CHAPTER 08: HEAD AND NECK Flashcards
What is the T classification of oral / oropharyngeal cancers?
Tx = Cannot assess
T0 = no evidence of tumour
T1 = less than 2cm
T2 = 2-4cm
T3 = >4cm
T4 Tongue = extrinsic muscles, fixed tongue or mandible invaded
T4 Lip = through cortical bone, inf alveolar nerve, floor of mouth, facial skin i.e. chin, nose
T4a = Invades locally (e.g., through cortical bone, into deep [extrinsic] muscle of tongue [genioglossus, hyoglossus, palatoglossus, and styloglossus], maxillary sinus, and skin of face)
T4b = Invades masticator space, pterygoid plates or skull base or encases the carotid artery
[Note: Superficial erosion alone of bone/tooth socket is not T4)
What is the N & M classification?
Nx = Regional nodes not assessed N0 = No regional nodes N1 = single mobile ipsilateral node < 3 cm diameter N2a = single mobile ipsilateral node 3-6 cm N2b = multiple mobile ipsilat not > 6 cm N2c = Bilat or contralat mobile node 3-6cm N3 = any node > 6cm or any fixed node Mx = mets not assessed M0 = no distant mets M1 = distant mets
How are H&N cancers staged?
Stage I - 75 – 95%
T1
N0
M0
Stage II - 60 – 65%
T2
N0
M0
Stage III - 40 - 50%
T3
N0
M0
T0, T1, T2 or T3
N1
M0
Stage IV - 10 - 30%
T4
N0 or N1
M0
Any T
N2 or N3
M0
Any T
Any N
M1
What are the principles of recon?
Why reconstruct?
o Restoration of form and function
o Enable more aggressive treatments
o Palliation
Immediate vs. delayed reconstruction?
o Immediate gets better results
o But delayed allows planning, prefabrication
Define the patient
Define and map the defect (defect is the main predictor of post-op function not reconstruction)
What are the non-surgical modes of treatment?
- Radiotherapy
- Electromagnetic radiation
- Irreparable double strand breaks in DNA
- Indications: close or +ve margins, perineural / vascular invasion
- given postop
- Modes of delivery: fractionated, intensity modulated, bolus - Chemotherapy
- neoadjuvant, adjuvant
- for close margins / extracapsular LN spread - Chemoradiotherapy
- neo, adjuvant, concomitant - Immunotherapy
- cell signal inhibition, antiangiogenesis - Lasers & PDT (light activated chemotherapy)
What are the LN levels of the neck?
Level 1 = (a) Submental + (b) Submandibular triangle
- Below inferior border of mandible
1a below bellies of digastric, 1b above
Level 2 = Upper jugular
- lateral border of Sternohyoid to post border of the SCM
- From skull base to carotid bifurcation (clinical landmark = HYOID)
- Includes upper jugular and jugulodigastric nodes
2A +B = divided by the accessory nerve
2B = posterior to nerve
Level 3 = Middle jugular
- lateral border of Sternohyoid to post border of the SCM
- bifurcation of carotids to omohyoid (clinical landmark = CRICOTHYROID MEMBRANE)
- Contains the middle jugular nodes
Level 4 = Lower jugular
- lateral border of Sternohyoid to post border of the SCM
- from omohyoid to clavicle
- contains lower jugular nodes and thoracic duct L
Level 5 = Posterior triangle
- anterior border = post edge of SCM
- Post border = anterior edge of trapezius
- Inferior = clavicle
- Contains cervical plexus and transverse cervical artery
Level 6 = Anterior neck
- hyoid
- suprasternal notch
- medial border of carotid sheath
Level 7 = superior mediastinum
How do you manage N0 neck?
- Palpation
- Imaging - mainly USS
- FNA
- Treat if high risk of occult mets (>20%)
- How to treat? Depends on Mx of primary
- Site, size and morphology dependent
How do you manage node +ve neck?
- Surgery or radiotherapy → same effectiveness but worse side effects with radiotherapy
- Brachytherapy good if not close to mandible
SOUTAR RCT - T1&2 ELND vs wait - ELND = increased survival
What are the predictors of nodal disease?
- High T stage
- Sites → tongue, floor of mouth, tonsils, PNS, retromolar trigone. Nasopharynx and tonsil behave very differently form the other oral tumours ? more lymphatics
- Better prognosis for palate, gingiva
- Thicker tumours
What investigations are there for neck nodes?
- Clinical 70% effective
- CT/MRI 85% Nodes over 1 cm
- US + FNA 95% effective
Management of the Unknown Primary
History
- Smoking drinking, oral lesions, voice changes (larynx and thyroid), pain, ulceration, trismus (=lingual nerve perineural spread), ↓wt, swallowing problems, night sweats (lymphoma).
Examination
- Intra–oral: (with head light) tumour, ulcer, thickenings, tongue wasting, deviation
- Nasendoscopy: and look for signs of other secondaries
- General: cachexia
What are the investigations for unknown primary?
- CXR (hilar nodes in lymphoma)
- MRI/CT H+N
- PET-CT identify 60% of unknown primaries
- Rigid Panendoscopy for 1ry and other synchronous lesions. Nasopharynx, Oropharynx, Hypopharynx, Oesophagus, Stomach, Larynx, Trachea/bronchi
- Biopsy any abnormal areas + pyriform fossa, nasopharynx, tonsillar fossa, base of tongue
- Cervical node FNA -> open biopsy – (use LND compatible incision in case of extracapsular spread)
Isolated cervical mets with unknown primary - what biopsies should be take?
Classic sites (Waldeyer’s Ring (Fossae) & Tongue)
- Rosemuller Fossa - nasopharynx (behind opening of Eustachian tubes) Needs bilateral Level III
- Base of tongue
- Tonsilar fossa
- Piriform fossa (Pharynx) Level III
What is the treatment for unknown primary?
o Obtain histological confirmation = neck dissection
o If still can’t find primary, treat neck with radiotherapy or surgery (LND) + radio to possible primary sites.
What radiological investigations are useful in H&N cancers?
X-rays - only pick up late bony invasion
OPG
PA mandible
MRI Tissue excited with high-power magnet When magnetic field switched off the excited photons emit a radiofrequency wave T1 images fat = white T2 images water = white
CT
Malignant nodes have radiolucent core and radio-opaque periphery
PET & PET-CT
Radiolabelled Glucose to identify metabolising cells
FDG – Fl-18 labelled 2-F-2 deoxy-d-glucose
Identifies up to 60% of unknown primaries
Also good for regions prone to submucosal disease e.g. Head & Neck
High sensitivity, but low specificity (picks inflammation up)
CT-PET – co-registration of Pet images with CT images
How did neck dissection evolve?
Crile 1906 - described RND
Bocca & Pignataro 1967 - functional ND
1991 - neck dissection terminology standardised
What types of incisions for neck dissection do you know?
Breach - Apron
McFee - parallel hi low transverse
Hayes-Martin - chevron / sideway H
Conley - Y
What are the fascial layers of the neck?
Superficial cervical fascia • Deep cervical fascia – Superficial layer • SCM, strap muscles, trapezius – Middle or Visceral Layer • Thyroid • Trachea • esophagus – Deep layer (also prevertebral fascia) • Vertebral muscles • Phrenic nerve
DRAW!
What important structures lie over the SCM?
Which muscle is a useful landmark for identifying important structures?
- External jugular v.
- Greater auricular n.
- Spinal accessory n.
Digastric muscle Posterior belly is superficial to: • ECA (facial & lingual arteries) • Hypoglossal nerve • ICA • IJV
Anterior belly
• Landmark for identification of mylohyoid for dissection of the submandibular triangle
Marginal mandibular nerve
Spinal accessory nerve
MMN
• Most commonly injury dissection level Ib
• 1cm anterior and inferior to angle of mandible
- At mandibular notch
- Deep to fascia of submandibular gland (superficial layer of deep cervical fascia)
- Superficial to adventitia of facial vein
SAN
• Crosses IJV
• Occipital artery crosses SAN
• Descends obliquely in level II (forms Level IIa and IIb)
• Penetrates deep surface of SCM
• Exits posterior surface of SCM deep to Erb’s point
• Enters trapezius ~5 cm above clavicle
Phrenic nerve
Sole nerve supply to diaphragm
• C3-5 -> diaphragm
• Runs obliquely toward midline on anterior scalene
• Covered by prevertebral fascia
• Lies posterior and lateral to carotid sheath
Hypoglossal nerve
- Motor nerve to tongue
- Lies deep to the IJV, ICA, CN IX, X, and XI
- Curves 90deg and passes b/t IJV and ICA
- Common site of injury - floor of submandibular triangle, just deep to duct
What is the clinical significance of cervical LN levels?
Suggested by Suen and Goepfert (1997)
• Biologic significance for lymphatic drainage depending on site of tumour
Level I
• Lower lip, FOM, ventral tongue – Ia
• Other oral cavity subsites – Ib, II, and III
Level II
• Oropharynx and nasopharynx – IIb
– XI should be mobilized
• Oral cavity, larynx and hypopharynx – may not be necessary to dissect IIb if level IIa is not involved
Level IV subzones
• Level IVa nodes – increased risk in Level VI
• Level IVb nodes – increased risk in Level V
Level V subzones
• Oropharynx, nasopharynx, and skin – Va
• Thyroid - Vb
How did the Academy’s Committee for Head and Neck Surgery and Oncology standardise the classification system in 1991?
1) RND = All lymph nodes in Levels I-V + spinal accessory nerve (SAN), SCM, and IJV
= the standard basic procedure for cervical lymphadenectomy against which all other modifications are compared
2) MRND = Modifications of RND which include preservation of any non-lymphatic structures
3) SND (Selective) = one or more groups or levels of lymph nodes preserved
4) END (Extended) = removal of additional lymph node groups or non-lymphatic structures relative to RND
Academy’s Classification
1) Radical neck dissection (RND)
2) Modified radical neck dissection (MRND)
• MRND1 - keep XI (Accessory n.)
• MRND2 - keep XI + either SCM or IJV
• MRND3 - keep XI + both SCM and IJV
3) Selective neck dissection (SND) • Supra-omohyoid type • Lateral type • Posterolateral type • Anterior compartment type
4) Extended radical neck dissection
What other classifications do you know?
Medina, Spiro
When are different NDs indicated?
RND
- Extensive cervical involvement or
- matted lymph nodes with gross extracapsular spread and invasion into SAN, IJV, or SCM
MRND
– Clinically obvious lymph node metastases
– SAN / SCM / IJV not involved by tumor
– Intraoperative decision
RND vs MRND Type I (Andersen)
- 5-year survival and neck failure rates
for RND (63% and 12%) not statistically
different compared to MRND I (71% and 12%)
END
- carotid artery invasion
- hypoglossal or digastric muscle resection
Which SND is indicated for different N0 H&N carcinomas?
Selective neck dissection
- Indicated for N0 if primary lesion >20% risk of occult metastasis
- Oral T1 N1
– Reduce postsurgical shoulder pain and shoulder dysfunction
– Improve cosmetic outcome
– Reduce likelihood of bilateral IJV resection if contralateral neck involvement
- Supra-omohyoid type (oral ca)
- Lateral type (oropharynx, hypopharynx, supraglottis, and larynx)
- Posterolateral type (cutaneous & sarcomas)
- Anterior compartment type
(Selected thyroid, parathyroid,subglottic, laryngeal with subglottic extension & cervical oesophagus)
What are the different types of neck dissection skin incisions?
Apron (Breach) Half-apron / Hockey stick Conley Y Double Y H MacFee (1 parallel & under mandible, 1 above clavicle) Y incision (inf limb = over SCM) Schobinger, Modified Schobinger (inf limb = over posterior triangle)
Learn Jatin Shah's incisions A. Transverse high - supraomohyoid middle - jugular - larynx low - comprehensive - thyroid B. Modified - parotid (Blair + lazy S curving lower into neck to do supraomohyoid dissection) C. Posterolateral (S) D. Comprehensive - RND (Y)
What are the indications for adjuvant radiotherapy?
- positive histology in neck dissection
- N2 disease
- Extracapsular spread
- Oral T3 and T4
What are the complications of neck dissection?
Specific Early intra-op
- Bleeding
- Air Embolus: vein (immediate ligation, pack, head down, turn head to left side)
- Pneumothorax
- Carotid artery injury
- Nerve injury (phrenic, vagus, brachial plexus, lingual, hypoglossal, glossopharyngeal)
Specific Intermediate
- Skin-flap necrosis
- Carotid blow out: often fatal, inc risk pts with salivary fistulas, radiotherapy
- Chyle leak = damage to thoracic duct. Rx Fat free diet or TPN
- Salivary fistula
Specific Late
- Scar contracture
- Neuroma (cervical plexus)
- Shoulder pain syndrome (reduced incidence if CN XI preserved)
- Cellulitis and facial oedema (IJV excised)
Talk me through how you perform a radical neck dissection
Skin incision
- Mastoid Process to opposite SCM keeping 2 fingerbreadths below angle of mandible.
- Trifurcation point is kept posterior to carotid where possible.
How does Jatin Shah classify neck dissection?
Comprehensive - remove contents of all 5 levels
- Classic Radical
- Extended Radical
- Modified Radical 1,2,3
Selective
- Supraomohyoid
- Levels 1-3 + submandibular gland
- oral cavity tumours
- avoids risk to thoracic duct (level 4 on left) - Jugular = Anterolateral
Levels 2,3,4
- laryngeal, hypopharyngeal tumours - Anterolateral
- Levels 1-4 common for T1/2 N0 oral tumours as don’t go to 5 - Anterior
- Levels 2, 3, 4 + tracheo-oesphageal
- thyroid tumours - Posterior = Posterolateral
- Levels 2,3,4,5
- posterior scalp tumours - Central
- Level 6
How do you manage intra-op bleeding from upper end of IJV?
- Tell anesthetist: bleeding problem.
- Prevent air embolus by pressure on vein distally.
- Isolate bleeding point with suction and local dissection.
- If possible, repair or oversew IJV defect.
- If not possible, plug with finger or gauze
- Apply pressure while finishing dissection
- If still bleeding plug area with segment of SCM.
- May require thoracic surgeon to enter superior mediastinum.
- IJV may retract into temporal bone (pack with Surgicel, locate posterior belly of digastric over hole).
How do you perform a radical neck dissection?
Posterior triangle
Skin incision
- Vertical limb is curvilinear and ends at midclavicular point.
- Posterior flap is elevated subplatysmal until anterior border of trapezius.
- Spinal accessory nerve is preserved at this point in MRND – seen coming into anterior edge of post. triangle
- Dissection of soft tissue from floor of post. triangle exposing splenius capitus and levator scapulae.
- Superior edge of SCM is detached from mastoid process.
- At the lower end, transverse cervical artery and vein are tied off. Inferior belly of omohyoid is divided allowing posterior scalene muscle to be exposed.
- Lower end of external jugular ligated
- Roots of cervical plexus come into view – these are preserved until phrenic nerve and motor branches of the cervical plexus are identified. Cutaneous branches of cervical plexus then ligated (to catch accompanying vessels)
- Brachial plexus comes into view – dissection here is easy because of loose areolar tissue
- Post triangle dissection now complete.
How do you perform a radical neck dissection?
Anterior dissection
- Anterior part of transverse incision now made.
- Sternal head of SCM exposed using large loop retractor – this, along with manubrial and clavicular attachments is then divided with diathermy – loose areolar tissue between muscle and carotid aids protection of the vessel.
- Vessels entering the anterior skin flap near the clavicle are preserved (branches of int. mammary which supply skin flap)
- SCM pulled upwards to reveal carotid sheath. IJV blunt and sharp dissected out
- Prox. end of transverse cervical artery and vein ligated
- Thoracic duct dissected out and ligated
- Tissue pulled out from behind IJV to keep it in continuity with specimen
- Common carotid and vagus identified and kept out of the way medially whilst bottom end of IJV is double-ligated.
- Middle thyroid vein enters medial IJV - ligated
- Dissection continues upwards along carotid sheath until skull base
- This reveals the hypoglossal nerve, superior belly of omohyoid leading to hyoid – omohyoid detached from here
- Superior thyroid artery preserved, but vein is ligated.
- Anterior dissection now complete
How do you perform a radical neck dissection?
Supraomohyoid & mandibular gland
- Superior flap elevated
- Marginal mandibular nerve is identified over the submandibular gland (2 fingerbreadths below and 2 fingerbreadths anterior to angle of mandible) – preserved by retracting it upwards with skin flap.
- Facial artery and vein ligated along with branches of occipital artery that enter specimen.
- Contents of submandibular triangle (level 1 nodes, submandibular gland, its nerve supply and Wharton’s duct) are dissected, preserving lingual and hypoglossal nerves
- Tail of parotid is separated or transected along posterior belly of digastric which can then be retracted upwards
- Occipital artery may need to be divided if it is very low.
- Accessory nerve divided and ligated (vasa nervorum) near jugular foramen
- Upper end of IJV double ligated.
- Irrigation, drains x2 (one over trapezius, other over strap muscles), haemostasis
- Closure and airtight dressing
- Specimen pinned out on to board, labeled, marked etc.
What are the complications?
Fistulae Wound breakdown XI nerve palsy XII nerve palsy Carotid blow-out & if survive like to have CVA Airway obstruction
What is the anatomy of salivary glands?
Parotid
- Deep, superficial lobes & tail
- Separated by facial nerve
- surrounded by continuation of deep cervical fascia
- Serous acini mainly
- Stensen’s duct - opens at 2nd maxillary molar
Submandibular
- In submandibular triangle
- Mucous & Serous Acini
- Wharton’s Duct - into anterior floor of mouth
Sublingual
- In anterior floor of mouth
- Multiple ducts of Rivinus → Bartholin’s duct → Wharton
Minor glands
- 600 - 1000 of them
- Mainly mucous secreting
- Mucous Acini
What factors are suggestive of malignancy?
- 3% of all head and neck malignancy
Factors suggestive of malignancy
- Pain, Obstruction, infection, Nerve involvement (but pleomorphic (benign) can rarely cause palsy too), Invasion of other structures, Bleeding from the duct, Rapid progression.
Bimanual palpation
Name some benign salivary tumours
PAWOM
- Pleomorphic Adenoma (benign mixed)
- Most common - 65% of all salivary lesions, 80% of benign
- Slow growing, painless
- 30-50yr olds
- Rarely - Invasion of nerve → palsy
- Superficial parotidectomy better – Simple enucleation → high recurrence (tumour is not encapsulated)
- EXCISE - risk of enlargement and CNVII - Adenoma
- Cannalicular Adenoma (75% in upper lip)
- Basal Cell Adenoma (75% in parotid)
- Females 2:1
- May look like a mucocoele
- Surgical excision usually curative
3. Warthins – Adenolymphoma (papillary cystadenoma lymphomatosum) - 10%of all parotid neoplasms - 10% bilateral - 10 x risk in smokers - 10:1 M:F - 10% malignant - Minimal margin excision or superficial parotidectomy (elderly - observe)
- Oncocytoma
- rare - <1% - Monomorphic adenoma
- similar presentation to pleomorphic
- various cell types
- almost exclusive to men 50-70 years
Name some malignant salivary tumours
MAMPAL
- Mucoepidermoid
- 30% of all malignant parotid tumours
- Well differentiated → limited invasiveness rarely mets
- Intermediate grade → similar to well diff SCC
- Poorly differentiated high grade malignancy, local invasion and regional spread. - Adenoid Cystic Carcinoma
- 20%
- Cribriform = best prognosis
- Tubular = intermediate
- Solid form = worst prognosis
- Skip lesions along facial nerve common, prone to perineural invasion
- V high recurrence rate +/- lung mets - Malignant Mixed Cell (Carcinoma ex pleomorphic adenoma)
- Usually after a benign lesion present for over 10yrs - Polymorphous Low-grade adenocarcinoma
- Acinic Cell Carcinoma
- Lymphoma
- Asociated with Sjogren’s
How do you perform a superficial parotidectomy?
Blair incision - upper anterior border of ear → preauricular crease → mastoid → hyoid (2cm below mandible)
Elevation of skin flap (raise SMAS, down to parotid fascia).
Separation of parotid tail (from SCM & digastric). Preserve post. facial vein
Isolate and preserve facial nerve (tragal pointer, 1cm anterior and inferior to tragal pointer, note that it’s quite deep).
Antegrade approach - trace forward from 1cm deep to tragal pointer
Retrograde approach - trace back from cervical br (retromandibular vein), marginal br (lower mandible, over facial artery), buccal br (Stensen’s duct) - if lesion if very large in retromandibular area
Buccal branch - in line tragus and corner of mouth, identify Stensen’s duct
Tell me something about nasal and paranasal sinus tumours
3% of head and neck malignancy
More common in Far East
Affect : nasal cavity, maxillary sinus, ethmoid, sphenoid, frontal sinuses
Benign: Osteoma. Fibroma, Fibrous Dysplasia
Osseous malignancy: Osteogenic Sarcoma, Ewing’s sarcoma.
Connective tissue (malignant): Chondrosarcoma, Fibrosarcoma, Malignant fibrous histiocytoma (MFH), Rhabdomyosarcoma
Epithelial Tumours: SCC, Adenocarcinoma, Mucoepidermoid carcinoma, MM
How do you manage these tumours?
Stage (MRI, CT)
Biopsy
Ohngren’s line - plane b/t medial canthus & angle of mandible. Above line = poorer prognosis (more vital structures invaded)
Weber - Fergusson incision for maxillary sinus
How are invasive mandibular tumours managed?
History → loose teeth, numb lip, pain, (inf alveolar nerve invasion)
Exam → Big tumour, path #
X-ray → OPG, PA mandible → specific not sensitive, false -ve
CT → specific more sensitive
MRI
Operative assessment →
- If periosteum peels away easily = no invasion (Rim excision)
- If periosteum adherent = suspicious (Segmental excision)
If periosteum invaded consider rim resection (marginal mandibulectomy) or segmental resection.
How does bone invasion occur?
Bone invasion occurs
1. soft tissues = infiltrative spread
2. lymphatic channels = embolic spread
3. nerves = permeative spread
4. occlusal surface after tooth extraction
DXT may disrupt periosteal integrity → tumour spread
What is the resultant defect?
Defects
- Segmental
- Rim
- Atrophic
- Pathological Fracture
What resection techniques are there?
What is the resultant defect?
Rim resection
- resect alveolus with preservation of body of mandible. Only if tumour is abutting bone. NOT after radiation as this alters the pattern of tumour spread.
- not for edentulous patients
Segmental resection
- for significant bone invasion or after radiation. Needs reconstruction.
- Classify defects:
o C = central segment between the canine teeth
o L = lateral segment not including condyles
o H = lateral and Horizontal segment including the condyle
o Many are combination (LC - central and lat but not condyle, LCL = large central but no condyles, HC – central & lateral including condyles)
o Central segment most important to reconstruct → if not get Andy Gump deformity
o Least important → condyles
What is the history of lip reconstruction?
- 1597 – Tagliacozzi – distal pedicle from arm to lip
- 1768 – Louis – wedge excision & direct closure
- Late 1700s – Chopart – local advancement – failed
- 1838 – Sabattini – lip switch from lower to upper lip
- 1898 – Abbe
- 1857 – von Bruns – curvilinear nasolabial flaps
- 1853 – Bernard cheek advancement, von-Burrow modification
- 1872 – Estlander – for lower lateral / commissure
- 1957 – Gillies – fan flap
- Karapandzic - myoneurovascular pedicled advancement flap
- 1974 - Harii and Ohmori- microvascular free tissue transfer for lip reconstruction
What are the principles of reconstruction?
- No bone recon
- span w contoured recon plate, pec major wrap
- eventually extrudes, not suitable w DXT - Non-vascularised
- bone graft max 5cm
- autograft, allograft, alloplast
- titanium tube filled with cancellous bone - Vascularised - pedicled / free
- Vascularised bone
- Free fibula
- DCIA
- RF
- Scapular - Osseointegrated implants
Name the anatomical landmarks of the lip
NL fold, philtral columns and groove, tubercle, cupid’s bow, white roll, commissure, vermilion, labiomental fold
Name the muscles acting on the lip
Orbicularis Oris
• 2nd branchial arch.
• forms sphincter encircling oral aperture
• fibres decussate in midline at modiolus
• Extrinsic fibres intermingle with buccinator
• Intrinsic fibres → incisive and mental slips
• Acts to form a whistling expression
Elevators • Levator labii superioris alaeque nasi • Levator labii superioris • Levator anguli oris • Zygomaticus major • Zygomaticus minor
Depressors
• Depressor anguli oris
• Depressor labii inferioris
• Mentalis
What are the nerves of the lips?
Motor • Upper Lip - levators – buccal VII • Lower Lip - depressors – marginal mandibular VII • Orbicularis supplied by both • Platysma - cervical br of VII
Sensory
• upper – infra-orbital (maxillary V)
• lower – mental (inf. alveolar – mandibular V)
What is the blood supply to the lips?
- Superior & inferior labial arteries from facial artery
- 1 mm posterior to the white roll and 1 mm deep to the mucosa of the lip.
- deep to the orbicularis oris muscle
What is the lymphatic drainage of the lips?
- Upper lymphatics are unilateral, lower is bilateral
- Both lips drain into submandibular and submental nodes
- Upper lip also drains into peri-parotid and preauricular nodes
What are the aesthetic units of the lip?
Lip has 4
- Lateral wings between philtral columns and nasolabial folds
- Philtrum between philtral columns
- Lower lip between vermillion and labiomental fold
- Vermillion between vermillion border and the dry-wet line
What are the considerations of lip reconstruction?
- Oral competence
→ drooling (loss of sensation innervation and depth of lower sulcus) - Adequate access to oral cavity
Microstomia → difficult eating, dentures, teeth cleaning and repairs. Stretching devices can be used esp. if < 50% - Communication
- Cosmesis
What do the lesions on the upper lip tend to be? And lower?
- Upper lip lesions tend to be BCCs
- Lower lip lesions tend to be SCCs
- More metastasis with commissural or mucosal
What is Gilles’ principles of lip reconstruction?
What do the algorithms of lip reconstruction depend on, i.e. how do you classify lip defects?
Restoration is designed from within outwards. The lining membrane must be considered first, then the supporting structures and finally the covering.
Classification depth size location subunits
Anatomic considerations blood supply sensation muscular function motor innervation topographic subunits
How do you reconstruct >50% defects?
Over 50% full thickness • Webster’s modification of Bernard lip reconstruction = Bernard-Burows / Webster-Bernard (PRS 1960) • Gilles’ fan flap • Karapandzic (1974 BJPS) • McGregor • Nakajima • Abbe (1898 Med Rec) • Estlander (Arch Klin Chir, 1872) • Perialar flaps
- Free transfer - radial forearm & PL sling
- Replantation
What are the reconstruction options for:
- mucosa only
-
Mucosa only
• excised vermillion and mucosal advancement
Less than 30% width
• wedge / pentagon excision, direct closure
Between 30 and 50% • Johansson’s step technique • Karapandzic flap • Abbé flap • Estlander flap
What is the epidemiology of laryngeal and pharyngeal cancer?
- Commonest H&N Ca
- 2-5% of overall Ca (10th in UK)
- Late presentation > 50% stage III/IV
- M>F
- Reduced age of onset
- Stage I 90% 5yr survival
- Stave IV <40% 5yr survival
- 2-5% per annum metachronous H&N Ca
- Lung tumour – 10%
- 20% new Ca @ 5yrs
- 50% patients die
- Speech/Cosmesis/Swallow
What are the functions of the larynx?
What are the symptoms and signs of ca?
Larynx Function:
• Phonation
• Breathing
• Protection against aspiration
Symptoms & Signs: • Dysphagia • Hoarseness (≥4/52) • Neck swelling • Persistent sore or painful throat • Stridor • Unilateral pain assoc with otalgia
What investigations are useful?
Staging - Cross-sectional imaging, PET-CT Airway ? Tracheostomy Surgery Resection +/- Recon Medical evaluation Dental assessment Speech Rx Dietician assessment: BMI/Feeding regime Cancer Nurse specialist MDT
How do you treat laryngeal / pharyngeal ca?
Early Ca
o DXT or Laser Rx
Advanced Ca
- Surgery + post op RT
- Chemoradiation
Recurrent disease - surgery + free flap Surgical Options Total laryngectomy Partial laryngectomy Partial pharyngectomy Total laryngo-pharyngectomy
Reconstruction - ALT, RFF if large build patient
What are the functions of the larynx?
What are the symptoms and signs of ca?
Larynx Function:
• Phonation
• Breathing
• Protection against aspiration
Symptoms & Signs: • Dysphagia • Hoarseness (≥4/52) • Neck swelling • Persistent sore or painful throat • Stridor • Unilateral pain assoc with otalgia
What are the complications?
- Fistulae
- Wound breakdown
- XI nerve palsy
- XII nerve palsy
- Carotid blow-out & if survive likely to have CVA
- Airway obstruction
What investigations are useful?
Staging - Cross-sectional imaging, PET-CT Airway ? Tracheostomy Surgery Resection +/- Recon Medical evaluation Dental assessment Speech Rx Dietician assessment: BMI/Feeding regime Cancer Nurse specialist
How do you treat laryngeal / pharyngeal ca?
Early Ca
o DXT or Laser Rx
Advanced Ca
- Surgery + post op RT
- Chemoradiation
Recurrent disease
- surgery + free flap
Surgical Options Total laryngectomy Partial laryngectomy Partial pharyngectomy Total laryngo-pharyngectomy
If patient has a small (1cm) malignant lesion in the retromolar trigone area, after excision the defect is 2cm diameter. Is it safe to leave it to heal by 2nd intention?
No, because scar will contract and cause trismus
What do pts complain of after harvesting of DCIA?
- skin flap over DCIA not reliable
- they c/o trousers slip down because loss of iliac crest
- for curved piece of bone - harvest laterally
- for straighter piece - harvest more posteriorly
- scapular flap with bone - poor quality bone
How do you perform free jejunum reconstruction?
- Plan skin cover first – use regional flaps rather than further frees
- Harvest the jejunum 40cm from Ligament of Treitz
- Ischaemic time for jejunum is 2hrs, so don’t waste time
- General surgeon to do laparotomy, but harvest your own jejunum
- Top anastomosis, micro, then bottom anastomosis
- Soutar says make it short and tight – the neck is extended anyway, so unlikely to end up too tight
What other options are available for oesophageal reconstruction?
- Simple skin tubes – local
- Free radial forearm
- ALT
- VRAM?
How common is H&N cancers?
7% of all cancers 30% die 20% have synchronous tumour M>F smoking and alcohol increase risk 15x
How are H&N cancers categorised by AJCC?
lip and oral cavity pharynx larynx paranasal sinus salivary gland thyroid oesophagus
What is the pertinent points in history taking of a head and neck cancer?
Age Occupation General health smoking spirits spices sharp teeth syphilis sunlight HPV weight loss, systemic symptoms lumps elsewhere
What is important in the work-up of patients with H&N cancer?
Complete HN examination, 20% have synchronous tumours Biopsy of lesion Panendoscopy MRI, CT for neck staging and planning blood tests FBC, U&E, LFTs, Ca etc US neck, FNA of any neck masses PET CT
What premalignant lesions predispose to intraoral cancers?
leukoplakia - uniform / verrucous, 15-20% malignant change
erythroplakia - 50% malignant change
In H&N reconstruction, what are the common recipient arteries and veins?
Arteries
- facial
- superior thyroid
Vein
- IJV - end to side or end to end to a branch
- EJV - formed by posterior auricular vein joined by posterior retromandibular vein, crosses SCM
facial vein
Vessel depleted neck Aeteries - transverse cervical (bottom lateral corner of posterior triangle) - thoracoacromial (pectoral branch) - external carotid
Veins
- cephalic turn over
Vein grafts - in radiotherapised necks
What are the boundaries of the oral cavity, oropharynx, nasopharynx and hypopharynx?
Oral cavity - vermillion border to circumvallate papillae, and junction of soft and hard palate superiorly
Oropharynx - circumvallate papillae to tip of epiglottis (hyoid level). Includes soft palate, tonsils, aryepiglottic folds and valleculae
Nasopharynx - above oropharynx
Hypopharynx - aryepiglottic folds down to origin of oesophagus (cricoid cartilage level). Includes postcricoid region, piriform fossa and posterior pharyngeal wall
How do you treat oral cancers?
T1N0M0
surgery alone - 99%+ debulked, free tissue transfer aids postop DXT
DXT alone - 25% debulked, not recommended, as DXT may be needed postop if narrow margins
chemotherapy - adjuvant, neoadjuvant, palliation
T2 N0
Excision +/- ND (usually yes, for higher risk tongue/ FOM cancers, and for access)
+/- DXT
T3 N0
Excision and MRND
DXT - incomplete or narrow (0.5mm) excision margins, extra capsular spread. perineural invasion, N2/N3 disease
T4 Excision and reconstruction Mandible - rim resection if tumour abuts bone, segmental resection if invading or edentulous or previous DXT MRND DXT
What excision margins are used normally?
Well defined tumours: 1cm
Ill-defined, recurrent tumours or previously irradiated tissues: 2cm+
Frozen section guided
Consider perineural spread along lingual or inf alveolar nerves, divide nerves as close to skull base as possible
What are the reconstructive options?
Direct closure
SSG
Local flaps
- mucosal
- tongue
- NL fold (6x3cm)
- submental
Pedicled flaps
- pec major
- LD
Free flaps
- ALT
- RFFF
Buccal mucosa / gingiva
- tend to invade bone early
- 25% nodal mets in T1 tumours
Floor of mouth tumours
- At presentation, 15% will have mandibular invasion, 30% nodal mets
- 10% have occult nodal disease
T1 - DXT / surgery
T4 - surgery
Reconstruction
small - buccal mucosal / NL flaps
large - PM / free flap
Retromolar trigone
Faucial
RMT - b/t upper and lower 1/3 molar teeth, medial to ascending mandibular ramus and medial pterygoid muscle (trismus)
Lymphatics drain to jugulodigastric and submandibular nodes
Reconstruction
RFFF +/- bone
Pec major
What is important in examination of tongue cancers?
Tumour size
Does it cross midline?
Is tongue fixed to FOM?
Hypoglossal nerve palsy?
Investigations
EUA
MRI
What is your algorithm for tongue cancers?
Submandibular ‘visor’ incision & pull through technique (spares mandible)
Lip split and Y incision, paramedian mandible osteotomy
Synchronous neck dissection (increased rate of fistula formation)
TisN0 - CO2 laser
T1 - 1cm excision margins, d/c / SSG
T2 - surgery, RFFF
Neck dissection
DXT
T3 - surgery, ALT/LD
MRND
DXT
What does depth of invasion predict for cervical LN metastasis?
less than 5mm - 6% ND
greater than 5mm - 60% ND
When is total glossectomy indicated?
T3/T4 tumours
post DXT recurrence
> 50% tongue involvement
Reconstruction
- PM myocutaneous
- free myocutaneous rectus, ALT
- laryngeal suspension, hyoid to mandible
What are the principles of oropharyngeal cancer excision?
Access
- perioral
- Slaughter’s pull-through
- midline / paramedian mandibulotomy +/- midline glossotomy
Laryngectomy (if significant tongue base involvement)
Neck dissection (50% have nodal disease at presentation)
Tracheostomy
Reconstruction
- RFFF / ALT
- PM myocutaneous
- Temporalis muscle or TPP fascial flap
What is the blood supply of the mandible?
buccal and submandibular periosteal branches of facial arteries
inferior alveolar artery - supplies teeth and alveolar part of mandible only
What are the different types of mandibular osteotomies?
Symphyseal
Paramedian
Lateral
Vertical (b/t 2nd incisor and canine) or step or sagittal split (exposes dental roots)
How does intraoral SCCs spread to the mandible?
Dentate mandible - via periodontal membrane at occlusal surface
Edentulous mandible - via alveolar surface at tooth gaps - where cancellous bone is in contact with overlying mucosa
Post-DXT - spread through multiple sites as periosteum no longer resistant to tumour invasion
Within mandible
- medullary spread
- permeative spread along mandibular canal
Investigations for mandibular spread
OPG
CT
MRI
What are the principles of mandibular excision?
Rim resection
T1-2
non-DXT
good vertical height (not edentulous)
Segmental resection
T3-4
irradiated
short vertical height
What are the aims of mandibular reconstruction?
normal chewing, swallowing and oral competence
denture rehab and aesthetics
non-vascularised bone graft - iliac crest / rib
vacularised bone graft if 5cm+
1 Fibula
- 25cm bone
- 10% cannot rely on overlying skin paddle
- short pedicle
- angiography: peronea magna
2 RFF
- 12cm, reliable skin paddle
- b/t PT and BR
- leave 1/3 of cross-sectional area to avoid fracture
3 DCIA
- 15x6cm bone, can also harvest int oblique muscle (ascending br of DCIA) for intraoral lining
- 10% cannot rely on skin paddle
- Scapula
- 12x3cm bone with skin paddle
- subscapular artery
Others
- lateral trapezius and spine of scapula
- PM with 5th rib / edge of sternum
- SCM with medial clavicle
Alloplastic materials for mandibular recon
metal plates
allogenic bone
bone substitutes - hydroxyapetite
recon plates - for poor prognosis. Most fail within 1yr after DXT
Hypopharynx cancers - subsites
piriform fossa (70%)
post pharyngeal wall (20%)
post-cricoid region (10%)
Types of recon
direct closure
tubed FC flap
free jejunum - take 2nd / 3rd jejunal loop beyond ligament of Treitz
What are the risk factors for NPC?
HLA type (ethnicity)
EBV
dietary nitrosamines
(smoking, alcohol less impt)
What are the subtypes of NPC?
SCC
- keratinising
- non-keratinising
- undifferentiated
How do patients present?
How are they investigated?
neck nodes (70%), otitis media, obstruction, epistaxis
endoscopy
biopsy
heck node FNA
CT / MRI with contrast
What is the mainstay of treatment for NPC?
- very radiosensitive
Stage 1 - DXT to primary and neck
Stage 2-4 - DXT +/- chemo
Recurrence - salvage surgery
What are the salivary glands?
Parotid (serous)
Submandibular (S&M)
Sublingual (mucous)
Minor salivary glands (mucous)
What are the 5 most common parotid gland tumours?
3% of H&N tumours 80% are parotid, 80% are benign Pleomorphic adenoma (75%) Adenolymphoma (Warthin's) (10%) Mucoepidermoid carcinoma (3%) Adenoid cystic (3%) Others: carcinoma ex-PA
Submandibular (10-15%)
Sublingual and minor salivary glands (10%)
The smaller the gland, the more likely the tumour is malignant
MRI diagnosis: 93% sensitivity
What is the most common parotid tumour in children?
Haemangiomas
What is the embryological origin and anatomy of the parotid gland?
Ectodermal origin
Deep and superficial (75%) lobes
Enveloped by parotid fascia (continuation of SMAS and investing fascia of neck)
Contains
- facial nerve
- retromandibular vein (posterior branch drains into EJV / post-auricular vein, anterior branch drains into anterior/common facial veins)
- ECA
- preauricular LNs
- auriculotemporal nerve
Stensen’s duct turns around ant border of masseter to pierce buccinator and travels obliquely into oral cavity opp upper 2rnd molar
What is the nerve supply to the parotid?
Sensation
- auriculotemporal nerve (V3)
- great auricular nerve (C2,3) - to fascia
Secretomotor
- preganglionic fibres from inferior salivary nucleus (glossopharyngeal IX)
Posterior belly of digastric is at deep inferior surface of gland and where facial nerve emerges from stylomastoid foramen
What is the anatomy of the submandibular gland?
Deep and superficial parts
- separated by free border of mylohyoid
Superficial part - grooved by facial artery posteriorly
Deep part - lies b/t lingual nerve above and hypoglossal nerve below
Wharton’s duct - passes deep to mylo and geniohyoid and opens next to frenulum
What are the differentials for parotid gland tumours?
sebaceous cyst
sialolithiasis
autoimmune conditions e.g. Sjogren’s
lymphoma
What are the differentials for salivary gland tumours?
sebaceous cyst
sialolithiasis
autoimmune conditions e.g. Sjogren’s
lymphoma
When is biopsy indicated?
when features do not suggest pleomorphic adenomas
or minor salivary gland tumours
What symptoms and signs may prompt towards malignancy?
pain short history facial nerve involvement bleeding from duct lymphadenopathy skin changes children and elderly
What are the different types of salivary gland adenomas?
PAWOM
Pleomorphic Adenoma
- different types of epithelial tissue + different types of stroma (chondroid, myxoid, mucoid)
- F:M 2:1, 30’s-60’s, slow growth
- 70% of parotid tumours (tail usually)
- invasion of facial nerve rare
- 2-10% malignant change
- well encapsulated, but simple enucleation has high recurrence rate.
Monomorphic (Adenolymphoma, Warthins) Adenoma
- uniform epithelial tissue with lymphoid stroma
- benign, usu elderly, male 5:1, smokers
- 10% of parotid tumours
- 10% bilateral
- 10% recur after surgery
Myoepithelioma
- tumour of minor salivary glands, like PA
large intramural swelling, slow growth, avoid biopsy
- MRI: for excision planning
Mucoepidermoid
- squamous and mucous metaplasia within ductal epithelium
- no discrete capsule
- can be well or poorly differentiated
How do you perform a parotidectomy?
Blair incision
• Commonly used, this incision starts at the upper anterior border of the ear, extends downwards along the preauricular crease and continues backwards over the mastoid process.
• From here it passes anteriorly in a cervical crease towards the hyoid bone.
• The neck incision lies approximately two finger breadths below the mandible.
Elevation of the skin flap
• The skin flap is elevated from the parotid gland.
• Care should be taken to preserve the greater auricular nerve as it may subsequently be required as a nerve graft.
Separation of the tail of the parotid gland
• The tail of the parotid gland is separated from the sternocleidomastoid and digastric muscles.
• Care must be taken not to damage the posterior facial vein as ligation causes venous congestion of the gland.
Approach to the facial nerve
• The facial nerve can be approached proximally as it enters the gland (antegrade approach) or distally as it exits the gland (retrograde approach).
• If the tumour is large, it may prove difficult to retract the parotid and a retrograde approach may be preferred.
The antegrade approach
• The cartilaginous tragal pointer should be visualized.
• The facial nerve can be found 1 cm deep to this point.
• A nerve stimulator can be used to confirm identification of the facial nerve.
• The superficial lobe of the parotid gland is then separated from the facial nerve by careful dissection along the perineural space.
The retrograde approach
The distal branches of the facial nerve can be identified at the following sites:
• The cervical branch as it runs alongside the retromandibular vein.
• The marginal branch below the lower border of the mandible as it runs superficially over the facial artery.
• The buccal branches as they run alongside the parotid duct (Stensen’s duct). Identification of Stensen’s duct may be aided by cannulation from inside the mouth.
What are the different types of salivary gland carcinomas 1?
MAMpal
Mucoepidermoid carcinoma (30%)
- M=F, 30-50’s
- low grade - 86% 5 yr survival
- high grade - 22%
- intermediate/ high grade: 40% LN +ve (adjuvant DXT).
Acidic cell ca (3% of parotid tumours)
- 50’s
- Can be multifocal, occasionally bilateral.
- Usually low grade (90% 5-year survival).
- Lymph node metastases - 10%.
- Total parotidectomy, preservation of uninvolved nerves.
- ELND not indicated.
- Not usu radiosensitive.
Carcinoma ex pleomorphic adenoma (malignant mixed tumour)
- sudden onset rapid enlargement of longstanding parotid mass. If very large - requires retrograde gland dissection
What is the treatment algorithm of salivary tumours?
Parotid
Benign / low-grade (preserve facial nerve)
- superficial parotidectomy e.g. mucoepidermoid
- deep lobe = total parotidectomy
High grade
- radical parotidectomy +/- facial nerve +/- surrounding involved structures; masseter, medial pterygoid, styloid process, post belly of digastric, skin
Submandibular
Low grade - gland excision
High grade - gland + surrounding platysma, mylohyoid, hyoglossus, hypoglossal & lingual nerves
What are the complications of parotidectomy?
Intraop
- facial nerve damage, retromandibular vein damage
Early
- skin flap necrosis, infection, haematoma
sialocele, salivary fistula
Late
- Frey’s syndrome = gustatory sweating. Post-ganglionic parasympathetic secrotomotor fibres reinnervate auriculotemporal nerve.
Rx: antiperspirants, Botox, tympanic neurectomy, dermofat graft, Strattice interposition
How do you perform a parotidectomy?
A. Blair incision
• upper anterior border of ear, down along pre auricular crease, backwards over mastoid process and anteriorly in a cervical crease towards hyoid bone (2 finger breadths below mandible).
B. Elevation of skin flap
• The skin flap is elevated from superficial parotid fascia.
• Take care to preserve greater auricular nerve (may be required as nerve graft) and EJV.
C. Separation of tail of parotid gland
• Tail is separated from SCM and post digastric muscles.
• Preserve posterior facial vein as ligation causes venous congestion of gland.
D. Approach to the facial nerve
Antegrade approach
• Visualise cartilaginous tragal pointer. Facial nerve is 1 cm deep to this. Confirm with nerve stimulator.
• Superficial lobe is separated from facial nerve by careful dissection along perineural space.
Retrograde approach (large tumours)
• Distal branches of facial nerve can be identified:
- Cervical branch alongside retromandibular vein.
- Marginal branch below lower border of mandible as it runs superficially over facial artery.
- Buccal branches as they run alongside parotid duct (can cannulate Stensen’s).
Neck dissection
N0 - no ELND
Positive neck / extensive deep lobe involvement, aggressive tumour - MRND
Face / scalp primary, parotid secondary - ND
Radiotherapy - not very sensitive, only for residual/ recurrent/ high grade T3-4
Excision of parotid tumour
Blair incision, preserve great auricular nerve (Erb’s pt 6cm below tragus on SCM)
- identify and mobilise tail of parotid
- identify facial nerve (find post belly of digastric, stylomastoid foramen, tragal pointer)
- preserve facial nerve if indicated (marginal mandibular runs with retromandibular vein, inf border of mandible and over facial artery)
- anterograde dissection
- retrograde dissection (find buccal branch) if large tumour
What is Frey’s syndrome?
Frey’s syndrome is gustatory sweating following parotidectomy, when transected postganglionic parasympathetic secrotomotor nerve fibres reinnervate the auriculotemporal nerve. When the patient is eating, the sweat glands on the temporal and ear skin supplied by auriculotemporal nerve are stimulated.
Treatment includes
Antiperspirants, dermal fat grafts, Strattice interposition, tympanic neurectomy, Botox
What are the types of orbital tumours?
Secondaries (89%) - local invasion (paranasal), breast, lung, melanoma
Primary malignant orbital tumours
- lymphosarcoma, rhabdomyosarcoma
- meingioma, glioma
- orbital MM
Inflammatory disease - thyroid, automimmune (Behcets), mucoceles
Vascular - haemangioma
Childhood conditions affecting the orbit
- dermoid cyst
- rhabdomyosarcoma
- haemangioma
- optic nerve glioma
- teratoma
When should neck dissection or DXT be performed in salivary gland tumours?
N0 - no ELND
Node +ve neck / extensive deep lobe involvement, aggressive tumour - MRND
Face / scalp primary, parotid secondary - ND
Radiotherapy - not very sensitive, only for residual/ recurrent/ high grade T3-4
What investigations are indicated for orbital tumours?
Xray, CT, MRI
Biopsy
What are the surgical approaches to the orbit?
Medial wall - Lynch, transcaruncular, endoscopic endonasal
Lateral wall - upper eyelid crease, lat canthal, lat orbital rim, coronal
Orbital floor - conjunctival, transantral (buccal gingival sulcus), subciliary may cause ectropion
What are the different types of orbital excisions?
Evisceration - excise within scleral shell
Enucleation - excise globe, keep eyelid and muscles
Total exenteration - globe, muscles, eyelids, orbital walls
How do you perform an open tracheostomy?
GA, theatre, supine, neck extended, shoulders on a small roll.
Check trache size with anaethetist, test balloon, and ensure 1 size bigger and smaller is available.
Palpate landmarks (thyroid notch, sternal notch, cricoid cartilage), mark horizontal skin incision midway b/t cricoid cartilage and suprasternal notch
Inject LA with adr
Dissect through platysma until midline raphe between strap muscles is identified.
Palpate inferior limit of field to assess proximity of innominate artery. Cauterize/ ligate aberrant anterior jugular veins and smaller vessels. Midline dissection is essential for hemostasis and avoidance of paratracheal structures.
Strap muscles are separated and retracted laterally with West self retainer, exposing pretracheal fascia and thyroid isthmus.
Divide isthmus with electrocautery and suture ligature.
Check trache tube again, and warn anesthesiologist of impending airway entry.
When preparations for transfer of circuitry tubes are complete, deflate endotracheal tube balloon and enter trachea.
For an inferior Bjork flap, reflect tracheal flap and tack to skin edges with 3/0 prolene sutures left long and secured to chest and neck skin, facilitating replacement of a displaced tube.
After trachea is entered, suction secretions and blood out of lumen and slowly withdraw ETT to a point just proximal to opening. Replace lateral retractors into trachea and insert tracheostomy tube.
After airway is confirmed intact based on carbon dioxide return and bilateral breath sounds, secure tracheostomy tube to skin with 4-0 permanent sutures.
Attach tracheostomy collar
Mepilex Ag dressing to stoma site is changed daily
You have to perform a neck dissection on a previously irradiated neck. What is your management?
I would perform the neck dissection with great care as the skin flaps will be less pliable, less vascularised and dissection will be more challenging.
After the ND, I would import well-vascularised tissue such as a pectoralis major flap to reduce risk of exposure of vital structures e.g. Carotid
How do you raise a pec major flap?
- Surface markings of thoracoacromial vascular pedicle: draw a line from shoulder acromion to xiphisternum + another line vertically from midpoint of clavicle to intersect 1st line
- Skin paddle is located inferomedially on pec major
- Flap is then raised off the chest wall
- To increase reach superiorly, flap can be carefully dissected off inferior aspect of clavicle, and passed under clavicle
What are the indications for lateral canthotomy?
Absolute indications for lateral canthotomy include
- retrobulbar hemorrhage resulting in acute loss of visual acuity,
- increased IOP,
- proptosis.
- unconscious patient, an IOP greater than 40 mm Hg (normal IOP is 10-21 mm Hg).
Lateral canthotomy may also be considered in
patients with retrobulbar hemorrhage along with any of the following: afferent pupillary defect, ophthalmoplegia, cherry-red macula, optic nerve head pallor, and severe eye pain. However, these findings are subjective, less reliable, and nonspecific.
Contraindication - globe rupture
What is the aetiology of orbital compartment syndrome?
Trauma
Post eyelid surgery
Recent retrobulbar anesthesia
Spontaneous retrobulbar hemorrhage due to venous anomalies, atherosclerosis, intraorbital aneurysm of ophthalmic artery, hemophilia, leukemia, von Willebrand disease, and hypertension has also been described.
Other less common causes of orbital compartment syndrome include orbital cellulitis, orbital abscess, tumors, orbital emphysema, and inflammation.
Want are the signs of retrobulbar haemorrhage?
- pain,
- decreased vision,
- diplopia,
- limited extraocular movements,
- proptosis,
- ecchymosis around eye,
- bloody chemosis,
- increased intraocular pressure (IOP),
- resistance to retropulsion,
- afferent pupillary defect.
How do you perform a lateral canthotomy and cantholysis?
Instruments required Lidocaine 1-2% with epinephrine Syringe with 25-gauge needle Sterile drapes Normal saline for irrigation Straight hemostat Sterile iris or suture scissors Forceps
Lateral canthotomy
- LA 1-2ml
- Use straight hemostat to crimp skin at lateral corner of eye, all the way down to orbital rim for 1-2 minutes. This crimp functions to achieve hemostasis and to mark location where incision is to be made.
Cantholysis
- Retract inferior lid downward to visualize lateral canthal tendon.
- With scissors directed along lateral orbital rim (pointing away from globe), dissect the inferior crux of lateral canthus tendon and cut it.
- If procedure is insufficient (ie, IOP remains >40 mm Hg), cut superior portion of lateral tendon by dissecting superiorly before cutting it.
What pearls are there for this procedure?
Pearls
- When cutting canthal ligament, aim inferoposteriorly toward lateral rim. This helps to avoid injury to levator muscle, lacrimal gland, and lacrimal artery, which are located in the upper lid.
- A successful procedure is marked by improved visual acuity, resolution of a previously detected afferent pupillary defect, and decrease in IOP to below 40 mm Hg.
- Always seek emergent consultation with an ophthalmologist when this procedure is performed.
- Treatment should not be delayed to obtain imaging.
Marcus Gunn pupil (afferent pupillary defect), is tested using the swinging flashlight test. Test is positive when the affected pupil dilates in response to light (the other normal pupil also dilates when light is shone in affected eye). Both pupils constrict when light is shone in normal eye. This results from injury to afferent fibers of cranial nerve II of defective eye, while efferent signals from cranial nerve III of normal eye are uninjured.
What are the complications?
Complications
- iatrogenic globe injury by forceps or scissor tips
- ptosis due to damage to levator aponeurosis, lacrimal gland and lacrimal artery, which lie superiorly.
- Ectropion (excessive cantholysis)
Less common complications include bleeding and infection.
Irreversible vision loss can occur if retina ischemia time is greater than 90-120 minutes.
Radical neck dissection: incision
Incision
• T-shaped incision:
∘ Transverse limb from mastoid to contralateral SCM (2 fingerbreadths below mandible in a skin crease)
∘ Vertical limb just posterior to carotid, to midclavicular point.
Radical neck dissection: Elevation of the posterior skin flap
- Subplatysmal as far as anterior border of trapezius (Avoid EJV).
- SAN is seen at posterior border of SCM in posterior triangle.
Radical neck dissection: Dissection of posterior triangle
- Peel soft tissues medially, exposing floor of posterior triangle.
- SCM is detached from mastoid.
- Transverse cervical vessels ligated.
- Inferior belly of omohyoid is divided.
- Inferior EJV is ligated.
- Motor branches of cervical plexus and phrenic nerve are preserved.
- The brachial plexus comes into view as dissection is completed.
Radical neck dissection: Elevation of the anterior skin flap
- Subplatysmal.
- Sternal and clavicular attachments of SCM are divided.
- Preserve branches of IMA entering the skin flap near clavicle.
Radical neck dissection: Dissection of the carotid sheath
• SCM reflected superiorly.
• IJV dissected using sharp and blunt dissection.
• Proximal end of transverse cervical vessels ligated.
• Thoracic duct ligated.
• Fascia between carotid sheath and strap muscles is incised.
- Strap muscles retracted medially.
- Common carotid artery and vagus nerve retracted medially.
• Inferior end of IJV doubly ligated. (Middle thyroid vein may enter IJV medially and is ligated).
• Dissection continues superiorly along carotid sheath to skull base.
∘ Lymph nodes posterior to IJV are pulled out to remain in continuity with specimen.
• Hypoglossal nerve is preserved.
• Superior belly of omohyoid is detached from hyoid.
• Superior thyroid artery is preserved, but vein ligated.
Radical neck dissection: Elevation of the superior skin flap
• Marginal mandibular nerve preserved by retracting it upwards with skin flap (overlies submandibular gland, 2 fingerbreadths below and anterior to mandibular angle).
• Facial vessels and branches of occipital artery ligated.
• Contents of submandibular triangle (level I nodes, submandibular gland, its nerve
supply and Wharton’s duct) are dissected.
• Lingual and hypoglossal nerves preserved.
• Tail of parotid separated or transected along posterior belly of digastric and retracted
upwards.
• SAN ligated and divided near jugular foramen.
• Upper end of IJV doubly ligated, and the specimen is delivered.
• Haemostasis, skin closure over 2 suction drains.
How is radiotherapy delivered?
∘ External beam
∘ Brachytherapy – implanting radioactive devices into the tumour.
What is the aim of radiotherapy?
∘ Cure: radical radiotherapy.
∘ Improving post-operative local control: adjuvant radiotherapy.
∘ Symptomatic relief: palliative radiotherapy.
When is radical radiotherapy indicated?
- In N0 neck, there is no difference between control rates at 5 years with elective neck dissection or prophylactic radiotherapy.
- Radical radiotherapy alone works best for N1 necks.
- > 30% of N2 or N3 necks have microscopic residual disease post radiotherapy.
- Very difficult to deal with neck recurrence following DXT.
When is adjuvant radiotherapy indicated?
• Adjuvant treatment for N2 or N3 necks can be given before or after neck dissection.
Indications for adjuvant DXT: ∘ Oral cavity primary tumours ∘ T3 or T4 lesions ∘ Close or positive surgical margins ∘ Perineural or lymphovascular invasion ∘ Extracapsular lymph node spread.
What are the side effects of radiotherapy?
∘ Mucositis
∘ Xerostomia (often permanent).
• Modern 3D CT planning delivers intensity-modulated radiotherapy (minimises collateral radiation damage to adjacent normal tissues, but is very hard to do in oral cancers due to mandible).
• Osteoradionecrosis is not commonly seen nowadays.
- Mainstay of treatment = resection with vascularised reconstruction.
What is the role of chemotherapy in H+N?
- Indications are not well established.
- Most often used for tumours at high risk of recurrence.
- Platinum-containing agents e.g. cisplatin are most effective.
- Cetuximab = monoclonal antibody targeted at epidermal growth factor receptor. Confers 9% survival advantage over radiotherapy alone in T3 and T4 lesions.
What clinical features are suggestive of malignancy in parotid masses?
rapid growth pain skin involvement facial nerve palsy deep fixation hard consistency palpable nodes
Besides benign and malignant parotid tumours, what are the other causes of parotid enlargement?
Infections
- bacterial parotitis: e.g. S aureus
- viral parotitis: mumps
Autoimmune
- Sjogren’s, Mikulicz disease (antiquated name for any parotid gland enlargement not TB, leukaemia or identifiable disease).
Blockage
- sialolithiasis (calculus)
How is a parotid mass investigated?
History
Examination
- USS (assess tumour and LN, guides FNAC)
- FNAC (90% accuracy for benign vs malignant)
(Not open biopsy due to seeding) - MRI
- Staging CT
- PET CT?
Discuss at MDT
How is a neck LN with unknown primary managed?
usu SCC (
How is a neck LN with unknown primary investigated?
Controversial / dependent on unit
- USS + core biopsy
- Cross-sectional imaging
- PET CT (identifies 30% of primaries, but significant false +ves)
- CT skull base to diaphragm (primary & synchronous tumours, lymphadenopathy, lung mets) - Panendoscopy
Visualise
∘ Nose, paranasal sinuses and nasopharynx
∘ Oral cavity, hard and soft palate
∘ Tongue base, tonsil and posterior pharyngeal wall
∘ Vallecula, supraglottis, glottis and subglottis
∘ Pyriform fossa, postcricoid region and proximal oesophagus.
4. Biopsy suspicious areas + ∘ Pyriform fossa ∘ Nasopharynx ∘ Tonsillar fossa ∘ Base of the tongue.
What if results are negative after investigations?
Tonsillectomy (ipsi / bilateral)
MRND / SND (ipsi / bilateral)
Radiotherapy if N2/N3 or extra capsular spread
- total mucosal irradiation
- neck
Briefly summarise different radiological modalities.
MRI • Demonstrates abnormalities of soft tissue well. • T1-weighted images: "anatomy" fat = white and water = black. • T2-weighted images: "pathology" water = white and fat = black.
CT
• Demonstrates bony detail well.
• Density measured in Hounsfield units (HU).
• Contrast agents usually iodinated compounds.
Positron emission tomography (PET)
• Useful for locating occult primary tumours and assessing recurrence.
• Map shows levels of glucose metabolism within tissues.
• Radiolabelled 16 fluorodeoxyglucose (FDG) is preferentially taken up by cancer than normal cells (detectable by gamma camera).
• Can incorporate CT or MRI to localise uptake to its precise anatomical site.
US
• Useful for occult cervical lymphadenopathy and salivary gland tumours.
• Soundwaves are partially reflected when tissue density changes.
