselling, therapeutic decision-making and comparison of end results.

1 Cervical metastasis with lymph nodes in the posterior triangle of the neck and closely related to the spinal accessory nerve. 2 Large tumour mass or multiple nodes in the upper neck.

1 Patients with cervical metastasis where the spinal accessory nerve is not involved by turnour and preservation will not result in a risk of entering tumour. 2 Elective treatment of the NO neck, although there is some questionwhether such an extensive procedure needs to be done in these situations.

1 NO neck for elective treatment in patientswith

1 Carcinoma of the larynx, oropharynx and hypopharynx staged T2 to T4NO. 2 Carcinoma of the larynx, oropharynx and hypophyarynx staged T1 N 1 when a palpable nodeis in level 1 or 2. For both of the above, bilateral neck dissections are usually performed, because of the high incidence of bilateral metastask.

Skin tumours such as melanoma, SCC and Merkel-cell Carcinoma that originate in the posterior and posterolateral aspect of the neck and occipital scalp.

1 Transglottic and subglottic carcinoma, carcinoma of the cervical oesophagus and thyroid Carcinoma: remove paratracheal and pretracheal nodes. 2 Neck dissection may be extended to remove the retropharyngeal nodes when the primary tumour originates in the pharyngeal wall. 3 Involvement of non-lymphatic structures such as the hypoglossal nerve, levator scapulae muscles or carotid artery.

Assuming that the primary site of metastasis has been identified, the next important issue is one’s ability to predict disease in the neck. The physical examination, various imaging modalities and the histological findings are all important in this regard. As we know, certain

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primary sites will have a higher incidence of cervical metastasis and the location of the primary tumour can often predict which group of lymph nodes will be involved. Bilateral metastasis is also morecommonin certain sites. In carcinoma of the supraglottic larynx for example, we would expect bilateral cervical metastasis to the deep cervical lymph nodes (level 2 , 3 and 4) with very little chance of involvement of the submental and submandibular group of nodes (level 1). There are many factors that may affect the correlation between the clinical and pathological findings of necknode metastasis. The experience of the examiner is important, but diagnostic means that improve the detection rate have been sought. CT scanning has been available as a diagnostic tool for over a decade. Most reports support a high correlation of 80-95% between CT scan and pathological findings (Stevens et al., 1985; Close et al., 1989). Although MRI provides soft-tissue contrast equal to or better than CT, MRI is unable to visualise necrosis within a node aswell as CT. It does, however, appear to be as sensitive as CT in identifying cervical lymph-node metastasis (Friedman et al., 1990). Balloon test occlusion and CT xenon flow studies are donein some institutions, usually if there is tumour involving the carotid vessels.

anterior border of the sternocleidomastoid muscle, the midline of the neck and the inferior border of the horizontalramus of themandible.Theposterior cervical triangle is formed by thesternocleidomastoid muscle anteriorly, theclavicle caudally and the trapeziusmuscle posteriorly. The base of the triangle is formed by the clavicle and the apex is located at the mastoid tip. The anterior cervical triangle is divided by the digastric and omohyoid muscles into the submandibular, submental,carotid and muscular triangles. The posterior cervical triangle is divided by the inferior belly of the omohyoid muscle into the occipital and subclavian triangles. The large occipital triangle is formed by the sternocleidomastoid muscle in front, the trapeziusmuscle behind and the omohyoid muscle below. The floor is formed by the splenius capitus,levatorscapulae and medial and posterior scalene muscles. The subclavian triangle is formed by the omohyoid muscle above, the clavicle below andthesternocleidomastoid muscle anteriorly. Within the triangle are the brachial plexus, subclavian vein and artery and branches of the thyrocervical trunk. The platysma muscle extends from the lower border of the mandible above, across theclavicle to the level of the first and second rib. Theexternal jugular vein descends down vertically from behind the angle of the mandible, acrossthe sternocleinomastoid muscle to its posterior border, and pierces the investing deep cervical fascia 2cm above the The neck is divided into the anterior and posterior trian- clavicle. The IJV lies lateral to the carotid artery within gles (Fig. 62.2). The anterior triangle is formed by the the carotid sheath. At the level of the hyoid bone it is

1

Fig. 62.2 Triangles of the neck.

~ a d i c aand l ConservativeNeckDissections

I

Descendens hypoglossi nerve

\carotid artery

Fig. 62.3 Spinal accessory and hypoglossal nerves in the upper neck.

joined by the common facial vein, and the middle thyroid vein flows into it slightly lower down. The carotid artery lies medial to the IJV and atthe level of the hyoid bone forms the carotidbulb and divides into the internal (ICA) and external carotid artery (ECA). The spinal accessory nerve is the most posterior of the three nerves leaving the jugular foramen (Fig. 62.3). At first it lies between the IJV and ICA and then it crosses to the lateral surface of the IJV as it continues to descend obliquely to theupperborder of the sternocleidomastoid muscle, approximately 4 cm below the tip of the mastoid. At this point cutaneous nerves from the cervical plexus (C2, C3 and C4) radiate from the posterior border of the sternocleidomastoid muscle just below the spinal accessory nerve. The nerve passes throughthesternocleidomastoid muscle and travels across the posterior triangle between the superficial and pre-vertebral layers of cervical fascia. The nerve is joined by a branch of C2 before entering the deep surface of the sternocleidomastoid muscle and by branches of C3 and C4 before entering the trapezius muscle. The hypoglossal nerve emerges between the IJV and ICA, covered by theposterior belly of the digastric muscle. It passes forward across the lateral surface of both the ICA and ECA at the level of the carotid bulb and givesoff the descendens hypoglossi (the superior root of the ansa cervicalis). The vagus nerve at first lies medial to boththe IJV and ICA. As it descends, it comes to lie behind and between

447

the carotid artery and IJV within the carotid sheath. The phrenicnerve arises from thecervical roots of C3, C4 and C5. It passes down in the neck with a slight medial inclination on the front of the anterior scalene muscle. It is covered by the prevertebral fascia. The brachial plexus appears between the anterior and medial scalene muscles and is covered by the prevertebral fascia. At the base of the neck is the termination of the large lymphatic ducts. On the left, the thoracic ductmay loop high into the neck and then open into the internaljugular vein, the subclavian vein or the angle of the junction between the two. The right lymphatic duct is formed by three channels, which usually emptyseparately or in variouscombinationsintothe angle between the IJV and subclavian vein or separately into either of these veins. The deep cervical fascia of the neck has three layers. The superficial (investing) layer of deep cervical fascia arises from the vertebral spinous processes and ligamentum nuchae and surrounds the entire neck. It divides to enclose thetrapezius muscle, butformsa single layer as it crosses the floor of the posterior triangle. Once again, it divides and surrounds the inferior belly of the omohyoid and sternocleidomastoid muscles. The middle (visceral) layer of deep cervical fascia is found in the anterioraspect of the neck, surrounding the visceral structures.The deep (pre-vertebral) layer of deep cervical fascia covers thevertebral muscles and extends laterally on the anterior andmedial scalene and levator scapulaemuscles, forming thefascial floor of the posterior triangle. Thecarotidsheath is formed by a fusion of all three layers of fascia.

Neck dissections are usually performed in conjuction with the resection. of a primary tumour but may also be done ontheir own. General anaesthesia is obtained, and it is important not to use long-acting muscle relaxants, particulary inneck dissections requiring identification of the spinal accessory nerve. Clean procedures are associated with a postoperative wound-infectionrate of less than 2% and antibiotic prophylaxishas little effect on reducing thatrate (Johnson & Wagner, 1987). Prophylactic antibiotics are not necessary if an isolated neck dissection is done; however, if the neck dissection is performed in conjunction with a primary resection involving the upper aerodigestive tract, prophylactic antibiotics should always be used. Antibiotics aremost effective whenadministration is priorto bacterial contamination (Burke,

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Chapter 62

Fig. 62.4 Positioning for routine neck dissection.

1961). The spectrum of coverage should include oral microflora, especially anaerobic bacteria. Coverage against Gram-negative aerobic bacteria is probably unnecessary. Antibiotics should be given 1h preoperatively before any incisions are made (Johnson & Yu, 1988).Most studies wouldsupportthree doses postoperatively, with no benefit obtained from longer coverage. High doses of cefazolin or clindamycin or a metronidazole-containing combination could be used. The positioningof the patient is important as thiswill often help withexposure of theoperative field (Fig. 62.4). The patient is placed in the supine position with

Fig. 62.5 Neck dissection incisions. (a) Latyschevsky and Freund. (b)Freund. (c) T-shaped.

a shoulder roll inserted under the neck and shoulder. The head is turned away and extended from the side being operated upon. The head and neck region is then cleaned and draped in the usual way. The incision described by Latyschevsky and Freund (1960)extends from the mastoid tip to the mandibleand is ideal for a neck dissection combined with an intraoral procedure (Fig. 62.5). A vertical limb can be extended down to the midportionof the clavicle, ensuring that the trifurcation is behind the sternocleidomastoid muscle. Whena neck dissection is combinedwitha laryngectomy, the apron incision described by Freund (1967)is ideal. For an isolated neck dissection, a T-shaped incision gives adequate exposure. Theincision extends from the mastoid tip, two fingers’-breadths below the mandible in a natural skin crease, up to the midline, with a vertical limb extendingdown to the midclavicular point. Once again, the trifurcation should be over the sternocleidomastoid muscle.

1 Using the scalpel, the incisions are made through the skin and platysma, takingcare to avoid theexternal jugular veins just deep to this on the surface of the sternocleidomastoid muscles. Lahey clamps are placed through the subcutaneoustissue and the skin is retracted perpendicular to the plane of dissection. With steady traction and sharp dissection, using either a scalpel or Bovie, the flaps are elevated in an avascular plane. 2 The common facial vein is identified and ligated and, while a long suture is maintained on the proximal end,

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the mastoid tip (Fig. 62.7’). Dissection continues down to the ‘sfilkiiius capitus and levator scapulae muscles, which form the floor of the dissection. The trapezius muscle is easily identified here and forms the posterior limit of the dissection. Using sharp dissection, the contents of the upper aspect of the posterior triangle are dissected towards the carotid sheath. At this stage the spinal accessory nerve is identified as it enters thelower third of the trapezius muscle. 4 Attention is now focused on the inferior aspect of the dissection. Using a scalpel or Bovie, the sternal and clavicular heads of thesternocleidomastoid muscle arecuthorizontally just above their insertions. The omohyoid muscle comes into view running across the field, just lateral to the carotid sheath, which is positively identified. The muscle is clamped and ligated at the level of the tendon and long a tie is kept on the upper end for retraction to be used later. 5 Next a superficial horizontal incision is made with a scalpel throughthe superficial layer of deep cervical fascia at a point just above the clavicle, lateral to the

Fig. 62.6 Removing the submandibular gland.

which is keptundertraction,the capsule of the submandibular gland is incised. This is reflected superiorly, with the marginal branch of the facial nerve being protected by the proximal stump of the common facial vein. The glandis then grasped with an Allis forceps and retracted inferiorly. The tissue between the inferior border of the mandible and submandibular gland is incised, exposing the mylohyoid muscle. Using a scalpel, the fibrofatty tissue is dissected off the anterior belly of the digastric and mylohyoid muscle. The posterior borderof the mylohyoid muscle is then well defined and retracted anteriorly by the assistant, while the surgeon maintains inferior retraction on thegland (Fig. 62.6). The first structure to be seen is the lingual nerve withthe submandibular ganglion. The inferior aspect of the ganglion is clamped and ligated. The submandibular duct, which is slightly deeper and runs in a parallel direction, is clamped and ligated. The hypoglossal nerve lies deeper and is identified but not disturbed. The facial artery is identified as it crosses under the posterior belly of the digastric muscle. It is clamped and carefully ligated, with the addition of a transfixion suture. 3 Using sharp dissection, the sternocleidomastoid muscle isthen incised horizontally, just below its insertion to

Fig. 62.7 Incision of sternocleidomastoid muscle just below its insertion to the mastoid tip.

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Fig. 62.8 Tunnel along floor of posterior triangle.

carotid sheath. While holding a gauze swab in either hand, the fascia is swept upwards. The brachial plexus and phrenic nerve, running from lateral to medial and protected by the deep (pre-vertebral) layer of deep cervical fascia, are positively identified. The transverse cervicalarteryrunningacrossthe base of theposterior triangle is often seen, and it is usually possible to avoid transecting this by sweeping it to the inferior aspect of the dissection. A tunnel is now created, using a finger, along the floor of the posterior triangle, above the deep (pre-vertebral) layer of deep cervical fascia towards the pointwherethespinal accessory nerve entersthe trapezius muscle (Fig. 62.8). Two curved artery forceps are placed on either side of the finger with the points exiting just below the spinal accessory nerve. The intervening fibrofatty tissue is cut, using a small scalpel blade. The tissue is oversewn, using a continuous suture, before releasing the clamps. The spinal accessory nerve is now transected and the entire contents of the posterior triangle are swept towards the carotid sheath, using sharp dissection. The roots of the cervical plexus are now identified, clamped and ligated, taking care to be abovethecontribution of the cervical plexus to the phrenic nerve. At this stage, the IJV should be identified from behind. G The IJV is now identified inferiorly and, while carefully grasping it with a Debakey forceps, the sheath is incised, using dissecting scissors. The carotid artery and vagus nerve are identified deep to the vein. While grasping the vein wall withthe Debakey forceps, arightangled forceps is inserted around the vein and, with the tip clearly showing, opened to grasp two silk sutures, whichare securely tied. Enough space should be left

between the ties for a transfixion sutureto be placed on either side before cuttingthe vein. This is best done using a scalpel and cutting on to the back of the flat surface of a forceps supporting the vein. At this point there is somefibrofatty tissue lateral to the inferior stump of the IJV and this is clamped and ligated in case it contains any of the large lymphatic ducts. 7 The specimen is now retracted superiorly and sharply dissected off the carotid artery. The middle thyroid and common facial veins are identified and ligated. The IJV is identified superiorly, deep to the posterior belly of the digastric muscle. It is cut and ligated in the same way as the inferior part of the vein. 8 The IJV, with the neck specimen, is now dissected off thecarotidartery.The hypoglossal nerve should be identified and preserved as it crosses the carotid artery on its way to the tongue (Fig. 62.3). The final part of the dissection is carried out with traction applied to the stump of omohyoid muscle, which is dissected up to and off the hyoid bone. 9 Thewound is irrigatedwithnormal saline and haemostasis is meticulously obtained. Two small suction drains are inserted and brought out of the inferior aspect of the wound. They are sutured in position and immediately connected to suction while the skin closure is completed (to prevent clottingwithinthetubing). Closure is undertaken in two layers; the platysma and subcutaneous tissue are closed with interrupted Vicryl sutures and the skin is closed with staples. There must be an airtight closure and any air leaks should be carefully sought. Bacitracin ointment is placed alongthe incisions and this is covered with thin Telfa strips. A dressing consisting of fluffed-out gauze sponges with a wrap around the neck is applied. Modified radical isseetion (type

I)

Steps 1 and 2 are exactly the same as for a radical neck dissection. When the spinal accessory nerve is identified entering the lower third of the trapezius muscle, it is carefully traced forward through the posterior triangle of the neck towardsthesternocleidomastoid muscle (Fig. 62.9). Using a Debakey forceps on either side of the nerve, with good assistance, the tissue is carefully dissected off the nerve, using small dissecting scissors. A s it enters the sternocleidomastoidmuscle, a small forceps is placed just above it and gently spread open, and the intervening muscle is cut. This continues up to the level of theposterior belly of the digastric muscle, where the nerve is noted to be lying just lateral to the IJV. A vessel loop -is now placed around the nerve, which should be completely free of soft-tissue attachments.

Radical and Conservative Neck Dissections

Fig. 62.9 The spinal accessory nerve is traced forward from the posterior triangle.

At this stage, the sternocleidomastoid muscle is incised horizontally, below its insertion to the mastoid tip. Care should be taken not to injure the spinal accessory nerve in its exposedpaththroughthesternocleidomastoid muscle. Using sharp dissection, the contentsof the upper aspect of the posterior triangle and sternocleidomastoid muscle are reflected below the nerve, which is retracted out of the wayby the assistant. Therest of the procedure is exactly the same asforaradical neck dissection, except that care is taken to preserve the integrity of thespinal accessory nerve whenapproaching it fromthe inferior aspect of the neck dissection and reflecting thecontentsforward onto thecarotid sheath.

This is the well-described functional neck dissection withpreservation of the IJV, spinal accessory nerve and sternocleidomastoid muscle. Onceagain, steps 1

45 I

and 2, arethe same asforaradical neck dissection. 3 The fascia is then dissected off the sternocleidomastoid muscle, using sharp dissection, from the posterior to the anterior border. The greater auricular nerve and external jugular vein can usually be preserved. The fascia is grasped and reflected forward.The sternocleidomastoid muscle is retracted towards the surgeon and the fascia is sharply dissected off the medial surface of the muscle. Thespinal accessory nerve is identified entering the muscle on the deep medial surface, at the junction between the upper third and lower two-thirds. Now, grasping the fibrofatty tissue on either side of the nerve with a Debakey forceps, it is dissected forward, using small dissecting scissors. A vessel loop can be applied around thenerve for traction, and dissectioncontinuesforward to theposterior belly of the digastric muscle, where it lies lateral to theinternal jugular vein. The nerve is completely freed and retracted inferiorly with the vessel loop, and the sternocleidomastoid muscle is retracted towards the surgeon. 4 The fibrofatty tissue is now cut at the apex of the posterior triangle, using a small scalpel blade. This is best performed by cutting directly down on tothe floor of theposterior triangle, withthe nerve retracted inferiorly out of the way. Troublesome bleeding can be noted in this area, but time is well spent in keeping the operative field dry. The muscles at the apex of the posterior triangle must be seen. The spinal accessory nerve is then retracted superiorly with the vessel loop, and the fibrofatty tissue of the apex is grasped from below with an Allis forceps and reflected beneaththe nerve (Fig. 62.10). 5 Using sharp dissection with a scalpel, the tissue is dissected off the cervical plexus. This is facilitated by using the left hand with swab a to sweep the tissue forwardand maintaintraction, while gently cutting down in a perpendicular plane to the cervical plexus (Fig. 62.1 1).At this stage the spinal accessory nerve is identified where it exitsfrom below the sternocleidomastoid muscle in theposterior triangle of the neck. It is freed of soft-tissue attachments, using a Debakey forceps and small dissecting scissors. 6 The fibrofatty tissue is now cut along the anterior border of thetrapezius muscle, using a scalpel. The tissue is reflected forward off the splenius, levator scapulae and scalenus medius muscles. 7 A horizontal incision is made through thesuperficial layer of deep cervical fascia, just abovethe clavicle. Theexternal jugular vein and omohyoid muscle are clamped and ligated. Using a sponge in one hand, the fibrofatty tissue is swept off the floor of the posterior

forms the inferior aspect of the dissection. Sharp dissection continues, staying superficial to the cervical plexus until the IJV comes into view from behind. The fascia is removed from the vein, using sharp dissection, and the entire specimen is then freed by following the omohyoid muscle up to its attachment to the hyoid bone.

Postoperatively, all neck dissections aretreated in a similar manner. Antibiotics are given for three postoperative doses and then discontinued. Ambulation is encouraged in the postoperative period as soon as possible. The drains are removed separately, when the total drainage in each is less than 15m1 over 24 h. This usually occurs on the third or fourthpostoperative day. The skin clips are removed on the tenth postoperative day, often when the patient returns for a postoperative visit.

Fig. 62.10 Fibrofatty contents at apex of posterior triangle reflected beneath spinal accessory nerve.

triangle. The brachial plexus and phrenic nerve are visualised. 8 The sternocleidomastoid muscle is retracted posteriorly and the contents are dissected forward towards the carotid sheath. It may be helpful to place Allis forceps along the edge of the tissue, which is gently held by an assistant at right angles to the field. 9 Continue with sharp dissection, staying superficial to the cervical plexus until theIJV comes into view from behind, and continue dissecting until it is completely freed of attached fascia (Fig. 62.12). 10 Theentire co-ntents are now reflected beyond the vein and the omohyoid muscle is used as a lever, with dissection continuing up to the hyoid bone.

A selective neck dissection with removal of lymphatic tissue from levels 1, 2 and 3 will be described. The dissection is exactly as described for a modified radical neck dissection (type 3) upto the dissection of the fibrofatty tissue off the cervical plexus, after the spinal accessory nerve has been isolated and mobilised in level 2. At this stage, dissection continues down in front to the omohyoid muscle, which is transected and ligated, keeping alongsuture on theproximalstump.This

This problem usually occurs within the first 24 h. Apart from good surgical technique with adequate haemostasis, care should be given to the drains. These should be attached to suction as soon as they are inserted into the wound in order to prevent clot formation. Continuous wall suction in the recovery room and ward will also prevent inadvertent loss of vacuum. All haematomas should be evacuated and the wound copiously irrigated.

Fig. 62.11 Dissecting tissue off cervical tissue,

Radical and Conservative Neck Dissections

45 3

This is by far the most dangerous and potentially lethal complicationthatcanoccur. Skin incisions shouldbe planned so as to avoidtrifurcations over thecarotid artery. Meticulous closure of oral and pharyngealdefects is imperative to stop contamination of the wound with saliva. A sentinel bleed may signalimpending rupture andprompt surgicalinterventionshould be attempted.

Fig. 62.12 Contents of neck dissection are reflected up towards the hyoid bone.

This is usually noted as an increased drainage o f clear fluid in theneckdrains in thepostoperative period. Once feeding occurs, the fluid becomes milky in colour. Althougha chylous fistula mayclosespontaneously, surgical intervention is usually required, as a significant amount of protein may be lost.

Antibiotic use in contaminatedcasesappears to have resulted in a significant decrease in infections. Isolated neck dissections do not require antibiotic coverage, as these are clean cases. Most infections appearto occur as aresult o f continualcontamination o f the tissues by saliva (Newman et al., 1983). Appropriateantibiotic treatment and drainage are required.

Burke JF (1961)The effective period of preventive antibiotic action in experimental incisions and dermal lesions. Surgery 50, 161-8. Close LG, Merkel M, Vuitch MF, Reisch J & Schaefer SD (1989) Computed tomographic evaluationof regional lymph node involvement in cancer of the oral cavity and oropharynx. Head Neck 11, 309-17. Freund HR (1967) The Principles of Head and Neck Surgery. New York, Appleton-Century-Crofts. Friedman M, Mafee MF, Pacella BL, Strorigl TL, Dew LL & Toriumi DM(1990) Rationale for elective neck dissection in 1990. Laryngoscope 100, 54-9. Johnson JT& Wagner RL (1987) Infection following uncontaminated head and neck surgery. Arch. Otolaryngol. 113, 368-9. Johnson JT & Yu VL (1988) Antibiotic use during major head and neck surgery. Ann. Surg. 207, 108-11. Johnson JT, Barnes EL, Myers EN, Schramm VL, Borochovitz D & Sigler BA (1981) The extracapsular spread of tumors in cervical node metastasis. Arch. Otolaryngol. 107, 725-9. JohnsonJT, Myers EN, Bedetti CD, Barnes EL, Schramm VL & Thearle PB (1985) Cervical lymph node metastasis: incidence and implications of extracapsular carcinoma. Arch. Otolaryngol. 11 1, 534-7. Latyschevsky A & Freund HR (1960) Long upper flap incision for radical neck dissection. Surgery 47, 206-9. Newman RK, Weiland FL, Johnson JT, Rosen PR & Gumerrnan LW (1983) Salivary scan after major ablative head and neck surgery with prediction of postoperative fistulization. Ann. OtoE.RhinoE. Laryngol. 92, 366-8. Robbins KT, Medina JE, Wolfe GT, Levine PA, Sessions RB & Pruet CW (1991 ) Standardizing neck dissection terminology. Arch. Otolaryngol. 117, 601-5. Shah JP, Stiang E, Spiro PH & Vikiam B (1981) Neck dissection: current status and future possibilities. Clin. Bull. 11, 25-33, Spiro RH, Alfonso AE, Farr H W & Strong EW (1974) Cervical node metastasis fromepidermoidcarcinoma of the oral cavity and oropharynx Am. J.Surg. 128, 562-7. Stevens MH, Harnsberger HR, Mancuso AA, Davis RK, Johnson LP & Parkin JL (1985) Computedtomography of cervical lymph nodes: staging and management of head and neck cancer. Arch. Otolaryngol. 111, 735-9.

KEITH J. DAVI

Introductio

mours allows the surgeon to formulate an appropriate differential diagnosis, which is based on physical examination and imaging techniques.

Parapharyngeal-space tumours may arise fromthe contents or surrounding structures of the potential parapharyngeal space. It is estimated that parapharyngeal-spacetumoursaccountforapproximately 0.5% of head and neck tumours, 80% of which are benign and 20% malignant. Tumours of salivarygland origin account for approximately SO% of masses, originating from the deep lobe of the parotid gland or from salivary-gland rests. Those of neurogenic origin makeup an additional 30% (Heeneman & Maran, 1979; Bass, 1982; Heeneman et al., 1987; Davidge-Pitts et al., 1983).

Clinical presentation

Patientswithparapharyngeal-spacetumours usually have a late clinical presentation. Parapharyngeal-space masses allow fairly unrestricted anteriorand medial growth. A benign tumour becomes extremely large before it produces any form of symptomatology. Malignanttumours present earlier asa result of direct invasion of adjacent vital structures. The site of the mass is directly related to the origin of thetumour.Themostcommon presenting feature is anteromedial displacement of the palatine tonsil. Occasionally masses may present inferior to the parotid gland in the neck (Bass, 1982).

indications 1 To obtain pathological tissue for histological evaluation. 2 Resection of tumours for curative reasons. 3 Debulking of unresectable tumour mass in order to alleviate symptoms such as dysphagia and airway obstruction.

Imaging techniques

Imaging is essential in the evaluationof parapharyngealspace masses, and techniques include CT scanning, MRI and, where indicated, selective angiography (Fig. 63.1). MRI has replaced contrast CT scanning as a primary imaging modality for parapharyngeal-space masses (Cross et al., 1989). It has several advantages over CT scanning. MRI hassuperiorcontrastresolution,enabling better definition of the normal anatomical structures and establishment of tumour margins. Apart from offering an accurate assessment of the total extentof the mass,. the spatial relationship of the tumours to crucial vessels is also clearly shown. This important information enables the clinician to make a better and more

Contraindications C

1 Poor general medical health. 2 Extensive local infiltration by malignant tumours. 3 Metastatic disease. 4 Major vessel invasion.

Preoperative Evaluation

Evaluation of patientswithparapharyngeal-spacetu454

Surgery for Parapbary~geal-spaceTumours informed decision concerning the appropriate treatment plan. MRI doeshave some disadvantages. The main one is poor detection of calcification and of subtle bony changes produced by tumours. Thus there are clinical situations where both MRI and CT scanning are required in order to make a moredefinitive diagnosis or to include certain pathology in the differential diagnosis. CT scanning andMRI will divide the parapharyngealspace masses into enhancing (vascular) and nonenhancing (non-vascular) masses (Biller et aE., 198 la). All masses that are shown, on imaging, to be vascular are further evaluated with angiography. This will confirm tumour vascularity, and it demonstrates feeding vessels and the position of the carotid arteries.

Relevant anatomy The parapharyngeal space is a pyramidal-shaped potential space defined by fascial planes. It has as its base the skull and asits apex the hyoid bone. The medial boundary is formed by the pharyngobasilar fascia covering the superior constrictor muscle complex and tonsillar fossa. The lateral boundary includes the ramus of the mandible, fascia covering the deep lobe of the parotid gland and the medial pterygoid and digastric muscles (Fig. 632).The posterior boundaryincludes the pre-vertebral fascia and muscles, while the anterior boundaryincludes the pterygomandibular raphe. It is important to note

Fig. 63.1 Preoperative diagnosis of parapharyngeal-space tumours.

4 55

that the superior, lateral and posterior borders of the space are bdny and the only area for tumour expansion is anterior, medial and inferior. The parapharyngeal space is divided into a lateral and posterior retropharyngeal space by fascial planes (Fig. 63.3).Thelateral space is further divided intoa prestyloid and poststyloid space by the fascia enveloping the styloid process and its muscles extending anterior and medially to merge with the fascia surrounding the tensor veli palatini muscle. The prestyloid space contains the pterygoid muscles, ramus of the mandible,deep lobe of the parotid, internal maxillary artery, lingual, auriculotemporal and inferior dental nerves and lymph nodes. The poststyloid space containstheinternalcarotid artery (ICA), internal jugular vein (IJV), cranial nerves 9, 10, 11 and 12 and lymph nodes. The retropharyngeal space contains lymph nodes and fibrofatty tissue (Table 63.1). Some authors have further divided the prestyloid space to give a lateral masticator space. The only relevance of this space is thattumours arising in this area have direct access to the foramen ovale (Curtin, 1987’). Compartmentalisation is important because imaging techniques allow a more accurate preoperative diagnosis based on the anatomy of the parapharyngeal space.

allow access to the mouthwhile the posterior limit is the anterior border of the trapezius muscle.

There are three basic surgical approaches to the parapharyngeal space. This will depend on the type and extent of the parapharyngeal-space tumour. 1 Transcervical approach. 2 Transcervical approach with parotidectomy. 3 Transcervical approach withmidline mandibulotomy. In all cases the procedure begins with a transcervical approach. This may then be extended to the other two approaches if necessary. Transcervical approach

Fig. 63.2 Parapharyngeal space boundaries.

perative tec Preparatio Anaesthesia

Because of the inaccessibility and potential complications of operating in the parapharyngeal space, general anaesthesia provides a more controlled situation than local anaesthesia. The endotracheal tube (ET) should be passed transnasally on the side opposite that of the parapharyngeal-space mass. This keeps the mouth empty and facilitates intra-oral surgery. Prophylactic antibiotics

These are always utilised once the oral or pharyngeal mucosa has been opened. The importance of adequate anaerobic cover must be stressed. Patient position

The patient is placed in the supine position with the neck slightly extended and the head tuned away from the surgeon. The table may either be horizontal or inclined in ahead-upposition so as to reduce venous pressure in the head and neck region. The towels are arranged so that theentire face fromthe eye to the clavicle isexposed. The anteriorlimit of the towels must

1 The incision is located at the level of the hyoid bone. Itshould be carriedfromthe midline to theanterior border of Sternomastoid, where it curves superiorly on to the mastoid tip. It is important that the incision line is at least 2cm below the angle of the mandible, in order to avoid damaging the mandibular branch of the facial nerve (Fig*63.4). 2 The incision is continued through subcutaneoustissue and the platysma to the superficial layer of deep cervical fascia overlying the submandibular gland. Dissection is continued between the platysma and the superficial layer of deep cervical fascia, exposing the anterior belly, intermediate tendon and posterior belly of the digastric muscle. The anterior border of the sternomastoid muscle is also exposed. The common facial vein is identified in the region where the digastric muscle meets the sternomastoid muscle. At this point, the anterior facial veinis divided and ligated. The ligature on the distal segment of this vein remains long and is clamped for use retraction as a suture. The fascia overlying the submandibular gland is incised at the same level as the

Table 63.1 Compartment contents.

Surgery for Parapharyngeal-space Tumours

4 57

Fig. 63.3 Axia.l section of the

parapharyngea.l space.

skin incision. The anterior facial vein and the overlying superficial layer of deep cervical fascia are carefully elevated over the submandibular gland and,in so doing, the mandibular branch of the facial nerve is reflected superiorlyawayfromtheoperative field. The facial artery is identified superior to the posterior belly of the digastric and is divided and ligated. This enables the posterior aspect of the submandibular glandto be mobilised and thenretractedanteriorly and superiorly. In most instances, it is not necessary to remove the submandibular gland. 3 The tail of the parotid gland is now elevated. In order to accomplish this, it is necessary to divide and ligate the posterior facial vein. The parotid gland is freed from the adjacent sternomastoid muscle. The tail of the parotidis elevated to expose the posterior belly of the digastric muscle (Fig. 63.5). The carotid sheath is now exposed by retracting the sternomastoid muscle posteriorly. The common carotid artery and IJV should be adequately mobilised, using an angled Lahey together with Debakey forceps. Once these have been mobilised, they should be taped, thus providing vascular control prior to entering the parapharyngeal space. The hypoglossal and vagus nerves are also identified. At this stage, the ICA can be followed superiorly, deep to the mandible and styloid process. The posterior belly of the digastric muscle is divided and retracted posteriorly. This

manoeuvre opens the operativefield and exposes all the important structures leaving and entering the space. Themostimportantfactor in operating on the parapharyngeal space is extensive exposure of all the relevant cranial nerves and major vessels. Using the approach described above, the majority of tumours can be adequately exposed and removed. Transcervical approach with parotidectomy

Tumours in theparapharyngeal space involving the parotidglandrequirea superficial parotidectomy to expose and protect the facial nerve. 1 The incision is extended superiorly across the mastoid process to the point atwhich the lobe of the earjoins the face. It then follows the preauricular crease upwards to a point superior to the tragus (Fig. 63.4). 2 The anterior flap is elevated, using rakeretractors. Retraction is maintained in an outward anterior direction as the proper plane of dissection in the investing fascia of the gland is sought. The cleavage plane is best developed and carried anteriorly by scissor dissection. The anterior flap must only be mobilised to the periphery of the gland, so that the risk of damaging the distal branches of the facial nerve is minimised. 3 The superior cutaneous flap bearing the ear lobe is elevated next. After the dissection is carried up to the

458

Chapter 63 to permit identification of the great auricular nerve and external jugular vein. The anterior branch of the great auricular nerve is divided, as is the external jugular vein. It is important to ligate any vessels whose bleeding may interfere with clear visualisation of thetrunk of the facial nerve astheposterior surface of thegland is mobilised. 5 The facial-nerve trunk is identified in thenormal manner (Fig. 63.6). After the trunk has been isolated, the dissection is carried anteriorly in the plane of its branches. This will expose the facial-nerve complex and provide adequate visualisation for further dissection of the deep portion of the parotid gland.

Transcervical a ~ ~ r o awith c h medial mandibulotomy (Biller et al., 1981b)

A tracheostomy must be performed in all cases requiring a medial mandibulotomy.Thisapproach is primarily reserved for large or vascular parapharyngeal-space tumours, where maximum exposure of the skull base is required. This is necessary for control of bleeding, isolation and protection of cranial nerves and adequate tumour removal. 1 If a midline-~andibuloto~y approach is required, the

Fig. 63.5 Exposure of the parapharyngeal space.

external auditory meatus (EAM), the posterior border of the superficial surface of the parotid gland may be identified and freed superficially. Deeper dissection in this region is best deferred until the remaining skin flap has been raised. 4 The posterior skin flap should be elevated sufficiently

Fig. 63.6 Facial nerve trunk exposure.

Surgery for ~ara~baryngeal-s~ace Tumours 4 59 transcervical incision is carried up the midline of the neck to the level of the mandible, where it is curved laterally around the contour of the chin and back to the midline of the lower lip (Fig. 63.4). The lip is transected in the midline. Oncethe skin incision has been completed, the periosteum overlying the mandible is incised and elevated laterally for approximately 2 cm. The osteotomy is carried out through the incisor tooth socket, extracting the tooth if necessary (Fig. 63.7). 2 The osteotomy can be performed with a Gigli saw, reciprocatingsaw or Lindermanncuttingburr.The osteotomy must be anterior to the submental foramen. Prior to performing the osteotomy, drill holes must be made. This assists accurate relocation and wiring of the mandible. It is important that the osteotomy is bevelled in both a vertical and a horizontal plane. This provides adequate locking of the osteotomy once the jaw is wired together. 3 The floor of the mouth is incised along the lateral gutter, mid-way between the alveolus and the tongue base. The incision is extended from between the submandibularduct openings, alongthe floor of the mouth to the anterior tonsillar pillar. As the soft tissue inthe floor of the mouth is separated, using peanut dissection, the lingual and hypoglossal nerves are identified and preserved (Fig. 63.8). The postganglionic connections of the lingual nerve to the submandibular gland are divided. 4 The mylohyoid muscle is divided prior to performing lateral retraction of the mandible. TheICA and external carotidartery (ECA)are identified and secured with tapes, while the submandibular gland is retracted superiorly. The ECA is ligated and divided at the level of the facial artery.

Fig. 63.7 Mandibular osteotomy.

Fig. 63.8 Floor of mouth exposure.

Using one of thethreeapproaches described above, exposure of both tumour and skull base should be adequate to enable safe dissection and removal of the mass.

Prior to closure, haemostasis must be secured and all associated cranial nerves should be identified and documented as being intact. The area should be thoroughly irrigatedwithwarm saline and the digastric muscle sutured back into position. Oncethetumour has been resected, the mandible should be realigned and wired, using 25-gauge wire. The platysma is sutured, using interrupted 4/0 Vicryl. The woundis drained through a separatestab incision below the main incision, using a suction drain. A nasogastric tube is now inserted and left in place until the patient is able to feed orally. No wound dressing is necessary as direct visualisation of the entire operative site during the postoperative period is desirable. The incision line is covered, using an antibiotic ointment.

460

Chapter 63

ures the parapharyngeal space include the following: 1 double mandibular osteotomy (Attia et al., 1984); 2 anterior dislocation of the mandible (Johnson et al., 1989); 3 details regarding management of carotid paragangliomas are given in Davidge-Pitts and Pantanowitz (1984).

Attention must be paid to the following points in the postoperative management. 1 Adequate postoperative analgesia. 2 Stabilisation of the patient’s haemodynarnic status. 3 Documentation of cranial-nerve function. 4 Meticulousattentionpaid to functioning of the suction-drainage system to prevent haematoma. 5 Attentionshould be paid to intra-oral hygiene and hydration. 6 A nasogastric tubeis always inserted, as patients have difficulty in swallowing during the first few postoperative days. 7 Standardtracheostomycarewhereatracheostomy has been formed.

1 Postoperativehaemorrhage.This may occurasa complication of hypotensive anaesthesia if haemostasis is attemptedprior to normalisation of thebloodpressure. The wound must be reopened and bleeding arrested. 2 Weakness of the associated cranial nerves. The incidence of weakness should be extremely low. Any weakness is generaliy temporary and rarely lasts longer that 2-3 weeks. Hypoglossal-nerve palsy results in deviation of the tongue to the affected side. No action need be taken in a unilateral palsy. 3 Of particular relevance in these procedures is weakness of the angle of the mouth, which may occur if the mandibular branch of the facial nerve is not adequately protected. 4 Salivary fistula may occur as a result of procedures carried out to the parotid and submandibular gland. 5 Intra-oral salivary leak occurs asa result of inadequate closure of theintra-oral mucosal defect. It is extremely uncommon and should be treated conservatively. 6 Gustatorysweating in thepreauricular region at

Fig. 63.9 Floor of mouth closure.

mealtimes occurs in approximately 15% of patients who have had a parotidectomy-type approach.

References Attia EL, Bentley KC, Head T & Mulder D (1984) A new external approach to the pterygomaxillary fossa and parapharyngeal space. Head Neck Surg. 6, 884. Bass RM (1982) Approaches to the diagnosis and treatment of tumours of the parapharyngeal space. Head Neck Surg, 4, 281-9. Biller HE, Som P & Lawson W (1981a) Tumours of the parapharyngeal space: pre-operative evaluation, diagnosis and surgical approaches. Ann. Otol. Rhinol. Laryngol. 90 (Suppl. 80) (4), 3-15. Biller HF, Shugar JMA & Krespi YP (1981b) A new technique for wide-field exposure of the base of the skull.Arch. Otolaryngol. 107, 698. Cross RR, ShapiroMD 8c Som PM (1989) MRI of the parapharyngeal space. Radiol. Clin. North Am. 27 (2), 353-78. CurtinHD(1987) Separation of themasticatorspacefromthe parapharyngeal space. Radiology 163, 195. Davidge-Pitts KJ & Pantanowitz D (1984) Carotid bodytumours. Surg. Ann. 16, 203-27. Davidge-Pitts KJ, Van Hasselt A & Modi PC (1983) Parapharyngeal space tumours. South Afr. 1.Surg. 21 (2), 83-91. PW & Wiot G (1992) Muscle Freije JE,GluckmanJL,Biddinger tumours in the parapharyngeal space. Head Neck 14 (l),49-54. Heeneman H & Maran AG (1979) Parapharyngeal space tumours. Clin. Otolarylgol. 4, 57-66.

Surgery f o r ~ a r ~ p ~ a r y ~ g e aTumours l - s p ~ ~ e 461 .

\

-L.

7

I

Heeneman H, Johnson JT, Curtin H D et al. (1987) The Johnson J T , Myers E N & Curtin HD (1989) Tumours of the ParapharyngealSpace:Anatomy andPathologic C ~ ~ d i t ~ ~parapharyngeal ~ s space. In: MyersEN & Suen JY (eds) Cancer o f t h e withEmphasis onNeurogenous Tumours. Rochester, M N , SIPac HeadandNeck, 2nd edn. NewYork,Churchill Livingstone. AmericanAcademy of Otolaryngology-HeadandNeck Surgery Foundation.

e Infection G R A H A M J. C O X A N D B I P P O N

Many of the definitive descriptions of the naturalhistory and surgical management of patients with deep-neckspace infections were published in the era before effective antimicrobial agents were available. The dearth of recent publications may relate to a reduced incidence of the condition itself, or reduced morbidity and mortality due to earlier recognition using high-resolution imaging techniques. Nevertheless, the problems in establishing the precise diagnosis remain, due to the confusing clinical presentation, the difficulties in defining the precise aetiology and the differences of opinion regarding treatment. Descriptions of deep-neck-space infection occur in the medical literature of theMiddle Ages, with cases of retropharyngeal-space infection described by Galen and in the works of Platerus in 1625.

Surgical anatom The clinically important deep neck spaces are defined by the anatomy of the three layers of deep cervical fascia (Fig. 64.1). Superficial layer (investing layer) of deep cervical fascia

This layer has been described asthe‘mother’ of the cervical fasciae, as all themajor deep cervical fascial layers develop as septa from it. It is a well-developed layer that surrounds the neck and extends superiorly to the face and inferiorly into the axilla. It encloses two glands, theparotidandsubmandibular glands; two muscles, the trapezius and sternomastoid muscles; and two spaces, thesuprasternal space of Burns and the space of the posterior triangle. Inferiorly, it attaches to

C. VINAYAK

the spine of the acromion, the clavicle and the sternum, It extends circumferentially around the neck from the spines of the cervical vertebrae and contributes to the carotid sheath. Superiorly, it attaches to the body of the hyoid bone, crossing the submandibular and submental spaces to become attached along the inferior border of the body of the mandible up to the symphysis menti. It is attached to the sheaths of the digastric muscles as it covers them,thusforminga closed submental space. Posteriorly, it splits to enclose the parotid gland before being attached to the zygomatic arch, continuing over the temporalis muscle to the occiput, the mastoid process of thetemporal bone and theexternalauditory meatus (EAM). Middle (visceral) layer of deep cervical fascia (Fig. 64.2)

This layer encloses the larynx, trachea, oesophagus and thyroid gland and contributes to the carotid sheath. It sheathes the strapmuscles that attach tothe hyoid bone and thyroid cartilage. The middle layer is derived from the superficial layer of deep cervical fascia at the deep surface of the sternomastoid muscle. It encloses the two layers of infrahyoid strap muscles, forming three laminae, which are attached to the hyoid bone. At the lateral border of theomohyoid muscle, thelaminae fuse to form a continuous sheet of fascia across the midline of the neck, attached to the sternum, clavicle and anterior scapula inferiorly. The visceral component of the middle layer forms the false capsule of the thyroid gland,and is continuous with the fascia that covers the trachea and oesophagusinthe mediastinum. Itformsa relatively closed space around these viscera as they extend superiorly into the neck, becoming the larynx and pharynx.

Fig. 64.1 Cross-section of the neck at the level of the thyroid gland illustrating the three layers of the deep cervical fascia. (After Shumrick DA, Gluckman JL & Meyerhoff WL (1991) Otolaryngology. With permission from W.B. Saunders Company.)

Fig. 64.2 Midsagittal section to illustrate the fascial layers, spaces and surgical landmarks. (After Shumrick DA, Gluckman JL & Meyerhoff WL (1991) Otolaryngology.With permission from W.B. Saunders ComDanv.)

464

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b

~64 ~

t

e

~

The visceral component then attaches to the skull base, the pharyngeal aponeurosis,the mandible and the pterygomandibular raphe. Posterior to the pharynx, it covers the constrictor muscles and buccinator, extending from the skull base to the level of the cricoid cartilage asthe buccopharyngeal fascia. The middle layer also largely forms the carotid sheath surrounding the common carotid artery (CCA), the vagus nerve and the internal jugular vein (IJV). The sheath has attachments to the visceral fascia medially along the midposterior surface of the pharynx, from thebase of the skull to the level of vertebra C”. The sheath is attached to the prevertebral and investing layers of deep cervical fascia as it covers the deep surface of thesternomastoid muscle, and to themiddle layer of deep cervical fascia along the lateral border of the sternothyroid muscle. The sheath is attached to the fascia covering theposterior belly of digastric and stylohyoid muscles superiorly.

(Fig. 64.3) The deep layer is divided into thepre-vertebral layer and the alar layer. The pre-vertebrallayer lies anterior to the bodies of the cervical vertebrae, just anterior to longus colli, longus capitis and the anterior longitudinal ligament of the vertebral column. It extends to the midthoracic region inferiorly and laterally it fuses with the tips of the transverse processes of the cervical vertebrae. It continues posterolaterally, sheathing thescalene

\bone

muscles and erector muscles of the spine before being attached to the spines of the cervical vertebrae. The alar layer lies just anterior tothe prevertebral layer and deep to the middle layer. It extendsfromthe midline of the neck to the tips of the transverse processes, and is attached to thecarotid sheath. Itis attached inferiorly to the base of vertebra T2, fusing at that point with the visceral fascia. Itextends superiorly to the skull base. It is important clinically, as it separatesthe retropharyngeal space from the parapharyngeal space.

The mortality rate from deep-neck-space infections has reduced since the preantibiotic era, although death from uncontrolled sepsis or from a significant complication still occurs. Whenever a deep-neck-space abscess is identified, surgical drainage must be considered to prevent further spread of infection and to allow resolution before complications occur. Surgical intervention may be required to protect an embarrassed airway and to prevent aspiration of purulent material into the respiratory tract. Surgical intervention may also be required to remove a foreign body fromthepharynx or upper oesophagus which may be associated withthe deepneck-space infection.

The diagnosis of deep-neck-space infections is often

Fig. 64.3 Oblique cross-section from the level of the hyoid inferiorly, emphasising the relationships among the various spaces. Note the connections of the parapharyngeal space with the retropharyngeal and prevertebral spaces and carotid sheath. (After Shumrick DA, Gluckman JL& Meyerhoff WL (1991) Otolaryngology. With permission from W.B. Saunders Company.)

Deep-neck-space Infection difficult. It may not be easy to distinguish an established deep neck abscess from either diffuse cellulitis or inflammatorylymphadenopathy.The clinical features that suggest deep-neck-space abscesses include fluctuating pyrexia, pain, dysphagia or odynophagia, neck swelling, trismus and torticollis. These rnay be masked by antibiotics takenprior to presentation. Airway embarrassment is not uncommonwithretropharyngealand parapharyngeal-space infection and with Ludwig’s angina. It may be possible from the historyto establish the source of the sepsis, but the initiatinginfection may have resolved prior to the neck-space infection becoming established. Common sites are dental infections, tonsillitis and nasopharyngitis. Historically, tubercular infection of the cervical spine and pharynx was an important aetiological factor and it may remain so in underdeveloped countries. With the widespread use of antibiotics, spread of infection from upper airway lymphoid tissues is becoming less common,whereasintravenousdrug abuse, ingested foreign bodies and instrumental trauma are becoming more important causes. There is a high incidence of associated systemic disease, such as diabetes, immunosuppression, AIDS and HIV infection. The presence of these associated conditions may affect the surgical management of the patient.

Themanagement of deep-neck-space infections is to establish formaldependentdrainage of thecompartments involved, togetherwithappropriate high-dose systemic antibiotics. The incision must allow adequate exposure to identify the anatomical landmarks and important structures of the neck, as well as allowing exposure of the abscess cavity itself. Incisions arenot primarily cosmetic, and adequate flap development and retraction are often requiredto allow safe dissection and identification of anatomical landmarks. The induration and oedema of the soft tissues associated with such infection often distort the anatomyand it is often essential to identify bony and cartilaginous structures,such as the cricoid cartilage in the midline, the greater cornuaof the hyoid bone laterally and the styloid process superiorly. Important muscular landmarks include the anterior border of the sternomastoid muscle and the anterior and posterior bellies of the digastric muscle.

465

The retropharyngeal space lies behind the pharynx and upper oesophagus, extending from the skull base to the level of vertebra T1 or T2, where the middle and deep layers of cervical fascia fuse. Posterior to this space lies the pre-vertebral space (danger space), extending from the skull base to thediaphragm and laterally to the transverse processes of the vertebrae. Infection can track from the retropharyngeal space through the alar fascia intothedanger space andthusinto theposterior mediastinum, Clinical mani~estati

Infection in this space usually results from involvement of the retropharyngeal lymph node in infections of the adenoids, nose andparanasal sinuses ininfants and young children. It may also occur as a result of pharyngeal perforation from foreign bodies or instrumentation, from the spreadof dental or otological infection or from spinal tubercular disease. In children the onset may be insidious. The signs and symptoms of a severe upper respiratory infection are present, with the neck held rigid, often with torticollis due to spasm of the involved muscles. There may be an associated dislocation of the cervical vertebrae. There is associated tender cervical lymphadenopathy and deepseated pain. Laryngeal oedema rnay compromise the upper airway, with signs of airway obstruction. On examination, a definite midline swelling of the posterior pharyngeal wall can be seen. Should palpation be required to establish the diagnosis, it should be gentle to prevent rupture of the abscess and subsequent aspiration. In adults, the signs and symptoms are largely pharyngeal, with dysphagia, dyspnoea, pharyngeal pain, nasal obstruction and cervical lymphadenopathy. Grave complications may occur, including haemorrhage and rupture intothe airway, withlaryngeal spasm and aspiration. The infection may spread into the prevertebral space and so into the posterior mediastinum, or into the parapharyngeal space. Operative tee

Peroral approach

The retropharyngeal abscess can be drained through the

466

Chapter 64

open mouth, either without anaesthesia or under local topicalanaesthesia.This may be the safest approach with an infant in extremis. It is essential to have the head in an extreme dependent position to prevent aspiration, and to have a good light and suction to hand. Using a mouth gag, a vertical incision is madethroughthe mucosa and the

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