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Surgery_Schwartz. This prevents nasal regurgitation of air Brunicardi_Ch18_p0613-p0660.indd 63901/03/19 5:24 PM 640SPECIFIC CONSIDERATIONSPART IIand liquids, therefore impacting both speech and swallowing. Similarly, total glossectomy reconstruction has several goals, including filling the oral cavity dead space, allowing the neo-tongue to reach the premaxilla to assist with articulation, and, most importantly, creating posterior bulk to allow the base of tongue to touch the posterior pharyngeal wall, which assists with the pharyngeal phase of swallowing. This is often achieved with a large rectus abdominis or anterolateral thigh free flap.138 If the neotongue does not successfully touch the premaxilla and hard palate and speech is impeded, a palatal obturator can be used to bring down the palate and achieve better contact.Hypopharynx and Cervical Esophagus The hypopharynx, which extends from the vallecular to the lower border of the cricoid cartilage (Fig. 18-30), has three subsites; the pyriform


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Surgery_Schwartz. better contact.Hypopharynx and Cervical Esophagus The hypopharynx, which extends from the vallecular to the lower border of the cricoid cartilage (Fig. 18-30), has three subsites; the pyriform sinuses, the lateral and posterior pharyngeal walls, and the post cricoid space. SCC of the hypopharynx typically presents with progressive dysphagia, first to solids then to liquids, fol-lowed by weight loss. Similar to oropharyngeal tumors, patients can also present with voice change, referred otalgia or a neck mass. Rarely, when the larynx is involved, patients may pres-ent with stridor and airway compromise necessitating an urgent tracheotomy.Unfortunately, there is significant delay in diagnosis of patients with hypopharyngeal cancer and late presentation is common.140 Routine physical examination will not typically detect the tumor. Fiberoptic nasolaryngoscopy is important in assessing the extent of the tumor and laryngeal function. Vocal cord paralysis is a poor prognostic factor and


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Surgery_Schwartz. will not typically detect the tumor. Fiberoptic nasolaryngoscopy is important in assessing the extent of the tumor and laryngeal function. Vocal cord paralysis is a poor prognostic factor and indicates fixation of the cricoarytenoid joint from direct extension of the tumor or recurrent laryngeal nerve invasion. A Valsalva maneuver dur-ing laryngoscopy allows for a better evaluation of the opened pyriform sinuses and postcricoid space. Functional endoscopic evaluation of swallowing (FEES) can be useful to assess laryn-geal penetration and aspiration, but a modified barium swal-low (MBS) is better at assessing inferior extent of the disease, multifocality within the esophagus, and aspiration. A thorough metastatic workup is required, with special attention paid to paratracheal and upper mediastinal metastases.This site has the poorest survival outcomes of all head and neck subsites. There is no difference in survival when surgery is used as the primary modality of treatment followed by


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Surgery_Schwartz. metastases.This site has the poorest survival outcomes of all head and neck subsites. There is no difference in survival when surgery is used as the primary modality of treatment followed by radio-therapy or chemoradiotherapy compared to primary radiother-apy or concurrent chemoradiotherapy followed by surgery.141 Concurrent chemoradiotherapy appears to be the modality of choice for laryngeal preservation; however, when surgical sal-vage is required, there is a low cure rate and increased wound complications.142 Early T1 lesions without clinical or radio-graphic evidence of adenopathy can be treated with primary radiotherapy, but this is relatively rare for this subsite due to a high rate of adenopathy and an advanced T stage at presentation.Surgical resection, typically in the salvage setting, involves a total laryngopharyngectomy typically with a circumferential defect or a very small strip of mucosa preserved in continuity with the cervical esophagus. A total thyroidectomy and


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Surgery_Schwartz. setting, involves a total laryngopharyngectomy typically with a circumferential defect or a very small strip of mucosa preserved in continuity with the cervical esophagus. A total thyroidectomy and cen-tral neck dissection (level VI) is simultaneously performed and removed en bloc with the specimen. Bilateral neck dissection of levels II to IV is indicated. Careful dissection of the central neck, and in some cases the upper mediastinum (level VII), is required to clear regional disease, and this is critical in prevent-ing a peristomal recurrence.Given the circumferential or near circumferential defect, reconstruction is required to prevent saliva from accumulating in the wound and to create a neopharynx. A pedicled pectoralis major flap sutured to the prevertebral fascia has been described, but advances in free flap reconstruction has popularized a num-ber of fasciocutaneous flaps for reconstruction of this defect, namely the radial forearm flap and the anterolateral thigh free


Surgery_Schwartz

Surgery_Schwartz. but advances in free flap reconstruction has popularized a num-ber of fasciocutaneous flaps for reconstruction of this defect, namely the radial forearm flap and the anterolateral thigh free flap.143-146 When total laryngopharyngoesophagectomy is required, a gastric pull-up may be performed for the pharyngeal reconstruction.Larynx Laryngeal carcinoma typical presents with a progres-sive voice complaint in a long-time smoker (Fig. 18-31). A thorough understanding of laryngeal anatomy is critical in the proper diagnosis, staging, and treatment of laryngeal cancers. The larynx is divided into the supraglottis, glottis, and subglottis as previously described (Fig. 18-32). The larynx starts superi-orly at the epiglottis and ends inferiorly at the inferior border of the cricoid cartilage of the larynx span from the epiglottis supe-riorly to the cricoid cartilage inferiorly. Laterally, it is separated from the hypopharynx by the aryepiglottic folds.The supraglottis includes all of the


Surgery_Schwartz

Surgery_Schwartz. of the larynx span from the epiglottis supe-riorly to the cricoid cartilage inferiorly. Laterally, it is separated from the hypopharynx by the aryepiglottic folds.The supraglottis includes all of the laryngeal structures above the inferior half of the ventricle, and this includes the upper half of the ventricle, the false vocal cords, the arytenoids, the aryepiglottic folds, and the epiglottis. The membranes and cartilages of the larynx act as barriers to laryngeal spread: the thyroid and cricoid cartilage, conus elasticus, the quandrangular membrane, the ventricle, the hyoepiglottic ligament, thyrohyoid membrane, and cricothyroid membrane. Although the majority of tumors of the larynx are SCC, minor salivary glands, and their associated malignancies, can be found in the supraglot-tis and subglottis. Other rarer pathologies include granular cell EpiglottisNasopharynxOropharynxEustachiantube orificeSoft palateHyoid boneLarynxHypopharynxPalatine tonsilAdenoidThyroid


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Surgery_Schwartz. supraglot-tis and subglottis. Other rarer pathologies include granular cell EpiglottisNasopharynxOropharynxEustachiantube orificeSoft palateHyoid boneLarynxHypopharynxPalatine tonsilAdenoidThyroid glandCricoidcartilageFigure 18-30. Relationship of nasopharynx, oropharynx, and hypopharynx.Brunicardi_Ch18_p0613-p0660.indd 64001/03/19 5:24 PM 641DISORDERS OF THE HEAD AND NECKCHAPTER 18tumors and laryngeal framework tumors, typically arising from the cricoid, such as chondroma and chondrosarcoma.The larynx functions to (a) phonate, (b) protect the air-way during swallowing, and (c) maintain airway patency. This is a fine balance. For instance, if the glottic aperture is enlarged and/or supraglottic structures are excised, phonation and air-way protection suffer while airway patency is improved. It is therefore not surprising that patients with laryngeal tumors can present with dysphonia (hot potato voice in supraglottic tumors and hoarseness in glottic tumors), dysphagia, and airway


Surgery_Schwartz

Surgery_Schwartz. It is therefore not surprising that patients with laryngeal tumors can present with dysphonia (hot potato voice in supraglottic tumors and hoarseness in glottic tumors), dysphagia, and airway con-cerns. These patients can also present with dysphagia, weight loss, referred otalgia, and a neck mass. Vocal cord fixation can be a result of a mass effect from large obstructing masses, sec-ondary to direct extension into the paraglottic space or through direct invasion of the cricoarytenoid joint involving either the muscle or the recurrent laryngeal nerve (RLN). Although sub-glottic tumors represent <1% of laryngeal cancers, they can also present with vocal cord paralysis and/or airway compromise.Direct laryngoscopy is beneficial in the assessment of laryngeal tumors to assess the local extent of tumor spread. This is particularly important in assessing vallecula and base of tongue as there can be direct extension to the oropharynx. Simi-larly, glottic cancers can have subglottic


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Surgery_Schwartz. extent of tumor spread. This is particularly important in assessing vallecula and base of tongue as there can be direct extension to the oropharynx. Simi-larly, glottic cancers can have subglottic extension, which neces-sitates a wider radiation field and/or a more extensive resection. Esophagoscopy and bronchoscopy are also recommended to assess second primary tumors. Furthermore, when a laryngec-tomy is planned, the direct laryngoscopy provides information about the best possible site of entry into the pharynx. Entry can be achieved through (a) a suprahyoid pharyngotomy, (b) ) lat-eral pharyngotomy (lateral to the thyroid cartilage), or (c) infe-riorly through a postcricoid or hypopharyngeal pharyngotomy.Appropriate preoperative staging with a CT scan with contrast is critical in assessing cervical lymphadenopathy and extralaryngeal spread. Erosion or invasion of the thyroid and cri-coid cartilage can significantly impact outcomes and treatment as can extension into the


Surgery_Schwartz

Surgery_Schwartz. in assessing cervical lymphadenopathy and extralaryngeal spread. Erosion or invasion of the thyroid and cri-coid cartilage can significantly impact outcomes and treatment as can extension into the preepiglottic or paraglottic spaces. The supraglottic and subglottic sites are lymphatic rich, and bilateral lymphadenopathy is not uncommon, whereas the glottic site has relatively poor lymphatic drainage (1%–4% regional metasta-sis for isolated larynx cancer). The supraglottis drains through the neurovascular bundle to the thyrohyoid membrane, mainly draining to the upper and lateral cervical nodes (levels II–IV), whereas the glottis and subglottis drain through the cricothyroid membrane and can have spread to the prelaryngeal (Delphian nodes), paratracheal, and lower cervical nodes (levels IV and VI), although in these cases we still treat levels II to IV surgi-cally because of the significant occult nodes in this region.The primary management of laryngeal cancer depends on a variety of


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Surgery_Schwartz. and VI), although in these cases we still treat levels II to IV surgi-cally because of the significant occult nodes in this region.The primary management of laryngeal cancer depends on a variety of factors, including tumor extent, patient comorbidi-ties, and surgeon/center experience. In general, similar to other subsites, early-stage disease can be treated with single modality treatment (surgery or radiotherapy) while advanced stage dis-ease is treated with at least two modalities, typically either sur-gery followed by radiotherapy (with or without chemotherapy) or concurrent chemoradiotherapy. Supraglottic and subglottic lesions are typically treated with primary concurrent chemo-radiotherapy in an attempt to preserve the organ; however, in patients where the primary functions of the larynx are not being fulfilled preoperatively (tracheotomy– and gastrostomy tube–dependent), primary surgical management with a total lar-yngectomy (Fig. 18-33) can be considered. The original trials


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Surgery_Schwartz. larynx are not being fulfilled preoperatively (tracheotomy– and gastrostomy tube–dependent), primary surgical management with a total lar-yngectomy (Fig. 18-33) can be considered. The original trials that popularized organ preservation techniques with concurrent chemoradiotherapy either excluded or had a very small sample size of large (T4) tumors.147,148 Similarly, advanced glottic can-cers (T3/T4a), even when there is no evidence of nodal disease or supraglottic tumors of all stages, have superior survival out-comes when surgery is used as the primary treatment modality.149,150 This is particularly true for tumors that extend beyond the endolarynx or with cartilage destruction, for which total Figure 18-31. Endoscopic view of a laryngeal squamous carcinoma.Figure 18-32. Total laryngectomy specimen featuring a locally invasive advanced stage glottic squamous carcinoma.Brunicardi_Ch18_p0613-p0660.indd 64101/03/19 5:24 PM 642SPECIFIC CONSIDERATIONSPART IIlaryngectomy followed


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Surgery_Schwartz. specimen featuring a locally invasive advanced stage glottic squamous carcinoma.Brunicardi_Ch18_p0613-p0660.indd 64101/03/19 5:24 PM 642SPECIFIC CONSIDERATIONSPART IIlaryngectomy followed by postoperative radiotherapy continues to be the standard of care. When primary chemoradiotherapy is used, surgical salvage is available if there is treatment failure or recurrent disease.The early glottic and supraglottic lesions can be safely treated with CO2 laser transoral microlaryngoscopic resection with excellent oncologic outcomes and laryngeal preservation rates.151,152 Patients with limited involvement of the arytenoid or anterior commissure are the best candidates for a good posttreat-ment vocal quality result with this approach. One of the benefits of this approach is that it does not burn any bridges to more inva-sive treatment. Often, multiple procedures are required to control the disease. Nonetheless, for early stage cancers of the glottis and the supraglottis, radiation therapy


Surgery_Schwartz

Surgery_Schwartz. any bridges to more inva-sive treatment. Often, multiple procedures are required to control the disease. Nonetheless, for early stage cancers of the glottis and the supraglottis, radiation therapy is equally as effective as surgery in controlling disease with excellent voice outcomes.Laryngeal Preservation Techniques Beyond CO2 laser tran-soral microlaryngoscopic resection for the most early of lesions, more advanced open laryngeal preservation techniques have been developed for the resection of select, moderately advanced supraglottic and glottic tumors. These techniques can be divided into vertical and horizontal partial laryngeal procedures.Vertical partial larygnectomy (VPL) (Fig. 18-34) involves a midline thyrotomy followed by dissection of the inner peri-chondrium off of the thyroid cartilage with resection of the entire true cord and a portion of the false cords, followed by reconstruction with pedicle strap muscles and bipedicled outer perichondrial flaps. A temporoparietal


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Surgery_Schwartz. cartilage with resection of the entire true cord and a portion of the false cords, followed by reconstruction with pedicle strap muscles and bipedicled outer perichondrial flaps. A temporoparietal fascial free flap has also been used to reconstruct these defects with excellent voice outcomes.153 This can be extended to include a frontal verti-cal VPL where the excision crosses the midline as far laterally as to leave only the posterior commissure and one functional cricoarytenoid unit. This procedure is best reserved for recurrent glottic T1/T2 lesions involving only one vocal cord (although anterior commissure involvement is not a contraindication), <5 mm sublottic extension, with a mobile cord, and no cricoid cartilage or extralaryngeal extension. This technique leads to excellent locoregional control with improvements in voice related quality of life with advanced reconstructive techniques.153Supraglottic and supracricoid partial laryngectomies are horizontally oriented


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Surgery_Schwartz. locoregional control with improvements in voice related quality of life with advanced reconstructive techniques.153Supraglottic and supracricoid partial laryngectomies are horizontally oriented resections. In a supraglottic laryngectomy, a laryngectomy is performed below the hyoid and includes the upper portion of the thyroid cartilage while preserving a lower portion approximately the height of the cricoid cartilage. This is reserved for lesions not involving the vocal cords, false cords, or the arytenoids. Cartilage invasion and extensive base of tongue involvement are contraindications. Most lesions amenable for resection using this procedure are typically small enough that a laser or TORS procedure is adequate for resection, and there-fore this procedure is rarely performed. For T3 glottic lesions without preepiglottic space or cricoarytenoid joint involvement, a supracricoid laryngectomy with a cricohyoidopexy or crico-hyoidoepiglottopexy (CHEP) are options. A single


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Surgery_Schwartz. For T3 glottic lesions without preepiglottic space or cricoarytenoid joint involvement, a supracricoid laryngectomy with a cricohyoidopexy or crico-hyoidoepiglottopexy (CHEP) are options. A single cricoaryte-noid unit is preserved to allow for phonation through apposition with the remnant epiglottis or base of tongue. The procedure is associated with excellent oncologic outcomes, tracheostomy decannulation rates, and swallowing function.154 Phonation is reasonable after this procedure but can be characterized as breathy and coarse. Many surgeons prefer not to decannulate patients until the patient has had a significant period of time with good oral intake to allow for pulmonary toilet given the high initial rate of aspiration with this procedure.All partial laryngeal procedures are associated with a high risk of aspiration. Therefore, patients should have excellent pul-monary reserve through pulmonary function tests. When this is not possible, a simple measure includes whether


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Surgery_Schwartz. associated with a high risk of aspiration. Therefore, patients should have excellent pul-monary reserve through pulmonary function tests. When this is not possible, a simple measure includes whether patients can climb two flights of stairs without stopping.PerichondriumUnilaterallesionThyroidcartilageFigure 18-33. Example of the resection of a vertical partial laryn-gectomy for an early stage glottic carcinoma.Angle of mandibleOhngren'slineMaxillarysinusMedial canthusFigure 18-34. Example of the Ohngren’s line and the relationship to the maxilla.Brunicardi_Ch18_p0613-p0660.indd 64201/03/19 5:24 PM 643DISORDERS OF THE HEAD AND NECKCHAPTER 18Speech and Swallowing Rehabilitation Speech and lan-guage pathology (SLP) assessment is critical in the manage-ment of patients with laryngeal and hypopharyngeal cancer. It is a critical part of the preoperative assessment and counseling and postoperative therapy. In the elderly larynx cancer popula-tion, Starmer et al demonstrated that SLP


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Surgery_Schwartz. and hypopharyngeal cancer. It is a critical part of the preoperative assessment and counseling and postoperative therapy. In the elderly larynx cancer popula-tion, Starmer et al demonstrated that SLP care is underutilized and is largely reserved for select patients in anticipation of total laryngectomy or after the onset of impaired airway and swal-lowing function. SLP care was, however, strongly associated with improved outcomes (lower rates of dysphagia, stricture, weight loss, and pneumonia).155SLP often discusses with the patient speech rehabilita-tion options after total laryngectomy, which include esophageal speech, tracheoesophageal puncture, and use of an electrolar-ynx. Esophageal speech is produced by actively swallowing and releasing air from the esophagus, resulting in vibrations of the esophageal walls and pharynx that can then be articulated into words. This requires a very motivated patient, and unfor-tunately, <20% of postlaryngectomy patients develop fluent esophageal


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Surgery_Schwartz. of the esophageal walls and pharynx that can then be articulated into words. This requires a very motivated patient, and unfor-tunately, <20% of postlaryngectomy patients develop fluent esophageal speech.The electrolarynx is a device that creates vibratory elec-tric type sounds when held against the neck or cheek that the patient can articulate into speech. This device is typically used in the postoperative inpatient setting, but it can also be used by patients who are not able to create esophageal speech.The ultimate speech rehabilitation for patients with laryn-gectomy is a tracheoesophageal puncture (TEP) with insertion of a voice prosthesis. This prosthesis is a one-way valve that allows air from the trachea to enter the upper esophagus while preventing retrograde passage of food or saliva into the trachea. Patients who undergo placement of a tracheoesophageal punc-ture have a success rate of >90% in achieving functional speech. Many surgeons do not like to place a TEP at the time


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Surgery_Schwartz. into the trachea. Patients who undergo placement of a tracheoesophageal punc-ture have a success rate of >90% in achieving functional speech. Many surgeons do not like to place a TEP at the time of the primary laryngectomy, particularly in the salvage setting after radiotherapy due to wound complication concerns. However, primary and secondary TEP patients experience similarly high complication rates, and the extent of the pharyngeal reconstruc-tion rather than preoperative exposure to radiotherapy appear to be more important factors in selection of TEP timing.156 Free flap patients used their TEP more commonly for primary com-munication after secondary versus primary TEP.Postoperative swallowing rehabilitation is another impor-tant task performed by SLPs. Modified barium swallows where the consistency and amount of food provided is varied to mini-mize aspiration can be critical particularly in the management of patients with partial laryngeal procedures. This is performed under


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Surgery_Schwartz. the consistency and amount of food provided is varied to mini-mize aspiration can be critical particularly in the management of patients with partial laryngeal procedures. This is performed under fluorosocopy in the radiology suite to allow for the assess-ment of all phases of swallowing. A more limited examination in FEES utilizes the fiberoptic nasolaryngoscope to visualize the larynx during swallow and directly visualize whether there is any laryngeal penetration.Unknown Primary Tumors Patients with cervical nodal metas-tases confirmed to be carcinoma without clinical or radiologic evidence of an upper aerodigestive tract primary tumor are referred to as having carcinoma of unknown primary (CUP). CUP comprise 2% to 5% of all head and neck cancers, although the true incidence is probably lower given advances in surgical visualization and radiological imaging to identify the primary site.157-159 Recently, there has been a rise in CUP likely related to the increase in HPV-associated


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Surgery_Schwartz. lower given advances in surgical visualization and radiological imaging to identify the primary site.157-159 Recently, there has been a rise in CUP likely related to the increase in HPV-associated oropharyngeal cancer, although CUP could also be from a primary thyroid or skin malignancy.160 After a thorough history and physical examination including fiberoptic nasolaryngoscopy, an FNA biopsy is used to confirm carcinoma in the cervical metastases. This is preferred over an open biopsy to avoid the risk of tumor spillage, challeng-ing revision surgery secondary to disruption of fascial planes, and increased risk of recurrence and distant metastases.161 If the primary is not identified on physical examination, patients should undergo a PET-CT scan. A recent systematic review of 7 studies (246 patients) demonstrates an overall sensitivity of 44% and specificity of 97% with this technique, which can often detect tumors >1 cm in size.162 This should be followed by thorough diagnostic


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Surgery_Schwartz. (246 patients) demonstrates an overall sensitivity of 44% and specificity of 97% with this technique, which can often detect tumors >1 cm in size.162 This should be followed by thorough diagnostic operative endoscopy (nasopharyngos-copy, direct laryngoscopy, esophagoscopy, and bronchoscopy). Operative manipulation of the tissues in the upper aerodiges-tive tract specifically with biopsy may lead to false positive results on the PET-CT scan, and therefore PET-CT should be performed before endoscopy. Furthermore, having the PET-CT results prior to operative endoscopy allows the surgeon to focus on specific high-risk sites for biopsy, particularly as it relates to the base of tongue.163 When the primary site is not evident, bilat-eral tonsillectomies and bilateral base of tongue biopsies can be performed to try to identify the primary site. Patients in whom a primary is identified proceed to receive appropriate treatment, and if radiotherapy is part of this treatment regimen, a more


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Surgery_Schwartz. can be performed to try to identify the primary site. Patients in whom a primary is identified proceed to receive appropriate treatment, and if radiotherapy is part of this treatment regimen, a more limited radiation field is administered, highlighting the impor-tance of identifying a primary site. When the primary site is not identified, primary chemoradiotherapy is advocated, treating all of the mucosal sources of the upper aerodigestive tract at risk (from nasopharynx to hypopharynx) and the cervical regional basin bilaterally. For patients with advanced neck disease (N2a or greater) or with persistent lymphadenopathy after radiation, a neck dissection may be necessary. In the preradiation setting, a neck dissection is preferred over radiotherapy for patients with N1 disease, according to the NCCN guidelines, because some of these patients will be upstaged, ECE is not accurately diagnosed on imaging alone, and because some patients without ECE and a pathologically N1 node benefit


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Surgery_Schwartz. to the NCCN guidelines, because some of these patients will be upstaged, ECE is not accurately diagnosed on imaging alone, and because some patients without ECE and a pathologically N1 node benefit from radiation alone without chemotherapy.106,164 The additional prognostic information pro-vided by a neck dissection can significantly impact treatment algorithms and is also associated with lower morbidity com-pared to postoperative neck dissection.Nose and Paranasal SinusesCancers of the nasal cavity and paranasal sinuses are exceed-ingly rare, and pathology in this anatomic subsite is dominated by infectious and inflammatory sources as previously discussed in the “Sinonasal Inflammatory Disease” section of this chapter. Malignant pathology at this site is often diagnosed after failed repeated treatment of suspected benign inflammatory sinona-sal pathology. Concerning preoperative imaging findings (uni-lateral disease; extensive disease; bony, orbital or intracranial invasion) and


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Surgery_Schwartz. repeated treatment of suspected benign inflammatory sinona-sal pathology. Concerning preoperative imaging findings (uni-lateral disease; extensive disease; bony, orbital or intracranial invasion) and unusual clinical features may raise concerns about malignancy, and in these cases referral to a tertiary head and neck oncology center is preferred. A concerning history is one that involves a slow progression and worsening of symptoms, which may include nasal obstruction, facial pain, headache, epistaxis, and facial numbness. Most tumors at this site pres-ent with advanced stage given the inevitable delay in diagnosis. Numbness in the V2 distribution suggests invasion of pterygo-palatine fossa, and V3 distribution numbness can be an indi-cation of extension to the infratemporal fossa and skull base invasion to foramen ovale. Proptosis, epiphora, diploplia, and change in vision (typically starting with loss of color vision) are Brunicardi_Ch18_p0613-p0660.indd 64301/03/19 5:24 PM


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Surgery_Schwartz. skull base invasion to foramen ovale. Proptosis, epiphora, diploplia, and change in vision (typically starting with loss of color vision) are Brunicardi_Ch18_p0613-p0660.indd 64301/03/19 5:24 PM 644SPECIFIC CONSIDERATIONSPART IIall signs of advanced orbital invasion. Maxillary sinus tumors, the most common site for cancers of this site, can be prognos-ticated simply using Ohgren’s line (Fig. 18-35), an imaginary line from medial canthus to the angle of the mandible, which divides maxillary sinus into anterior-inferior and posterior-superior parts. Tumors from the anterior-inferior are more prognostically favorable.Although the most common pathology at this site continues to be squamous cell carcinoma, a brief discussion of other histo-pathology is warranted given significant variety, prognostic, and treatment-related differences between these at this subsite. Benign pathology at this site includes inverted papilloma, hemangiomas, hemangiopericytomas, angiofibromas, minor salivary


Surgery_Schwartz

Surgery_Schwartz. prognostic, and treatment-related differences between these at this subsite. Benign pathology at this site includes inverted papilloma, hemangiomas, hemangiopericytomas, angiofibromas, minor salivary tumors, and benign fibrous histiocytomas. Fibro-osseous and osseous lesions, such as fibrous dysplasias, ossifying fibromas, osteo-mas, and myxomas, can also arise in this region. Additionally, encephaloceles and meningo-encephaloceles with herniation of intracranial content into the nasal cavity can present as sinonasal lesions; therefore, imaging, typically with an MRI, is warranted before biopsy of any sinonasal mass to prevent an iatrogenic CSF leak. In the evaluation of sinonasal malignant pathology, both CT and MRI are required because they provide complimentary information. MRI provides improved skull base, intracranial, and orbital invasion assessment, while CT provides better assessment of bony anatomy and invasion.Beyond squamous cell carcinoma, the next two most com-mon


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Surgery_Schwartz. provides improved skull base, intracranial, and orbital invasion assessment, while CT provides better assessment of bony anatomy and invasion.Beyond squamous cell carcinoma, the next two most com-mon malignancies at this site include adenoid cystic carcinoma and adenocarcinoma. Other pathologies include sinonasal undif-ferentiated carcinoma (SNUC), mucosal melanoma, lymphoma, esthesioneuroblastoma (previously known as olfactory neuro-blastoma), rhabdomyosarcoma, and angiosarcoma. Unlike other head and neck cancers, metastases to the regional lymphatic basis are extremely rare, and rarely will patients require or receive pri-mary or adjuvant treatment to the neck unless there is clinical or radiographic evidence of neck disease (approximately 15%).165The standard treatment for malignant tumors of the para-nasal sinuses is driven by the primary pathology; however, for most pathology, including SCC, the standard of care includes surgical resection followed by adjuvant radiotherapy.166


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Surgery_Schwartz. tumors of the para-nasal sinuses is driven by the primary pathology; however, for most pathology, including SCC, the standard of care includes surgical resection followed by adjuvant radiotherapy.166 Advances in EEAs has led to a shift in management of these tumors with minimally invasive approaches that are associated with significantly lower complication and morbidity rates with comparable oncologic outcomes.167,168 Open approaches are, however, indicated when there is tumor abutting the anterior wall of the frontal sinus, anterior extension into nasal bones, anterior maxillary wall invasion, facial skin or soft tissue inva-sion, dural involvement above the orbit or periorbital invasion, tumors with significant inratemporal fossa invasion, and exten-sion into the oral cavity, including the hard palate or the floor of the maxillary sinus. Many tumors can be treated with an endo-scopic approach such a medial maxillectomy when the tumor arises from the medial wall of the maxilla.


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Surgery_Schwartz. the hard palate or the floor of the maxillary sinus. Many tumors can be treated with an endo-scopic approach such a medial maxillectomy when the tumor arises from the medial wall of the maxilla. Multidisciplinary assessment and treatment should include a skull base tumor board discussion with a head and neck oncologist/surgeon, a neurosurgeon, opthalmologist including oculoplastic surgeons, prosthodontists, and reconstructive surgeons. Preoperative embolization within 24 hours of tumor excision can be useful for vascular tumors.Extent of surgery and prognosis is dependent on the tumor location and extension. For tumors limited to the hard palate and lower maxillary sinus, an infrastructure maxillectomy is sufficient. A total maxillectomy without removal of the orbital floor may be warranted for more extensive tumors limited to the maxillary sinus. When the orbital periosteum is not invaded but tumor abuts this region, removal of the orbital floor with appro-priate reconstruction is


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Surgery_Schwartz. for more extensive tumors limited to the maxillary sinus. When the orbital periosteum is not invaded but tumor abuts this region, removal of the orbital floor with appro-priate reconstruction is warranted. When there is invasion of periorbita, an orbital exenteration is warranted for most pathol-ogy. Tumors originating in the ethmoid sinuses may require excision of the cribriform plate and repair of subsequent skull base defect if the tumor originates or invades through the bony skull base. This is performed through an anterior craniofacial resection, where a neurosurgeon performs a frontal craniotomy for exposure of the anterior cranial fossa floor, while the head and neck surgeon performs a transfacial or endoscopic resection of the inferior bony and soft tissue structures. This approach often requires resection of dura and a dural repair to achieve negative margins. A less extensive surgery including a sphe-noethmoidectomy or medial maxillectomy can be entertained for smaller


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Surgery_Schwartz. often requires resection of dura and a dural repair to achieve negative margins. A less extensive surgery including a sphe-noethmoidectomy or medial maxillectomy can be entertained for smaller tumors originating in the lateral nasal wall through endoscopic or open approaches.Tumors are deemed to be unresectable if both optic nerves are involved, if there is carotid artery invasion, or if there is extensive intracranial extension. Chemotherapy has a limited application in the management of tumors at this subsite with two exceptions: rhabdomyosarcoma, which is primarily treated with chemotherapy followed by radiation therapy with surgery reserved for the salvage setting, and SNUC, where triple modal-ity treatment is required given tumor aggressiveness. Chemo-therapy in this setting may help to reduce the tumor bulk and allow for orbital preservation.NasopharynxThe anatomic borders of the nasopharyx are superiorly the adenoid patch, superolaterally the fossa of Rosenmüller and the


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Surgery_Schwartz. help to reduce the tumor bulk and allow for orbital preservation.NasopharynxThe anatomic borders of the nasopharyx are superiorly the adenoid patch, superolaterally the fossa of Rosenmüller and the Eustachian tube orifices (torus tubarius), inferiorly the plane of the hard palate from the choana, anteriorly the posterior nasal cavity, and posteriorly the posterior pharyngeal wall. Malignant Subtotal temporalbone resectionTotal temporalbone resectionLateraltemporalbone resectionFigure 18-35. Examples of resection specimens for lateral tem-poral bone resection, subtotal temporal bone resection, and total temporal bone resection.Brunicardi_Ch18_p0613-p0660.indd 64401/03/19 5:24 PM 645DISORDERS OF THE HEAD AND NECKCHAPTER 18tumors of the nasopharynx are typically well differentiated or lymphoepithelial SCC. However, other tumors can present in this region including lymphoma, chordoma, chondroma, nasopharyngeal cyst (Tornwaldt’s cyst), angiofibroma, minor salivary gland tumor,


Surgery_Schwartz

Surgery_Schwartz. or lymphoepithelial SCC. However, other tumors can present in this region including lymphoma, chordoma, chondroma, nasopharyngeal cyst (Tornwaldt’s cyst), angiofibroma, minor salivary gland tumor, paraganglioma, rhabdomyosarcoma, extramedullary plasmacytoma, and, rarely, sarcoma.Unlike other head and neck cancers, the nasopharynx site has unique ethnic and geographic predilection, namely, a higher incidence in southern China, Africa, Alaska, and in Green-land Eskimos. EBV is also more commonly seen in patients with NPC, and EBV titers are helpful in following treatment response.As previously discussed, a posterior (level V) neck mass should be considered NPC until proven otherwise. Other signs and symptoms include nasal obstruction, epistaxis, unilateral serous otitis media in an adult, and otalgia. Advanced disease can present with cranial neuropathies, particularly of the cranial nerves, which run in the cavernous sinus (CN V1, V2, III, IV, VI). Bilateral regional disease spread is


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Surgery_Schwartz. otalgia. Advanced disease can present with cranial neuropathies, particularly of the cranial nerves, which run in the cavernous sinus (CN V1, V2, III, IV, VI). Bilateral regional disease spread is common, and the lym-phatic level involved include the posterior neck (level V), as well as the upper (level II) cervical nodes and retropharyngeal nodes. Distant metastatic disease is present in 5% of patients at diagnosis, highlighting the importance of a thorough staging workup.Staging includes a thorough physical examination using either a flexible or rigid endoscope to assess the mucosal extent of the disease. CT and MRI are complimentary as in the assess-ment of nasal cavity and paranasal sinus tumors with CT provid-ing better assessment of bony invasion and the MRI providing better soft tissue delineation, skull base invasion, and perineural spread with cranial nerve enhancement. Multimodality therapy with chemoradiotherapy is superior to radiotherapy alone in the management of


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Surgery_Schwartz. soft tissue delineation, skull base invasion, and perineural spread with cranial nerve enhancement. Multimodality therapy with chemoradiotherapy is superior to radiotherapy alone in the management of nasopharyngeal carcinoma.169 Recurrent tumors are treated typically with reirradiation; however, there has been recent success with surgical salvage procedures, particular in those patients in which a negative margin can be achieved.170When resection is contemplated for recurrent nasopharyn-geal carcinoma or for low grade tumors such as some minor salivary gland tumors, a number of surgical approaches can be utilized for resection. These include endoscopic, transpalatal, transfacial via a maxillary swing procedure, and transcervical. In many cases, a combination of these techniques is required to achieve a negative margin. The transcervical approach pro-vides the added benefit of early access and control of the carotid artery. For benign and low-grade tumors, advances in EEA have made use


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Surgery_Schwartz. to achieve a negative margin. The transcervical approach pro-vides the added benefit of early access and control of the carotid artery. For benign and low-grade tumors, advances in EEA have made use of the open approaches less common.Ear and Temporal BoneTemporal bone and ear tumors are rare account for <0.5% of all head and neck cancers. Subsites in this head and neck site from lateral to medial include the pinna (external ear), external auditory canal, middle ear, mastoid, and petrous portion of the temporal bone. Although the typical pathology at this site is squamous cell carcinoma, minor salivary gland tumors such as adenocarcinoma and adenoid cystic carcinoma can also present here. Given that the ear is in the high-risk region for aggressive skin cancers due to its unique exposure to ultraviolet light, cuta-neous malignancies such as basal cell carcinoma and melanoma can also present here. In the pediatric population, soft tissue sar-comas, most commonly rhabdomyosarcoma, can


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Surgery_Schwartz. to ultraviolet light, cuta-neous malignancies such as basal cell carcinoma and melanoma can also present here. In the pediatric population, soft tissue sar-comas, most commonly rhabdomyosarcoma, can present at this site. These tumors typically present with an advanced stage,171 and resection with clear margins and functional preservation is challenging because of the close proximity of vital structures, namely the facial nerve and the external auditory canal.172 Tumors involving the petrous apex or intracranial structures may present with headache and palsies of CN V and VI as well.Patients can present with ulceration, granulation, or bleed-ings from the external ear and auditory canal. This is often mistaken for an infectious or inflammatory process given the rarity of malignancy at this subsite; however, persistent granu-lation tissue in the ear should be biopsied and imaged to rule out malignancy. Patients can then present with otorrhea, otal-gia, hearing loss, vertigo, and facial


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Surgery_Schwartz. subsite; however, persistent granu-lation tissue in the ear should be biopsied and imaged to rule out malignancy. Patients can then present with otorrhea, otal-gia, hearing loss, vertigo, and facial nerve paralysis. Appropri-ate imaging with CT and MRI is often required to appropriately delineate the lesion and stage and assist with the appropriate management plan.Cutaneous malignancies of the pinna and tragus can usu-ally be locally excised. However, at this subsite, spread into the perichondrium and cartilage can lead to rapid spread long that tissue plane. The importance of negative margins cannot be overstated at this subsite. Mohs microsurgery has been advo-cated for select tumors at this subsite for this reason; however, some tumors are so extensive that a total auriculectomy provides the best oncologic and cosmetic result. When there is exten-sion of tumor to the bony cartilaginous EAC junction, spread to parotid, temporomandibular joint, and skull base is possible. Advanced


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Surgery_Schwartz. the best oncologic and cosmetic result. When there is exten-sion of tumor to the bony cartilaginous EAC junction, spread to parotid, temporomandibular joint, and skull base is possible. Advanced tumors anterior to a vertical line along the EAC from a sagittal view benefit from a parotidectomy as well as a suprao-mohyoid neck dissection (levels I–III), whereas those behind this line benefit from a posterolateral neck dissection (levels II–V). As with other cutaneous malignancies, adjuvant radio-therapy is indicated for positive margins, perineural spread, or multiple involved lymph nodes.Tumors involving the EAC and middle ear require differ-ent management, including a sleeve resection of the external auditory canal, a lateral temporal bone resection, or a subtotal temporal bone resection (Fig. 18-36). A sleeve resection of the EAC skin and cartilage is rarely enough to achieve negative margins with the exception of some basal cell carcinomas of the skin overlying the cartilaginous


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Surgery_Schwartz. (Fig. 18-36). A sleeve resection of the EAC skin and cartilage is rarely enough to achieve negative margins with the exception of some basal cell carcinomas of the skin overlying the cartilaginous EAC. For more extensive IIIIIIVIIVVFigure 18-36. Levels of the neck denoting lymph node bearing regions.Brunicardi_Ch18_p0613-p0660.indd 64501/03/19 5:24 PM 646SPECIFIC CONSIDERATIONSPART IItumors and more aggressive pathology, a lateral temporal bone resection may be required removing the cartilaginous and bony external auditory canal as well as the middle ear en bloc.173 A subtotal temporal bone resection also removes the inner ear and facial nerve as part of the resection and is indicated when the tumor extends into the middle ear and a deeper resection margin is required. Both of these procedures are followed by postopera-tive radiotherapy, which provides improved locoregional con-trol.173 The neck is managed in a similar fashion to pinna and external auditory canal malignancies


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Surgery_Schwartz. procedures are followed by postopera-tive radiotherapy, which provides improved locoregional con-trol.173 The neck is managed in a similar fashion to pinna and external auditory canal malignancies typically requiring a supra-omohyoid (levels I–III) neck dissection. Survival outcomes are poor with a 5-year overall survival of <40%.174 Important pre-dictors of disease free survival include margin status, perineu-ral invasion, and regional lymphatic spread; the most important of these on multivariate analysis being lymphatic spread of disease.171Lateral temporal bone resections often require reconstruc-tion to close the wound, provide bulk, and vascularize tissue. If dura is encountered and even resected, a watertight dural closure is required to prevent a CSF leak and meningitis. Vascularized tissue has the added benefit of preparing the surgical bed for postoperative radiotherapy. These defects can be reconstructed with regional pedicled flaps (e.g., submental flap) or free flaps. The


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Surgery_Schwartz. tissue has the added benefit of preparing the surgical bed for postoperative radiotherapy. These defects can be reconstructed with regional pedicled flaps (e.g., submental flap) or free flaps. The most common free flaps used are the anterolateral thigh, although depending on body habitus and the depth of the defect, the radial forearm, lateral arm, and rectus abdominus may also be used.175 The deformity resulting from a total auriculectomy is often not reconstructed primarily, but an auricular prosthesis can be designed for further rehabilitation. Facial nerve reconstruc-tion when sacrifice is required is typically performed with cable grafts from the proximal facial nerve to select distal facial nerve branches. Because of the long distance between the proximal and distal branches, facial movement is typically delayed 6 to 12 months. However, if the masseteric nerve is connected through a cable graft to select distal facial nerve branches (typically the zygomatic branch), a shorter


Surgery_Schwartz

Surgery_Schwartz. movement is typically delayed 6 to 12 months. However, if the masseteric nerve is connected through a cable graft to select distal facial nerve branches (typically the zygomatic branch), a shorter cable graft is required, and facial movement can be achieved earlier. A variety of other static and dynamic procedures can be provided secondarily. The most important of these procedures are related to preserving eye clo-sure to avoid corneal abrasions or desiccation, which can ulti-mately lead to blindness. In the immediate postoperative period, taping of the eyelids and generous application of eye lubrication is required to prevent exposure keratitis. Upper lid gold weight implants, lower lid shortening procedures, and tarsorrhaphy can be performed secondarily to assist with eye closure.NeckAn undiagnosed neck mass needs to be carefully evaluated and worked up so as to not interfere with the definitive management of the patient and future treatment options. The patient’s age, social


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Surgery_Schwartz. undiagnosed neck mass needs to be carefully evaluated and worked up so as to not interfere with the definitive management of the patient and future treatment options. The patient’s age, social history, including alcohol and smoking history, preced-ing illness history, and synchronous upper aerodigestive tract physical examination findings can significantly impact the dif-ferential diagnosis and the investigation to work up a neck mass. A thorough history and head and neck examination, including fiberoptic nasolaryngoscopy, are therefore paramount to com-plete evaluation. With regard to age, in children, a neck mass is far more likely to be congenital, inflammatory, or infectious, whereas in adults, neck masses >2 cm have a >80% probability of being malignant. Typically, the first investigation is an FNA biopsy, which can be performed with ultrasound or CT guid-ance when the mass is not easily palpable or largely cystic with a small solid component. Imaging is critical in


Surgery_Schwartz

Surgery_Schwartz. investigation is an FNA biopsy, which can be performed with ultrasound or CT guid-ance when the mass is not easily palpable or largely cystic with a small solid component. Imaging is critical in characterizing the neck mass, particularly assessing the borders, consistency, and location which then impacts the differential diagnosis. For instance, a cystic neck mass can be a branchial cleft cyst or a regional metastasis from an oropharynx cancer or metastatic papillary thyroid cancer. Therefore, the imaging findings also significantly impact the differential diagnosis.When the imaging and FNA does not provide adequate information for a diagnosis, a core biopsy can be considered, particularly if the diagnosis of lymphoma is suspected and an open biopsy wants to be avoided. For a suspected carcinoma, an open biopsy may be required; however, in that case, the incision needs to be planned such that the procedure can be converted to a neck dissection, and a frozen section can be sent. If the


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Surgery_Schwartz. an open biopsy may be required; however, in that case, the incision needs to be planned such that the procedure can be converted to a neck dissection, and a frozen section can be sent. If the diagnosis of squamous cell carcinoma is confirmed on frozen section, then a neck dissection should be performed to further prognosticate the disease. In the case of lymphoma, biopsy does not need to remove the entire lymphoma, particularly if there is an added risk of injuring normal anatomical structures.Patterns of Lymph Node Metastasis. The lymphatic drain-age into the neck is divided into seven levels with standardized reporting within and across specialties, particularly as radiolo-gists, pathologists, surgeons, radiation oncologists, and radiolo-gists share the findings176,177 (Fig. 18-37). The levels include• Level I—the submental and submandibular nodes• Level Ia—the submental nodes; medial to the anterior belly of the digastric muscle bilaterally, symphysis of mandible superiorly, and


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Surgery_Schwartz. levels include• Level I—the submental and submandibular nodes• Level Ia—the submental nodes; medial to the anterior belly of the digastric muscle bilaterally, symphysis of mandible superiorly, and hyoid inferiorly; this level does not have any laterality as it includes both right and left sides• Level Ib—the submandibular nodes and gland; posterior to the anterior belly of digastric, anterior to the posterior belly of digastric, and inferior to the body of the mandibleFigure 18-37. Shaded region indicates the region included in a supraomohyoid neck dissection.Brunicardi_Ch18_p0613-p0660.indd 64601/03/19 5:24 PM 647DISORDERS OF THE HEAD AND NECKCHAPTER 18• Level IIa—upper jugular chain nodes; anterior to the poste-rior border of the sternocleidomastoid (SCM) muscle, poste-rior to the posterior aspect of the posterior belly of digastric, superior to the level of the hyoid, inferior to spinal accessory nerve (CN XI)• Level IIb—submuscular recess; superior to spinal accessory nerve


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Surgery_Schwartz. posterior aspect of the posterior belly of digastric, superior to the level of the hyoid, inferior to spinal accessory nerve (CN XI)• Level IIb—submuscular recess; superior to spinal accessory nerve to the level of the skull base• Level III—middle jugular chain nodes; inferior to the hyoid, superior to the level of the cricoid, deep to SCM muscle from posterior border of the muscle to the strap muscles medially• Level IV—lower jugular chain nodes; inferior to the level of the cricoid, superior to the clavicle, deep to SCM muscle from posterior border of the muscle to the strap muscles medially• Level V—posterior triangle nodes• Level Va—lateral to the posterior aspect of the SCM muscle, inferior and medial to splenius capitis and trapezius, superior to the spinal accessory nerve• Level Vb—lateral to the posterior aspect of SCM muscle, medial to trapezius, inferior to the spinal accessory nerve, superior to the clavicle• Level VI—anterior compartment nodes; inferior to the hyoid,


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Surgery_Schwartz. Vb—lateral to the posterior aspect of SCM muscle, medial to trapezius, inferior to the spinal accessory nerve, superior to the clavicle• Level VI—anterior compartment nodes; inferior to the hyoid, superior to suprasternal notch, medial to the lateral extent of the strap muscles bilaterally• Level VII—paratracheal nodes; inferior to the suprasternal notch in the upper mediastinumThere is a well-established pattern of regional spread from upper aerodigestive tract primary tumors.178 Lesions of the lip and oral cavity typically metastasize to levels I to III and skip metastases to the lower basin (levels III–IV) without involve-ment of the upper level (levels I–II). Oropharyngeal, laryngeal, and hypopharyngeal tumors most commonly spread to the lat-eral neck (levels II–IV). It is rare for any of these tumors to have isolated regional metastases to level V; however, naso-pharyngeal, thyroid, and head and neck malignant melanoma can metastasize to this level. Other sites for metastasis


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Surgery_Schwartz. any of these tumors to have isolated regional metastases to level V; however, naso-pharyngeal, thyroid, and head and neck malignant melanoma can metastasize to this level. Other sites for metastasis include the retropharyngeal nodes (oropharyngeal, nasopharyngeal, and hypopharyngeal tumors), paratracheal and level VII nodes (thyroid, hypopharynx, and cervical esophageal tumors), and pretracheal (Delphian) nodes (thyroid and advanced glottic tumors with subglottic extension).Historically, a radical neck dissection (RND) was per-formed for all upper aerodigestive tract malignancies with sac-rifice of the SCM, internal jugular vein (IJV), and accessory nerve (CN XI) and removal of all lymphatic level (levels I–V). This was because cervical metastasis decreased the 5-year over-all survival rate by approximately 50%. However, growing evi-dence demonstrated that this was not necessary, and now a neck dissection is only recommended for upper aerodigestive tract malignancies when the risk of


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Surgery_Schwartz. by approximately 50%. However, growing evi-dence demonstrated that this was not necessary, and now a neck dissection is only recommended for upper aerodigestive tract malignancies when the risk of occult disease is >20% in the clinically negative neck.179 When the neck is clinically positive, the level discussed in the previous paragraph for each site are excised with every attempt to preserve the SCM, IJV, and CN XI (selective neck dissection; SND). When there is direct exten-sion of the tumor or extralymphatic spread into these structures, sacrifice may be necessary in a modified radical neck dissection (MRND). The RND has been largely abandoned because the SND and MRND have been demonstrated to be equally effec-tive when it comes to oncologic outcomes with far improved functional outcomes.180,181SND has become the standard of care for most patients who are clinically node negative (cN0) and in those with limited cN1 disease. Patients with oral cavity cancer typically receive a


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Surgery_Schwartz. has become the standard of care for most patients who are clinically node negative (cN0) and in those with limited cN1 disease. Patients with oral cavity cancer typically receive a supraomohyoid (Fig. 18-38) neck dissection (levels I–III). Many surgeons will include a portion of level IV just below the omohyoid muscle given the rate of skip metastases previously discussed. Approximately 80% of patients with oral cavity can-cer present cN0; however, the rate of occult metastatic disease is approximately 30% and differs by subsite.182 This rate is further impacted by tumor thickness at the tongue subsite, with tumors 4 mm or thicker having a higher rate of occult disease.183 A recent prospective, randomized trial demonstrated the oncologic benefit of an elective neck dissection in cN0 oral cavity patients regardless of tumor thickness over an observation followed by therapeutic neck dissection in those with regional failures.184 An additional role of SND is as a staging tool to


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Surgery_Schwartz. oral cavity patients regardless of tumor thickness over an observation followed by therapeutic neck dissection in those with regional failures.184 An additional role of SND is as a staging tool to determine the need for postoperative radiation therapy. The lateral (Fig. 18-39) neck dissection (levels II–IV) is typically used in laryngeal and hypo-pharyngeal cancers. The posterolateral (Fig. 18-40 neck dissec-tion (levels II–V) is typically recommended in thyroid cancers, although recent evidence has demonstrated that a partial level V dissection may be all that is necessary for equivalent outcomes to a full level II to V neck dissection.176,185,186Despite advances in the surgical management of neck dis-ease, in clinically advanced nodal disease (with the exception of uncomplicated N1 disease), an MRND remains the treatment of choice. When the neck disease is advanced with extrano-dal extension (ENE), perineural invasion (PNI), lymphovas-cular invasion (LVI), and the presence of


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Surgery_Schwartz. disease), an MRND remains the treatment of choice. When the neck disease is advanced with extrano-dal extension (ENE), perineural invasion (PNI), lymphovas-cular invasion (LVI), and the presence of multiple involved nodes, postoperative radiotherapy improves locoregional con-trol.103 If there is a positive margin or ENE, then the addition of adjuvant chemotherapy to radiotherapy provides a survival benefit.113,187,188In patients receiving primary radiotherapy with advanced N stage disease (N2a or greater) or only a partial response to Figure 18-38. Shaded region indicates the region included in a lateral neck dissection.Brunicardi_Ch18_p0613-p0660.indd 64701/03/19 5:24 PM 648SPECIFIC CONSIDERATIONSPART IItreatment, a planned postradiotherapy neck dissection can be performed 6 to 8 weeks after completion of radiotherapy. This is to consolidate the treatment and provide prognostic information.Tumor factors that preclude surgery include prevertebral fascia invasion, skull base


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Surgery_Schwartz. 8 weeks after completion of radiotherapy. This is to consolidate the treatment and provide prognostic information.Tumor factors that preclude surgery include prevertebral fascia invasion, skull base invasion, and >270o circumferential encasement of the internal carotid artery. These factors are asso-ciated with very poor 5-year survival (<20%). In such cases, sac-rifice of the carotid is not indicated given the risk of stroke and death. Surgical debulking is also not associated with improved survival. However, there is a role for neoadjuvant chemother-apy, and in those that respond and if the disease becomes resect-able, survival benefit has been demonstrated.189 Recurrent neck metastasis after radiotherapy to the neck or a comprehensive neck dissection is associated with very poor survival.190Parapharyngeal Space Masses. The parapharyngeal space is a potential inverted pyramidal space bordered superiorly at the skull base along the sphenoid and inferiorly at the greater cornu of the


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Surgery_Schwartz. Space Masses. The parapharyngeal space is a potential inverted pyramidal space bordered superiorly at the skull base along the sphenoid and inferiorly at the greater cornu of the hyoid. Medially it is bordered by the buccopha-ryngeal fascia covering the superior constrictor, anteriorly the pterygomandibular raphe, posteriorly the prevertebral fascia, and laterally by the deep surface of the parotid gland and ramus of the mandible. The differential diagnosis for parapharyngeal masses is very much dependent on the anatomy and contents of this space which is divided into the preand poststyloid spaces by the tensor-styloid fascia. This fascia attaches the tensor veli palatini muscle to the styloid. The contents of the prestyloid parapharyngeal space include fat, the deep lobe of the parotid, and lymph nodes, and branches of V3 (lingual, inferior alveo-lus, and auriculotemporal nerves), whereas the contents of the poststyloid space including cranial nerves IX to XII, the inter-nal jugular


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Surgery_Schwartz. and lymph nodes, and branches of V3 (lingual, inferior alveo-lus, and auriculotemporal nerves), whereas the contents of the poststyloid space including cranial nerves IX to XII, the inter-nal jugular vein, the internal carotid artery, and the sympathetic chain. Nearly half of all parapharyngeal masses are of parotid origin, while 20% to 25% are of neurogenic origin, such as paragangliomas (glomus vagale, carotid body tumor), schwan-nomas, and neurofibromas. Lymphatic origin masses such as lymphoma and lymph node metastases represent 15% of tumors at this subsite. Therefore, most prestyloid lesions are considered of salivary gland origin, whereas poststyloid lesions are typi-cally vascular or neurogenic.Tumors of the parapharyngeal space can displace the lat-eral pharyngeal wall medially into the oropharynx (Fig. 18-41) and can thus cause obstructive sleep apnea, voice change, and dysphagia in addition to cranial neuropathies, Horner’s syn-drome, or vascular compression. In addition to


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Surgery_Schwartz. the oropharynx (Fig. 18-41) and can thus cause obstructive sleep apnea, voice change, and dysphagia in addition to cranial neuropathies, Horner’s syn-drome, or vascular compression. In addition to CT and MRI, poststyloid lesions should be investigated with a 24-hour uri-nary catecholamine collection because some paragangliomas are functional and this should be managed preoperatively.Surgical access to these tumors can be performed using a purely transcervical approach with the excision of the subman-dibular gland for access. A transfacial or transparotid approach can be used as an adjunct for certain tumors by removing the parotid gland. This ensures identification of the facial nerve Figure 18-39. Shaded region indicates the region included in a posterolateral neck dissection.ParotidglandStylomandibularligamentFigure 18-40. Parapharyngeal mass—prestyloid with prominent oropharyngeal presentation typical of a dumbbell tumor.Brunicardi_Ch18_p0613-p0660.indd 64801/03/19 5:24 PM


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Surgery_Schwartz. 18-40. Parapharyngeal mass—prestyloid with prominent oropharyngeal presentation typical of a dumbbell tumor.Brunicardi_Ch18_p0613-p0660.indd 64801/03/19 5:24 PM 649DISORDERS OF THE HEAD AND NECKCHAPTER 18prior to removal of the mass, which is just deep to it. Rarely, a transmandibular approach is required by performing a midline or parasymphyseal mandibulotomy with a lateral swing. Tran-soral approaches have been described, but they are not recom-mended and are largely contraindicated due to poor exposure and control of the associated vasculature.Benign Neck Masses. Many benign neck masses require surgical intervention for diagnostic, cosmetic, and symptom-atic relief. This is particularly true for lesions that are prone to recurrent infections, especially in the pediatric population. Such masses include thyroglossal duct cyst, branchial cleft cyst, lymphangioma (cystic hygroma), hemangioma, and der-moid cyst. Lymphangioma and hemangioma were previously discussed and will not be


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Surgery_Schwartz. Such masses include thyroglossal duct cyst, branchial cleft cyst, lymphangioma (cystic hygroma), hemangioma, and der-moid cyst. Lymphangioma and hemangioma were previously discussed and will not be discussed in this section.During fetal growth, the thyroid gland descends along a tract from the foramen cecum at the base of tongue into the ante-rior low neck. A vestigial remainder of this tract is called a thy-roglossal duct cyst, which typically presents as a subcutaneous swelling near the hyoid in the midline or slightly paramedian. Patients may complain of recurrent infections of this mass after an upper respiratory tract infection. Investigations include thy-roid function tests and a neck and thyroid ultrasound to confirm that the patient has thyroid tissue in the lower neck . Treatment involves removal of the cyst, the tract, and the central portion of the hyoid (Sistrunk procedure), often with a small portion of the base of tongue if the tract extends above the hyoid.During fetal


Surgery_Schwartz

Surgery_Schwartz. involves removal of the cyst, the tract, and the central portion of the hyoid (Sistrunk procedure), often with a small portion of the base of tongue if the tract extends above the hyoid.During fetal growth, the branchial cleft apparatus may persist, forming a branchial cleft remnant (cyst, sinus, or tract), numbered to their corresponding embryologic branchial cleft. First branchial cleft anomalies parallel the EAC (Work Type I; preauricular) or go through the parotid gland ending at the bony-cartilaginous EAC junction (Work Type II; angle of the mandible). Second branchial anomalies (Fig. 18-42), the most common type, start at the anterior border of the SCM and head toward the tonsillar fossa traveling deep to second arch struc-tures (CN VII and external carotid artery) and superficial to third arch structures (stylopharyngeus, IX, and internal carotid artery). Third and fourth branchial anomalies are difficult to dis-tinguish clinically and frequently open into the pyriform sinus


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Surgery_Schwartz. to third arch structures (stylopharyngeus, IX, and internal carotid artery). Third and fourth branchial anomalies are difficult to dis-tinguish clinically and frequently open into the pyriform sinus often presenting with recurrent thyroid infections.191 These anomalies ascend posterior the internal carotid artery and deep to CN IX but superficial to CN XI and XII. Dermoid cysts tend to present as midline masses and represent trapped epithelium originating from the embryonic closure of the midline. These can be reliably diagnosed and distinguished from thyroglossal duct cysts using an ultrasound predictive model.192Cervical Fascial Planes. The fascial planes often predict the pathway and extent of infectious spread in the neck and are there-fore clinically important. The deep fascial layers of the neck Figure 18-41. Computed tomography scan demonstrating a branchial cleft cyst with operative specimen.Facial n.Anterior facial v.Retromandibular v.Temporal branchFrontal branchPosterior


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Surgery_Schwartz. of the neck Figure 18-41. Computed tomography scan demonstrating a branchial cleft cyst with operative specimen.Facial n.Anterior facial v.Retromandibular v.Temporal branchFrontal branchPosterior bellyof digastric m.StylomastoidforamenCervicalbranchMasseter m.Zygomatic branchParotid ductBuccalbranchMandibularbranchFigure 18-42. Example of a tumor in the parotid with the pattern of the facial nerve and associated anatomy. m. = muscle; n. = nerve; v. = vein.Brunicardi_Ch18_p0613-p0660.indd 64901/03/19 5:24 PM 650SPECIFIC CONSIDERATIONSPART IIinclude three separate layers: the superficial deep (investing) layer, the pretracheal (visceral) layer, and the prevertebral layer. The investing layer forms a cone around the neck and surrounds the SCM muscle and the anterior and posterior neck. It spans from the mandible to the clavicle and manubrium. The visceral layer surrounds the trachea, thyroid, and esophagus and blends laterally with the carotid sheath extending inferiorly to the


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Surgery_Schwartz. It spans from the mandible to the clavicle and manubrium. The visceral layer surrounds the trachea, thyroid, and esophagus and blends laterally with the carotid sheath extending inferiorly to the upper mediastinum. Between this layer and the prevertebral fascia is the retropharyngeal space. The prevertebral fascia covers the pre-vertebral musculature and space and extends down to the tho-racic vertebra and diaphragm. Infections of the prevertebral space between this fascia and the prevertebral musculature are considered to be in the prevertebral space and can extend all the way down to the sacrum. Therefore, neck infections can extend to the mediasti-num or beyond and need to be treated aggressively.Salivary Gland TumorsPrimary malignant tumors of the salivary glands are relatively rare and account for <2% of all head and neck malignancies. As previously mentioned, minor salivary gland malignancies can present anywhere in the upper aerodigestive tract, particularly on the palate;


Surgery_Schwartz

Surgery_Schwartz. and account for <2% of all head and neck malignancies. As previously mentioned, minor salivary gland malignancies can present anywhere in the upper aerodigestive tract, particularly on the palate; however, the major salivary glands are the parotid, submandibular, and sublingual glands. The majority of tumors (80%) arise in the parotid gland (Fig. 18-44); however, 80% of these are benign, most commonly, pleomorphic adenomas (benign mixed tumors). As the salivary gland gets smaller, the proportion of tumors that are malignant increases; 50% of sub-mandibular/sublingual tumors and 80% of minor salivary gland tumors are malignant.Patients typically present with a mass because these tumors are well circumscribed and slow growing. However, certain signs and symptoms, such as pain, paresthesia, facial nerve weakness, or rapid growth, raise the concern for malig-nancy. If there is facial nerve weakness (10%–15% of cases), this usually represents tumor invading the facial nerve. Sub-mandibular


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Surgery_Schwartz. nerve weakness, or rapid growth, raise the concern for malig-nancy. If there is facial nerve weakness (10%–15% of cases), this usually represents tumor invading the facial nerve. Sub-mandibular and sublingual tumors present with a mass or swell-ing in the neck or floor of the mouth, respectively. Tumors in this region can invade the lingual nerve leading to tongue par-esthesia or the hypoglossal nerve invasion leading to paralysis. The close proximity to the mandible and tongue necessitates a thorough bimanual palpation to assess for fixation to these structures.The decision to dissect the neck in parotid cancers is fraught with uncertainty. However, parotid malignancies, par-ticularly carcinomas, have a propensity for regional lymphatic spread, first to the intraand periglandular nodes followed by the upper cervical chain (levels I–III). Occult nodal metastases are present in 30% of cases and are predicted by intraor peri-glandular nodes, high-risk histology (high histological


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Surgery_Schwartz. followed by the upper cervical chain (levels I–III). Occult nodal metastases are present in 30% of cases and are predicted by intraor peri-glandular nodes, high-risk histology (high histological grade), and extraparotid extension.193 Patients with advanced tumor stage (T3/T4a), perineural invasion, high risk histology, or clin-ically involved adenopathy should have their neck dissected. Submandibular gland cancers metastasize to the submental (Ia) and submandibular triangle lymph nodes followed by the upper cervical chain (levels II–III). Extraglandular extension and regional metastases are poor prognostic factors.Following a thorough history and physical examination, an FNA biopsy should be performed to provide an accurate preoperative diagnosis in 70% to 80% of cases when reviewed by an experienced cytopathologist. If the biopsy is nondiag-nostic, a repeat biopsy should be performed under image-guidance, typically with an ultrasound. An open or incisional biopsy should be avoided


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Surgery_Schwartz. an experienced cytopathologist. If the biopsy is nondiag-nostic, a repeat biopsy should be performed under image-guidance, typically with an ultrasound. An open or incisional biopsy should be avoided because of the risk of tumor spill-age and cutaneous spread. Also, this approach is fraught with risk to the facial nerve. Salivary gland tumors are worked up with appropriate imaging, typically with an MRI because of the increased soft tissue definition. FNA and imaging results are critical in guiding the surgeon to the extent of surgery. The minimal extent of surgery for salivary gland tumors is a superficial parotidectomy, removing all of the salivary gland tissue superficial to CN VII, which is meticulously dissected during this procedure.The final histopathologic diagnosis in salivary gland tumors can be challenging. Nonetheless, there is a well-outlined histological classification used by pathologists.194 Benign and malignant tumors of the salivary glands are divided into


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Surgery_Schwartz. gland tumors can be challenging. Nonetheless, there is a well-outlined histological classification used by pathologists.194 Benign and malignant tumors of the salivary glands are divided into epi-thelial, nonepithelial, and metastatic neoplasms. Benign epithe-lial tumors are most commonly pleomorphic adenoma (85%), monomorphic adenoma, Warthin’s tumor (papillary cystad-enoma lymphomatosum), oncocytoma, or sebaceous neoplasm. Nonepithelial benign lesions include lipoma and hemangioma. Treatment of benign neoplasms is surgical excision for diag-nostic and therapeutic purposes. The parotid superficial lobe is usually dissected off of the facial nerve, which is preserved. For pleomorphic adenoma, an extracapsular dissection is favored over enucleation due to tumor pseudopods, incomplete excision, and a higher risk of tumor spillage, all of which are associated with higher recurrence rates.195 Recurrence is associated with a high degree of morbidity.Malignant epithelial tumors range in


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Surgery_Schwartz. and a higher risk of tumor spillage, all of which are associated with higher recurrence rates.195 Recurrence is associated with a high degree of morbidity.Malignant epithelial tumors range in aggressiveness based on tumor histology, grade, perineural invasion, and regional metastases. Mucoepidermoid carcinoma is the most common primary malignancy of the salivary glands and can be high grade (more epidermoid) or low grade (more mucinous). High grade mucoepidermoid carcinoma can be hard to differentiated from squamous cell carcinoma, particularly on FNA. Adenoid cystic is the second most common primary salivary gland malignancy and has three histological subtypes: tubular, cribriform, and solid. Higher grade/risk tumors have a higher degree of solid differentiation.194 Adenoid cystic cancers are known for peri-neural invasion and late recurrences and distant metastases. Car-cinoma ex pleomorphic adenoma is an aggressive malignancy that arises from a preexisting benign mixed tumor


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Surgery_Schwartz. cancers are known for peri-neural invasion and late recurrences and distant metastases. Car-cinoma ex pleomorphic adenoma is an aggressive malignancy that arises from a preexisting benign mixed tumor highlighting the importance of removing these benign masses before malig-nant transformation.Surgical excision remains the standard of care, typi-cally with facial nerve preservation unless the nerve is directly invaded by tumor. For tumors that extend beyond the superficial lobe, nerve branches can be splayed, and a total parotid can be performed by removing parotid tissue deep to the nerve while preserving the integrity and function of the nerve. Whenever possible, the nerve is preserved even if microscopic disease is left on the nerve, so long as gross tumor is not left behind (i.e., the nerve is not encased). If this is not possible or if the nerve is not working preoperatively, nerve sacrifice is usually recommended.Elective neck dissection is warranted in high-grade muco-epidermoid


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Surgery_Schwartz. is not encased). If this is not possible or if the nerve is not working preoperatively, nerve sacrifice is usually recommended.Elective neck dissection is warranted in high-grade muco-epidermoid carcinomas and other high-risk pathology and grade where the risk of occult disease is greater than 15% to 20%. Therapeutic neck dissection is recommended in patients with clinically or radiographically evident disease. Postoperative radiotherapy is indicated in patients with perineural invasion, advanced local disease (T4a), extraglandular disease including regional metastases, and high-grade histology.Brunicardi_Ch18_p0613-p0660.indd 65001/03/19 5:24 PM 651DISORDERS OF THE HEAD AND NECKCHAPTER 18RECONSTRUCTIONLocal Flaps and Skin GraftsLocal flaps are commonly used for cutaneous reconstruction in the head and neck. Local flaps are most commonly utilized for reconstruction after Mohs micrographic surgery for cutaneous malignancy, or for reconstruction of melanoma defects. Skin grafts are


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Surgery_Schwartz. in the head and neck. Local flaps are most commonly utilized for reconstruction after Mohs micrographic surgery for cutaneous malignancy, or for reconstruction of melanoma defects. Skin grafts are also commonly used for reconstruction of scalp defects after surgical resection of cutaneous malignancies. Skin grafts may also be utilized in the oral cavity for resurfacing of super-ficial defects of the tongue, floor of mouth, and buccal mucosa.Regional FlapsThree regional flaps deserve mention as potential flaps for head and neck reconstruction. The first is the pectoralis major myo-cutaneous flap, based upon the thoracoacromial artery.196 This flap may be used as a primary option for hypopharyngeal recon-struction after total laryngectomy. This flap may also be utilized to protect the great vessels from becoming exposed, or as a sal-vage reconstructive procedure should the great vessels become exposed. Another commonly utilized regional flap is the sub-mental flap, based upon the


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Surgery_Schwartz. great vessels from becoming exposed, or as a sal-vage reconstructive procedure should the great vessels become exposed. Another commonly utilized regional flap is the sub-mental flap, based upon the submental vessel branches of the facial artery. This flap may be utilized for intraoral reconstruc-tion and/or parotid and temporal bone reconstruction.197 Care must be taken during the neck dissection in order to preserve the submental vessels that supply this flap. Finally, the supraclavic-ular flap is based upon the supraclavicular artery, arising from the transverse cervical artery.198 This is a thin, fasciocutaneous flap that is commonly used for external neck and facial recon-struction in which thin tissue is desired.Free Tissue TransferThe majority of major defects of the head and neck require free tissue transfer for optimal reconstruction.199 A full discussion of head and neck reconstructive microsurgery is beyond the scope of this chapter; however, a brief overview of free tissue


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Surgery_Schwartz. free tissue transfer for optimal reconstruction.199 A full discussion of head and neck reconstructive microsurgery is beyond the scope of this chapter; however, a brief overview of free tissue transfer is provided in this section. Free tissue transfer allows the sur-geon to transplant tissue from a wide array of donor sites, each of which have distinct advantages.200 For example, for floor of mouth reconstruction, where thin tissue is desired, the surgeon may select the radial forearm as the donor site. On the other hand, when presented with a total glossectomy defect, where thick tissue is desired for adequate volume reconstruction, the rectus may be the optimal donor site. Considering osseous defects, for reconstruction of a segmental mandible defect with minimal soft tissue deficit, the fibula osseocutaneous free tis-sue transfer may be the optimal choice.201 On the other hand, reconstruction of an osseous mandible defect with a large muco-sal and external soft tissue deficit may


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Surgery_Schwartz. fibula osseocutaneous free tis-sue transfer may be the optimal choice.201 On the other hand, reconstruction of an osseous mandible defect with a large muco-sal and external soft tissue deficit may be best served by the scapula donor site, where vascularized bone can be combined with a large skin paddle, and an additional latissimus dorsi myocutaneous free tissue transfer, if needed.202 The ability to harvest tissue from multiple donor sites is critical to obtain-ing the optimal reconstructive result. Table 18-6 lists the com-monly utilized donor sites and their reconstructive advantages and disadvantages.Table 18-6Free tissue transfer donor sites for head and neck reconstructionFLAPBLOOD SUPPLYCHARACTERISTICSCOMMON DEFECTSRadial forearmRadial arteryThin, pliable, long pediclePartial and hemiglossectomy, floor of mouth, buccal defectsAnterolateral thighDescending branch of lateral femoral circumflex arteryThicker adipose than radial forearm, can have myocutaneous (most common) or


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Surgery_Schwartz. hemiglossectomy, floor of mouth, buccal defectsAnterolateral thighDescending branch of lateral femoral circumflex arteryThicker adipose than radial forearm, can have myocutaneous (most common) or septocutaneous perforatorsHypopharynx, external neck/facial skin, extended hemiglossectomy/total glossectomyLateral armPosterior radial collateral arteryOutstanding color match for facial skin, resists ptosis, diminutive pedicleParotid, temporal bone, external face and neck skinRectusDeep inferior epigastric arteryThick adipose tissue for large volume defects, long pedicle, poor external skin color matchTotal glossectomy, skull baseLatissimus dorsiThoracodorsal arteryLarge surface area of muscle, requires semi-lateral position, can be difficult for two-team harvestExtensive scalp and skull base defectsFibula osseocutaneousPeroneal arteryExcellent bone stock and length, long pedicle, thin skin paddleSegmental mandible and maxillaScapula osseocutaneousCircumflex scapular arteryLess bone


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Surgery_Schwartz. base defectsFibula osseocutaneousPeroneal arteryExcellent bone stock and length, long pedicle, thin skin paddleSegmental mandible and maxillaScapula osseocutaneousCircumflex scapular arteryLess bone length compared to fibula, large scapular or parascapular skin paddles ideal for large composite defectsSegmental mandible and maxilla defects with extensive soft tissue componentsRadial forearm osseocutaneousRadial arteryLong pedicle, diminutive bone stockPartial mandible defects, orbitIliac crestDeep circumflex iliac arteryUp to 16 cm of bone available, limited soft tissue, significant donor site morbiditySegmental mandible defects with small intraoral component and large external skin componentBrunicardi_Ch18_p0613-p0660.indd 65101/03/19 5:24 PM 652SPECIFIC CONSIDERATIONSPART IIFigure 18-43 shows a prototypical hemiglossectomy defect from a T2 N0 oral tongue cancer that was reconstructed with a rectangle template radial forearm free tissue transfer.203 The radial forearm free tissue


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Surgery_Schwartz. shows a prototypical hemiglossectomy defect from a T2 N0 oral tongue cancer that was reconstructed with a rectangle template radial forearm free tissue transfer.203 The radial forearm free tissue transfer provides thin, pliable tis-sue, with a long pedicle, and is a staple for hemiglossectomy and partial glossectomy reconstruction.Figure 18-44 shows a composite mandible defect from a T4a N0 mandibular alveolus cancer, after segmental mandibu-lectomy, reconstructed with a fibula osseocutaneous free tissue transfer.204 The 2.5-mm titanium reconstruction plate was bent to a mandible model. A template of the osseous defect is made and transferred to the fibula, and wedge ostectomies are made in the bone so that it can be snug fit into the bone defect.Figure 18-45 shows a palate defect after an infrastructure maxillectomy for a T2 N0 maxillary alveolus cancer. The defect resulted in direct communication with the buccal space, nasal cavity, and maxillary sinus. A radial forearm free tissue


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Surgery_Schwartz. infrastructure maxillectomy for a T2 N0 maxillary alveolus cancer. The defect resulted in direct communication with the buccal space, nasal cavity, and maxillary sinus. A radial forearm free tissue transfer was utilized to achieve oronasal separation.TRACHEOTOMYIndications and TimingThe most common cause for tracheotomy is prolonged intuba-tion typically in critically ill intensive care unit patients. Pro-longed intubation increases the risk of laryngeal and subglottic injury, which may lead to stenosis. In the critically ill patient, it has been hypothesized that early tracheotomy may improve inpatient survival and decreased intensive care unit length of stay while increasing patient comfort. However, a large ran-domized clinical trial demonstrated no benefit from early tra-cheotomy on shortor long-term survival and other important secondary outcomes.205 Furthermore, clinicians are poor pre-dictors of which patients require extended ventilatory support. Another study demonstrated no


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Surgery_Schwartz. long-term survival and other important secondary outcomes.205 Furthermore, clinicians are poor pre-dictors of which patients require extended ventilatory support. Another study demonstrated no evidence that early tracheos-tomy reduced mortality, duration of mechanical ventilation, intensive care unit stay, or ventilatory associated pneumonia.206 It did, however, provide a shorter duration of sedation. Beyond prolonged intubation, tracheotomy is also indicated in patients who require frequent pulmonary toilet, in patients with neu-rologic deficits that impair protective airway reflexes, and in head and neck upper aerodigestive tract surgery as a temporary airway in the perioperative period to bypass airway obstruction.Technique and ComplicationsThe procedure can be performed using an open or a percuta-neous technique. Complications of tracheostomy include pneu-mothorax, tracheal stenosis, wound infection/stomatitis with large-vessel erosion, and failure to close after decannulation. A


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Surgery_Schwartz. or a percuta-neous technique. Complications of tracheostomy include pneu-mothorax, tracheal stenosis, wound infection/stomatitis with large-vessel erosion, and failure to close after decannulation. A meta-analysis of 15 randomized studies assessing nearly 1000 patients demonstrated no difference between the open and percutaneous techniques, although there was a trend toward fewer complications in the percutaneous approach.207 The per-cutaneous approach was also found to be cheaper and had the added benefit of being performed at the bedside outside of the operating room. A Cochrane review on the topic lower wound infection/stomatitis and unfavorable scarring rates with the per-cutaneous approach.208 Mortality and serious adverse events did not differ between the two techniques.The use of cricothyroidotomy, typically in the emergency setting, is inferior to a tracheotomy due to higher incidence of vocal cord dysfunction and subglottic stenosis. There-fore, soon after a cricothyroidotomy


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Surgery_Schwartz. typically in the emergency setting, is inferior to a tracheotomy due to higher incidence of vocal cord dysfunction and subglottic stenosis. There-fore, soon after a cricothyroidotomy is performed, a formal Figure 18-43. A. Defect after left hemiglossectomy for T2 N0 oral tongue squamous cell carcinoma. B. Radial forearm free tissue transfer harvested for reconstruction. C. Inset of the radial forearm free tissue transfer.ABCBrunicardi_Ch18_p0613-p0660.indd 65201/03/19 5:25 PM 653DISORDERS OF THE HEAD AND NECKCHAPTER 18Figure 18-45. A. Palate defect after infrastructure maxillectomy for T2 N0 squamous cell carcinoma of the maxillary alveolus. B. Inset of radial forearm free tissue transfer. C. Six month postop-erative result, with complete oronasal separation and return to full, preoperative levels of speech and swallowing.tracheotomy should be used with decannulation of the crico-thyroidotomy site. Most tracheostomies are not permanent and can be reversed simply by removing the


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Surgery_Schwartz. levels of speech and swallowing.tracheotomy should be used with decannulation of the crico-thyroidotomy site. Most tracheostomies are not permanent and can be reversed simply by removing the tube and applying a pressure dressing. The stoma usually spontaneously heals within 2 to 3 weeks.Speech with Tracheotomy and DecannulationWhen a large cuffed tracheostomy is initially placed, speech is not possible, particularly when the cuff is up. However, when the tube is downsized to a cuffless tracheostomy tube, ABCFigure 18-44. A. Segmental mandible defect after composite resec-tion for T4a N0 squamous cell carcinoma of the mandibular alveolus. B. Fibula free tissue transfer harvested for reconstruction and template for wedge ostectomy. C. Inset of fibula free tissue transfer.ABCBrunicardi_Ch18_p0613-p0660.indd 65301/03/19 5:25 PM 654SPECIFIC CONSIDERATIONSPART IIintermittent finger occlusion or placement of Passy-Muir valve can allow the patient to voice while still bypassing the upper


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Surgery_Schwartz. 65301/03/19 5:25 PM 654SPECIFIC CONSIDERATIONSPART IIintermittent finger occlusion or placement of Passy-Muir valve can allow the patient to voice while still bypassing the upper airway obstruction in inspiration. Prior to decannulation, the patient has to tolerate capping for 24 to 48 hours, but this period can be extended in patients with concerns for pulmonary toilet and an inability to clear secretions.LONG TERM MANAGEMENT AND REHABILITATIONPalliative CareFor patients with unresectable disease (greater than 180o of encasement around the carotid artery, prevertebral fascia inva-sion, and skull base invasion) or distant metastases, palliative care options exist. The NCCN guidelines recommend clinical trials for patients in this category because there is not a single accepted regimen for patients with incurable disease but the goal of treatment is to control symptoms and maintain quality of life while minimizing the side effects of treatment.106 This may include a combination of


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Surgery_Schwartz. for patients with incurable disease but the goal of treatment is to control symptoms and maintain quality of life while minimizing the side effects of treatment.106 This may include a combination of radiotherapy, usually in a hypofrac-tionated pattern with high dose per fraction regimen, chemother-apy, or simply pain management. A recent trial demonstrated the utility of immunotherapy, specifically, Nivolumab, in the management of recurrent unresectable head and neck cancer, showing a higher response rate (13.3%) compared to standard therapy (5.8%) with lower treatment-related adverse events (13.1% vs. 35.1%, respectively).209 From a surgical perspective, some patients require tracheostomy or gastrostomy tube place-ment to manage airway compromise and dysphagia, respec-tively. Palliative care facilities and hospice care allow patients to retain dignity when they have a limited short-term outlook.Follow-Up CarePatients diagnosed and treated for a head and neck tumor require follow-up


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Surgery_Schwartz. care facilities and hospice care allow patients to retain dignity when they have a limited short-term outlook.Follow-Up CarePatients diagnosed and treated for a head and neck tumor require follow-up care aimed at monitoring for recurrence and the side effects of therapy. The NCCN guidelines recommend follow-up assessment every 3 months for the first year after treatment, every 4 months during the following year, and then every 6 months until year 4, with an annual follow-up at 5 years post treatment and thereafter.106 This regimen is not well followed in North America, and further investigation is required to assess why this might be and to improve adherence rates.210 Follow-up should consist of a thorough history to assess for any emerg-ing symptoms such as pain, otalgia, or dysphagia as these are often the first sign of a recurrence. Assessment by speech lan-guage pathology and a dietician is often beneficial to ascertain swallowing function and nutritional intake, respectively.


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Surgery_Schwartz. as these are often the first sign of a recurrence. Assessment by speech lan-guage pathology and a dietician is often beneficial to ascertain swallowing function and nutritional intake, respectively. Some patients require dilation or reinsertion of a gastrostomy tube if they develop pharyngeal strictures and are unable to maintain their weight. The history should be followed with a thorough head and neck examination, including fiberoptic nasolaryg-noscopy, because of the significant risk of developing a sec-ond primary in the upper aerodigestive tract.93 Patients should have their thyroid stimulating hormone (TSH) checked once a year, especially in those that have radiation as they may develop hypothyroidism at an earlier age than the general population. Shoulder dysfunction after neck dissection with extensive accessory nerve dissection or in patients who have had a scapu-lar system free flap should be managed with physiotherapy to minimize the long-term effects and improve function.


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Surgery_Schwartz. with extensive accessory nerve dissection or in patients who have had a scapu-lar system free flap should be managed with physiotherapy to minimize the long-term effects and improve function. Chronic pain can occur in head and neck cancer patients, and this is often assessed and managed by a pain specialist. Ongoing dental evaluation is needed in some patients to treat caries and prevent osteoradionecrosis.REFERENCESEntries highlighted in bright blue are key references. 1. Hajioff D, MacKeith S. Otitis externa. BMJ Clin Evid. 2015;2015:0510. 2. Sylvester MJ, Sanghvi S, Patel VM, Eloy JA, Ying YM. Malignant otitis externa hospitalizations: analysis of patient characteristics. Laryngoscope. 2017;127(10):2328-2336. 3. Carfrae MJ, Kesser BW. Malignant otitis externa. Otolaryngol Clin North Am. 2008;41(3):537-549, viii-ix. 4. Venekamp RP, Damoiseaux RA, Schilder AG. Acute otitis media in children. Am Fam Physician. 2017;95(2):109-110. 5. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical


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Surgery_Schwartz. 2008;41(3):537-549, viii-ix. 4. Venekamp RP, Damoiseaux RA, Schilder AG. Acute otitis media in children. Am Fam Physician. 2017;95(2):109-110. 5. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical practice guideline: otitis media with effusion execu-tive summary (update). Otolaryngol Head Neck Surg. 2016;154(2):201-214. 6. American Academy of Pediatrics Subcommittee on Manage-ment of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113(5):1451-1465. 7. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diag-nosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-e999. 8. Principi N, Marchisio P, Rosazza C, Sciarrabba CS, Esposito S. Acute otitis media with spontaneous tympanic membrane perforation. Eur J Clin Microbiol Infect Dis. 2017;36(1): 11-18. 9. Kuo CL, Shiao AS, Yung M, et al. Updates and knowl-edge gaps in cholesteatoma research. Biomed Res Int. 2015;2015:854024. 10. Cunningham M, Guardiani E, Kim HJ, Brook I. Otitis


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Surgery_Schwartz. 2017;36(1): 11-18. 9. Kuo CL, Shiao AS, Yung M, et al. Updates and knowl-edge gaps in cholesteatoma research. Biomed Res Int. 2015;2015:854024. 10. Cunningham M, Guardiani E, Kim HJ, Brook I. Otitis media. Future Microbiol. 2012;7(6):733-753. 11. Choi JW, Park YH. Facial nerve paralysis in patients with chronic ear infections: surgical outcomes and radiologic anal-ysis. Clin Exp Otorhinolaryngol. 2015;8(3):218-223. 12. Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guide-line: Bell’s palsy. Otolaryngol Head Neck Surg. 2013;149 (3 suppl):S1-S27. 13. Gantz BJ, Rubinstein JT, Gidley P, Woodworth GG. Surgical management of Bell’s palsy. Laryngoscope. 1999;109(8):1177-1188. 14. Danner CJ. Facial nerve paralysis. Otolaryngol Clin North Am. 2008;41(3):619-632. 15. Jackler RK, Pfister MHF. Acoustic neuroma (vestibular schwanomma). In: Jackler RK, Brackmann DE, eds. Neurotol-ogy. 2nd ed. Philadelphia: Elsevier Mosby; 2005:727-782. 16. Carlson ML, Habermann EB, Wagie AE, et al. The


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Surgery_Schwartz. MHF. Acoustic neuroma (vestibular schwanomma). In: Jackler RK, Brackmann DE, eds. Neurotol-ogy. 2nd ed. Philadelphia: Elsevier Mosby; 2005:727-782. 16. Carlson ML, Habermann EB, Wagie AE, et al. The chang-ing landscape of vestibular schwannoma management in the United States—a shift toward conservatism. Otolaryngol Head Neck Surg. 2015;153(3):440-446. 17. Blackwell DL, Lucas JW, Clarke TC. Summary health statis-tics for U.S. adults: national health interview survey, 2012. Vital Health Stat 10. 2014;(260):1-161. 18. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinus-itis executive summary. Otolaryngol Head Neck Surg. 2015;152(4):598-609. 19. Fokkens WJ, Lund VJ, Mullol J, et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A sum-mary for otorhinolaryngologists. Rhinology. 2012;50(1):1-12. 20. Brook I. Microbiology of sinusitis. Proc Am Thorac Soc. 2011;8(1):90-100. 21. Miracle AC, Mukherji SK. Conebeam