Atlas of Head and Neck Surgery

Atlas of
HEAD & NECK

SURGERY
James I. Cohen, MD, PhD, FACS
Professor, Department of Otolaryngology/Head and Neck Surgery
Chief Otolaryngology/Assistant Chief Surgery, Portland VA Medical Center
Oregon Health and Science University
Portland, Oregon
Gary L. Clayman, MD, DMD, FACS

Alando J. Ballantyne Distinguished Chair of Head and Neck Surgery
Professor of Surgery and Cancer Biology
Director of Interdisciplinary Program in Head and Neck Oncology
Chief, Section of Head and Neck Endocrine Surgery
Deputy Head Division of Surgery
University of Texas MD Anderson Cancer Center
Houston, Texas
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
ATLAS OF HEAD & NECK SURGERY ISBN: 978-1-4160-3368-4
Copyright © 2011 by Saunders, an imprint of Elsevier Inc. All rights reserved.
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their
own experience and knowledge of their patients, to make diagnoses, to determine dosages and the
best treatment for each individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data

Atlas of head & neck surgery / [edited by] James I. Cohen, Gary L. Clayman.—1st ed.
p. ; cm.
Atlas of head and neck surgery
Includes bibliographical references and index.
ISBN 978-1-4160-3368-4 (hardcover : alk. paper) 1. Head—Surgery—Atlases. 2. Neck—
Surgery—Atlases. I. Cohen, James I. II. Clayman, Gary L. III. Title: Atlas of head and neck
surgery.
[DNLM: 1. Head—surgery—Atlases. 2. Neck—surgery—Atlases. WE 17]
RD521.A843 2011
617.5′1059—dc22
2011010051
Acquisitions Editor: Stefanie Jewell-Thomas

Developmental Editor: Roxanne Halpine Ward
Publishing Services Manager: Patricia Tannian
Senior Project Manager: Claire Kramer
Designer: Louis Forgione
Working together to grow
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Printed in China www.elsevier.com | www.bookaid.org | www.sabre.org
Last digit is the print number: 9 8 7 6 5 4 3 2 1

This book is dedicated to the concept that the wisdom and humility essential
to the practice of medicine are best acquired by rejecting dogma and instead
exploring the controversy that surrounds much of what we do every day.
My lifelong pursuit of this ideal has required constant nurturing. For this,
I am forever indebted to my father who instilled it in me at an early age by design
and example, to three decades of residents who have helped me learn and teach
in this context, and especially to my wife, Sherry, and my children, Alex and Adam,
who have always supported me with love and affection.
James I. Cohen
How we develop as individuals is shaped by both our genetics and our environment.
I dedicate this book to those who have directly and indirectly shaped my life, and
although I am hesitant to make too long of a list, such an opportunity comes too
infrequently. My parents provided encouragement, support, and love for which I am
forever grateful. I have had the honor to be educated by and to refer to as colleagues,
several surgeons who have been icons in the field of head and neck surgery. These men
inspired me with their wisdom, surgical art form, and humility and have remained
within me throughout my career. They notably include Drs. Helmuth Goepfert, Alando
J. Ballantyne, Robert Byers, and Oscar Guillamondegui. Inspiration has also come
from the honor and joy of training immensely talented and brilliant residents
and fellows during the past 20 years. Finally, my family, including my loving
wife, Mikyung, my beautiful children, Beau and Elizabeth, and my brothers,
Lawrence and Marty, and my dear friends have provided endless love and care
and the smiles, joy, and laughter that give my life meaning.
Gary L. Clayman
Associate Editors
Peter E. Andersen, MD William M. Lydiatt, MD, FACS
Professor, Department of Otolaryngology/ Professor and Vice Chair, Department of Otolaryngology
Head and Neck Surgery Director of Head and Neck Surgery
Professor, Department of Neurosurgery University of Nebraska Medical Center
Director of Head and Neck Surgery Professor, Department of Head and Neck Surgery
Oregon Health and Science University Nebraska Methodist Hospital
Portland, Oregon Omaha, Nebraska
Ehab Hanna, MD, FACS Joshua S. Schindler, MD

Professor and Vice Chairman Assistant Professor, Department of Otolaryngology
Director of Skull Base Surgery Medical Director, OHSU-Northwest Clinic for Voice
Department of Head and Neck Surgery and Swallowing
Medical Director, Head and Neck Center Oregon Health and Science University
University of Texas MD Anderson Cancer Center Portland, Oregon
Houston, Texas
Mark K. Wax, MD, FACS, FRCSC
F. Christopher Holsinger, MD, FACS Professor, Otolaryngology/Head and Neck Surgery
Associate Professor, Department of Head and Neck Surgery Professor, Oral and Maxillofacial Surgery
Director, Program in Minimally Invasive and Endoscopic Head Program Director
and Neck Surgery Director, Microvascular Reconstruction
University of Texas MD Anderson Cancer Center Coordinator, Education, AAOHNS(F)
Houston, Texas Department of Otolaryngology/Head and Neck Surgery
Oregon Health Sciences University
Portland, Oregon
vii
Contributors
Peter E. Andersen, MD Ehab Hanna, MD, FACS
Professor, Department of Otolaryngology/ Professor and Vice Chairman
Head and Neck Surgery Director of Skull Base Surgery
Professor, Department of Neurosurgery Department of Head and Neck Surgery
Director of Head and Neck Surgery Medical Director, Head and Neck Center
Oregon Health and Science University University of Texas MD Anderson Cancer Center
Portland, Oregon Houston, Texas
Mihir K. Bhayani, MD F. Christopher Holsinger, MD, FACS

Fellow, Department of Head and Neck Surgery Associate Professor, Department of Head and Neck Surgery
University of Texas MD Anderson Cancer Center Director, Program in Minimally Invasive and Endoscopic Head
Houston, Texas and Neck Surgery
University of Texas MD Anderson Cancer Center
Apostolos Christopoulos, MD, MSc, FRCSC Houston, Texas
Assistant Professor, Department of Otorhinolaryngology
Centre Hospitalier de l’Université de Montréal Kitti Jantharapattana, MD
Montréal, Québec, Canada Postdoctoral Fellow, Head and Neck Surgery
MD Anderson Cancer Center
Woong Youn Chung, MD, PhD Houston, Texas
Associate Professor, Department of Surgery Instructor, Otolaryngology Head and Neck Surgery
Yonsei University College of Medicine Prince of Songkla University
Seoul, Republic of Korea Songkhla, Thailand
Gary L. Clayman, MD, DMD, FACS Ollivier Laccourreye, MD

Alando J. Ballantyne Distinguished Chair of Head and Neck Professor, Department of Otorhinolaryngology–Head and Neck
Surgery Surgery
Professor of Surgery and Cancer Biology University Descartes-Paris V
Director of Interdisciplinary Program in Head and Neck Hôpital Européen Georges Pompidou
Oncology Member, Académie Nationale de Chirurgie
Chief, Section of Head and Neck Endocrine Surgery Paris, France
Deputy Head Division of Surgery, University of Texas MD
Anderson Cancer Center Daniel D. Lydiatt, MD, DDS, FACS
Houston, Texas Professor and Interim Chair, Otolaryngology/Head and Neck
Surgery
James I. Cohen, MD, PhD, FACS University of Nebraska Medical Center
Professor, Department of Otolaryngology/Head and Neck Medical Director, Head and Neck Surgery
Surgery Nebraska Methodist Hospital
Chief Otolaryngology/Assistant Chief Surgery, Portland VA Omaha, Nebraska
Medical Center
Oregon Health and Science University William M. Lydiatt, MD, FACS
Portland, Oregon Professor and Vice Chair, Department of Otolaryngology
Director of Head and Neck Surgery
Robert L. Ferris, MD, PhD, FACS University of Nebraska Medical Center
Professor and Vice-Chair of Clinical Operations Professor, Department of Head and Neck Surgery
Departments of Otolaryngology, Radiation Oncology, and Nebraska Methodist Hospital
Immunology Omaha, Nebraska
Eye & Ear Institute
Pittsburgh, Pennsylvania Henry A. Milczuk, MD
Associate Professor
Paul W. Gidley, MD, FACS Chief, Pediatric Otolaryngology
Associate Professor, Head and Neck Surgery Department of Otolaryngology–Head and Neck Surgery
University of Texas MD Anderson Cancer Center Oregon Health and Science University
Houston, Texas Portland, Oregon
Neil D. Gross, MD, FACS Raul Pellini, MD

Assistant Professor, Otolaryngology/Head and Neck Surgery Attending Surgeon, Department of Otolaryngology–Head and
Oregon Health and Science University Neck Surgery
Attending Surgeon, Operative Care Division National Cancer Institute “Regina Elena”
Portland VA Medical Center Rome, Italy
Portland, Oregon
viii
Contributors ix
Greg Reece, MD Mark K. Wax, MD, FACS, FRCSC

Professor of Plastic Surgery Professor, Otolaryngology/Head and Neck Surgery
Department of Plastic Surgery Professor, Oral and Maxillofacial Surgery
University of Texas MD Anderson Cancer Center Program Director
Houston, Texas Director, Microvascular Reconstruction
Coordinator, Education, AAOHNS(F)
Paolo Ruscito, MD Department of Otolaryngology/Head and Neck Surgery
Attending Surgeon, Department of Otolaryngology–Head and Oregon Health Sciences University
Neck Surgery Portland, Oregon
National Cancer Institute “Regina Elena”
Rome, Italy Gregory S. Weinstein, MD
Professor and Vice Chair, Otorhinolaryngology: Head and Neck
Joshua S. Schindler, MD Surgery
Assistant Professor, Department of Otolaryngology University of Pennsylvania
Medical Director, OHSU-Northwest Clinic for Voice and Philadelphia, Pennsylvania
Swallowing
Oregon Health and Science University Mark E. Zafereo, MD
Portland, Oregon Fellow, Head and Neck Surgery
MD Anderson Cancer Center
Giuseppe Spriano, MD Houston, Texas
Chief, Department of Otolaryngology–Head and Neck Surgery
Director, Department of Neuroscience
National Cancer Institute “Regina Elena”
Rome, Italy
Reviewers
Peter E. Andersen, MD William R. Carroll, MD
Professor, Department of Otolaryngology/Head and Neck Professor and Director of Head and Neck Oncology
Surgery Department of Surgery
Professor, Department of Neurosurgery University of Alabama–Birmingham
Director of Head and Neck Surgery Birmingham, Alabama
Portland, Oregon Salvatore M. Caruana, MD
Assistant Professor, Department of Otolaryngology–Head
William B. Armstrong, MD and Neck Surgery
Professor of Clinical Otolaryngology and Chair, Columbia University
Otolaryngology–Head and Neck Surgery New York, New York
University of California–Irvine
Irvine, California Claudio R. Cernea, MD
Associate Professor of Surgery, Department of Head and Neck
Leon A. Assael, DMD Surgery
Professor and Chair of Oral and Maxillofacial Surgery University of Sao Paulo Medical School
Medical Director, Hospital Dentistry Sao Paulo, Brazil
Portland, Oregon Francisco J. Civantos, MD, FACS
Associate Professor
Stephen W. Bayles, MD, FACS Co-Director, Division of Head and Neck Surgery
Deputy Chief of Surgery Department of Otolaryngology
Section Head-Otolaryngology Sylvester Cancer Center/University of Miami Hospital and
Director of Head and Neck Oncology Clinics
Virginia Mason Medical Center Miami, Florida
Seattle, Washington
Gary L. Clayman, MD, DMD, FACS
Peter C. Belafsky, MD, PhD Alando J. Ballantyne Distinguished Chair of Head and Neck
Associate Professor and Director, Center for Voice and Surgery
Swallowing Professor of Surgery and Cancer Biology
University of California–Davis Director of Interdisciplinary Program in Head and Neck
Sacramento, California Oncology
Chief, Section of Head and Neck Endocrine Surgery
Manuel Bernal-Sprekelsen, MD, PhD Deputy Head Division of Surgery, University of Texas MD
Head of Ear, Nose and Throat Department, Anderson Cancer Center
Otorhinolaryngology, Hospital Clinic Houston, Texas
Tenure Professor for Otorhinolaryngology, Department for
Surgical Specialties James I. Cohen, MD, PhD, FACS
University of Barcelona Professor, Department of Otolaryngology/Head and Neck
Barcelona, Spain Surgery
Privatdozent for ORL Chief Otolaryngology/Assistant Chief Surgery, Portland VA
Ruhr-University Medical Center
Bochum, Germany Oregon Health and Science University
Portland, Oregon
Nasir I. Bhatti MD, FACS
Associate Professor, Department of Otolaryngology Head Seth M. Cohen, MD, MPH
and Neck Surgery Assistant Professor, Duke Voice Care Center
Johns Hopkins University School of Medicine Division of Otolaryngology–Head and Neck Surgery
Baltimore, Maryland Duke University Medical Center
Durham, North Carolina
Brian B. Burkey, MD, FACS
Section Head, Head and Neck Surgery and Oncology Ted A. Cook, MD, FACS
Head and Neck Institute Professor, Facial Plastic and Reconstructive Surgery
Cleveland Clinic Foundation Department of Otolaryngology/Head and Neck Surgery
Cleveland, Ohio Oregon Health and Science University
Adjunct Professor, Department of Otolaryngology Portland, Oregon
Vanderbilt University Medical Center
Nashville, Tennessee Robin T. Cotton, MD, FACS, FRCSC
Director, Pediatric Otolaryngology–Head and Neck Surgery
Bruce H. Campbell, MD, FACS Director, Aerodigestive and Sleep Center
Professor, Department of Otolaryngology and Communication Cincinnati Children’s Hospital
Sciences Professor, Otolaryngology–Head and Neck Surgery
Medical College of Wisconsin University of Cincinnati College of Medicine
Milwaukee, Wisconsin Cincinnati, Ohio
x
Reviewers xi
Mark S. Courey, MD Jeremy L. Freeman, MD, FRCSC, FACS

Professor, Otolaryngology–Head and Neck Surgery Professor, Department of Otolaryngology–Head and Neck Surgery
UCSF Medical Center Professor, Department of Surgery
Director, Division of Laryngology University of Toronto
University of California–San Francisco Temmy Latner/Dynacare Chair in Head and Neck Oncology
San Francisco, California Mount Sinai Hospital/University of Toronto
Otolaryngologist in Chief, Department of Otolaryngology–Head
Bruce J. Davidson, MD and Neck Surgery
Professor and Chairman, Department of Otolaryngology–Head Mount Sinai Hospital
and Neck Surgery Toronto, Ontario, Canada
Georgetown University Medical Center
Washington, District of Columbia Paul L. Friedlander, MD, FACS
Chairman, Department of Otolaryngology
Terry A. Day, MD Tulane Medical Center
Professor and Clinical Vice Chairman, Department of New Orleans, Louisiana
Otolaryngology–Head and Neck Surgery
Medical University of South Carolina Neal Futran, MD, DMD
Charleston, South Carolina Professor and Chair, Otolaryngology–Head and Neck Surgery
University of Washington
Daniel G. Deschler, MD, FACS Seattle, Washington
Director, Division of Head and Neck Surgery
Department of Otolaryngology–Head and Neck Surgery Markus Gapany, MD
Massachusetts Eye and Ear Infirmary Associate Professor, Otolaryngology–Head and Neck Surgery
Associate Professor, Department of Otology and Laryngology University of Minnesota
Harvard Medical School Minneapolis, Minnesota
Boston, Massachusetts
C. Gaelyn Garrett, MD
Gianlorenzo Dionigi, MD, FACS Professor, Department of Otolaryngology
Associate Professor of Surgery, Department of Surgical Sciences Vanderbilt Medical Center
University of Insubria Medical Director, Vanderbilt Voice Center
Varese, Italy Vanderbilt Bill Wilkerson Center for Otolaryngology and
Communication Sciences
Paul James Donald, MD, FRCSC Nashville, Tennessee
Professor and Vice Chair, Otolaryngology–Head and Neck Surgery
University of California, Davis Eric M. Genden, MD, FACS
Sacramento, California Professor and Chairman, Department of Otolaryngology–Head
and Neck Surgery
David W. Eisele, MD, FACS Professor of Neurosurgery
Professor and Chairman, Department of Otolaryngology–Head Mount Sinai School of Medicine
and Neck Surgery New York, New York
Irwin Mark Jacobs and Joan Klein Jacobs Endowed Chair in
Head and Neck Cancer Helmuth Goepfert, MD
UCSF Helen Diller Family Comprehensive Cancer Center Professor Emeritus, Head and Neck Surgery
University of California–San Francisco University of Texas MD Anderson Cancer Center
San Francisco, California Houston, Texas
D. Gregory Farwell, MD, FACS Andrew N. Goldberg, MD, MSCE, FACS

Associate Professor, Otolaryngology–Head and Neck Surgery Professor, Director, Division of Rhinology and Sinus Surgery
University of California–Davis Department of Otolaryngology–Head and Neck Surgery
Sacramento, California University of California–San Francisco
San Francisco, California
Fred G. Fedok, MD, FACS
Professor and Chief, Section of Facial Plastic and Reconstructive Neil D. Gross, MD, FACS
Surgery Assistant Professor, Otolaryngology–Head and Neck Surgery
Division of Otolaryngology/Head and Neck Surgery Oregon Health and Science University
Department of Surgery Attending Surgeon, Operative Care Division
Penn State Milton S. Hershey Medical Center Portland VA Medical Center
Hershey, Pennsylvania Portland, Oregon
Robert L. Ferris, MD, PhD, FACS Patrick J. Gullane, MD, CM, FRCSC, FACS, FRACS (Hon),
Professor and Vice-Chair of Clinical Operations FRCS (Hon)
Departments of Otolaryngology, Radiation Oncology, and Otolaryngologist-in-Chief, University Health Network
Immunology Wharton Chair Head and Neck Surgery–Princess Margaret
Eye & Ear Institute Hospital
Pittsburgh, Pennsylvania Professor and Chair, Department of Otolaryngology Head
and Neck Surgery
Paul W. Flint, MD University of Toronto
Professor and Chair, Otolaryngology/Head and Neck Surgery Department of Otolaryngology–Head and Neck Surgery
Oregon Health and Science University University Health Network
Portland, Oregon Toronto, Ontario, Canada
xii Reviewers
Gady Har-El, MD, FACS Jonas T. Johnson, MD

Chairman, Department of Otolaryngology–Head and Neck Professor and Chairman, Department of Otolaryngology
Surgery University of Pittsburgh School of Medicine
Lenox Hill Hospital Pittsburgh, Pennsylvania
New York, New York
Professor, Departments of Otolaryngology and Neurosurgery Larry R. Kaiser, MD
State University of New York–Downstate Medical Center President, The University of Texas Health Science Center at
Brooklyn, New York Houston
Adjunct Professor, Otolaryngology–Head and Neck Surgery Houston, Texas
New York University
New York, New York Emad Kandil, MD, FACS
Assistant Professor of Surgery, Department of Surgery
Amy C. Hessel, MD Tulane University School of Medicine
Associate Professor and Surgeon, Department of Head and New Orleans, Louisiana
Neck Surgery
University of Texas MD Anderson Cancer Center Dennis Kraus, MD
Houston, Texas Attending Surgeon, Head and Neck Surgery Service
Department of Surgery
Peter A. Hilger, MD Memorial Sloan-Kettering Cancer Center
Professor, Division of Facial Plastic Surgery Professor, Department of Otorhinolaryngology–Head and Neck
Department of Otolaryngology Surgery
University of Minnesota Cornell University Medical Center
Minneapolis, Minnesota New York, New York
Frans J. M. Hilgers, MD, PhD Ronald B. Kuppersmith, MD, MBA, FACS

Chairman-Emeritus, Head and Neck Oncology and Surgery Texas Ear, Nose, and Throat and Allergy
The Netherlands Cancer Institute–Antoni van Leeuwenhoek College Station, Texas
Hospital
Professor, Oncology-Related Voice and Speech Disorders Ollivier Laccourreye, MD
Institute of Phonetic Sciences Professor, Department of Otorhinolaryngology–Head and Neck
Amsterdam Center for Language and Communication– Surgery
University of Amsterdam University Descartes-Paris V
Consultant, Head and Neck Oncology and Surgery, Hôpital Européen Georges Pompidou
Otorhinolaryngology Member, Académie Nationale de Chirurgie
Academic Medical Center–University of Amsterdam Paris, France
Amsterdam, The Netherlands
Eric S. Lambright, MD
Henry T. Hoffman, MD, FACS Assistant Professor of Thoracic Surgery
Professor Surgical Director of Lung Transplant
Director, Voice Clinic Vanderbilt Thoracic Surgery
Department of Otolaryngology Vanderbilt University Medical Center
University of Iowa Hospitals and Clinics Nashville, Tennessee
Iowa City, Iowa
Jeffrey E. Lee, MD
F. Christopher Holsinger, MD, FACS Professor of Surgery, Department of Surgical Oncology
Associate Professor, Department of Head and Neck Surgery University of Texas MD Anderson Cancer Center
Director, Program in Minimally Invasive and Endoscopic Head Houston, Texas
and Neck Surgery
University of Texas MD Anderson Cancer Center John P. Leonetti, MD
Houston, Texas Professor and Vice-Chairman, Neurotology, Otology, and Skull
Base Surgery
David B. Hom, MD, FACS Co-Director of the Loyola Center for Cranial Base Surgery
Professor, Director, Division of Facial Plastic and Reconstructive Department of Otolaryngology–Head and Neck Surgery
Surgery Loyola University Medical Center
Department of Otolaryngology–Head and Neck Surgery Maywood, Illinois
University of Cincinnati College of Medicine and Cincinnati
Children’s Hospital Medical Center Celestino Pio Lombardi, MD
Cincinnati, Ohio Endocrine Surgery Department
Università Cattolica Del Sacro Cuore Policlinico Gemelli
David Howard, MD Rome, Italy
Professor of Head and Neck Oncology
Imperial College London William M. Lydiatt, MD, FACS
Consultant Head and Neck Surgeon Professor and Vice Chair, Department of Otolaryngology
Charing Cross Hospital Director of Head and Neck Surgery
London, United Kingdom University of Nebraska Medical Center
Professor, Department of Head and Neck Surgery
Jonathan Irish, ND, FRCSC
Nebraska Methodist Hospital
Chief, Department of Surgical Oncology
Omaha, Nebraska
Princess Margaret Hospital
University Health Network
Toronto, Ontario, Canada
Reviewers xiii
Jeffery Scott Magnuson, MD Tanya K. Meyer, MD

Associate Professor of Surgery, Residency Program Director, Assistant Professor
Department of Surgery Department of Otolaryngology
Division of Otolaryngology University of Washington
University of Alabama at Birmingham Seattle, Washington
Birmingham, Alabama
Paolo Miccoli, MD
Robert H. Maisel, MD, FACS Professor of Surgery
Professor, Department of Otolaryngology–Head and Neck Surgery Head of the Department of Surgery
University of Minnesota University of Pisa
Chief, Department of Otolaryngology–Head and Neck Surgery Pisa, Italy
Hennepin County Medical Center
Minneapolis, Minnesota Henry A. Milczuk, MD
Associate Professor
Rosario Marchese-Ragona, MD Chief, Pediatric Otolaryngology
Assistant Professor, Department of Medical and Surgical Specialties Department of Otolaryngology–Head and Neck Surgery
Section of Otolaryngology Head and Neck Surgery Oregon Health and Science University
University of Padova Portland, Oregon
Padova, Italy
Oleg Militsakh, MD, FACS
Robert G. Martindale, MD, PhD Assistant Professor, Director Head and Neck Reconstructive
Professor and Chief, Division of General Surgery Surgery
Department of Surgery Division of Head and Neck Surgery
Oregon Health and Science University Department of Otolaryngology
Portland, Oregon University of Nebraska Medical Center
Assistant Professor, Director Head and Neck Reconstructive
Sam J. Marzo, MD Surgery
Professor, Residency Program Director Department of Head and Neck Surgery
Director, Parmly Hearing Institute Nebraska Methodist Hospital–Estabrook Cancer Center
Department of Otolaryngology–Head and Neck Surgery Omaha, Nebraska
Division of Otology, Neurotology, and Skull Base Surgery
Loyola University Health System Eric J. Moore, MD
Maywood, Illinois Consultant, Otorhinolaryngology–Head and Neck Surgery
Mayo Clinic
Timothy M. McCulloch, MD Associate Professor of Otolaryngology
Professor and Chairman, Division of Otolaryngology Head and Mayo College of Medicine
Neck Surgery Rochester, Minnesota
University of Wisconsin Hospital and Clinics
Madison, Wisconsin Meijin Nakayama, MD
Associate Professor, Otorhinolaryngology
Andrew J. McWhorter, MD Kitasato University School of Medicine
Director of Voice Center Sagamihara, Kanagawa, Japan
Assistant Professor, Department of Otolaryngology–Head and
Neck Surgery Roger C. Nuss, MD, FACS
Louisiana State University Health Sciences Center Assistant Professor of Otology and Laryngology
New Orleans, Louisiana Harvard Medical School
Children’s Hospital
Jesus E. Medina, MD, FACS Boston, Massachusetts
Paul and Ruth Jonas Professor, Department of
Otorhinolaryngology Kerry D. Olsen, MD
University of Oklahoma Health Sciences Center Professor, Otolaryngology Head and Neck Surgery
Oklahoma City, Oklahoma Mayo Clinic
Rochester, Minnesota
Eduardo Méndez, MD, MS
Assistant Professor, Department of Otolaryngology–Head and Steven M. Olsen, MD
Neck Surgery Resident, Otolaryngology Head and Neck Surgery
University of Washington Mayo Clinic
Assistant Member, Clinical Research Division Rochester, Minnesota
Fred Hutchinson Cancer Research Center
Seattle, Washington Lisa A. Orloff, MD, FACS
Robert K. Werbe Distinguished Professor of Head and Neck
Albert L. Merati, MD, FACS Cancer
Associate Professor and Chief, Laryngology Director, Division of Head and Neck and Endocrine Surgery
Department of Otolaryngology–Head and Neck Surgery Department of Otolaryngology, Head and Neck Surgery
University of Washington School of Medicine University of California–San Francisco
Adjunct Associate Professor, Department of Speech and Hearing San Francisco, California
Sciences
College of Arts and Sciences
University of Washington
Seattle, Washington
xiv Reviewers
Robert H. Ossoff, MD, DMD John A. Ridge, MD, PhD

Guy M. Maness Professor of Laryngology and Care of the Professor, Senior Member, and Chief, Head and Neck Surgery
Voice Section
Department of Otolaryngology Departments of Surgery and Developmental Therapeutics
Assistant Vice-Chancellor, Office of Compliance and Corporate Fox Chase Cancer Center
Integrity Professor, Departments of Surgery and Otolaryngology–Head
Vanderbilt Medical Center and Neck Surgery
Nashville, Tennessee Temple University
Philadelphia, Pennsylvania
Giorgio Peretti, MD
Associate Professor, Department of Otorhinolaryngology–Head Clark A. Rosen, MD, FACS
and Neck Surgery Professor, Department of Otolaryngology
University of Brescia University of Pittsburgh School of Medicine
Brescia, Italy Director, University of Pittsburgh Voice Center
University of Pittsburgh Medical Center
Nancy D. Perrier, MD, FACS Pittsburgh, Pennsylvania
Professor of Surgery, Department of Surgical Oncology
University of Texas MD Anderson Cancer Center Eben L. Rosenthal, MD
Houston, Texas Julius Hicks Professor of Surgery, Division of Otolaryngology–
Head and Neck Surgery
Cesare Piazza, MD University of Alabama at Birmingham
Assistant Professor, Department of Otorhinolaryngology–Head Birmingham, Alabama
and Neck Surgery
University of Brescia John R. Saunders, Jr., MD, MBA
Brescia, Italy Executive Vice-President, Chief Medical Director
Medical Director, Milton J. Dance, Jr. Head and Neck Center
Joe B. Putnam, Jr., MD Greater Baltimore Medical Center
Professor of Surgery and Chairman, Department of Thoracic Associate Professor, Otolaryngology–Head and Neck Surgery
Surgery Surgery, Plastic Surgery
Ingram Professor of Cancer Research Johns Hopkins School of Medicine
Vanderbilt Ingram Cancer Center Baltimore, Maryland
Professor of Biomedical Informatics
Vanderbilt University Medical Center Joshua S. Schindler, MD
Nashville, Tennessee Assistant Professor, Department of Otolaryngology
Medical Director, OHSU-Northwest Clinic for Voice and
Gregory W. Randolph, MD, FACS Swallowing
Director of General, Thyroid, and Parathyroid Surgical Oregon Health and Science University
Divisions Portland, Oregon
Massachusetts Eye and Ear Infirmary
Member, Division of Surgical Oncology and Endocrine Surgical David E. Schuller, MD
Service Vice President, Medical Center Expansion and Outreach
Massachusetts General Hospital Otolaryngology–Head and Neck Surgery
Boston, Massachusetts John W. Wolfe Chair in Cancer Research
Associate Professor of Otology and Laryngology College of Medicine
Harvard Medical School CEO Emeritus, Arthur G. James Cancer Hospital and Richard
Cambridge, Massachusetts J. Solove Research Institute
The Ohio State University
Marc Remacle, MD, PhD Columbus, Ohio
Professor, Associate Head, Otorhinolaryngology–Head and
Neck Surgery Aniel Sewnaik, MD, PhD
Louvain University Hospital of Mont-Godinne Head and Neck Surgeon, Otorhinolaryngology Head and Neck
Mont-Godinne, Belgium Surgery
Erasmus MC-Daniel Den Hoed Cancer Center
Alan T. Richards, MD, FACS Rotterdam, The Netherlands
Associate Professor, Otolaryngology–Head and Neck Surgery
University of Nebraska Medical Center Ashok R. Shaha, MD, FACS
Associate Professor, Head and Neck Surgery Jatin P. Shah Chair in Head and Neck Surgery
Nebraska Methodist Hospital Head and Neck Service
Omaha, Nebraska Department of Surgery
Memorial Sloan-Kettering Cancer Center
William J. Richtsmeier, MD, PhD Professor of Surgery, Department of Surgery
Director, Clinician Research, Department of Otolaryngology– Weill Cornell Medical College
Head and Neck Surgery Cornell University
Bassett Healthcare Network New York, New York
Cooperstown, New York
Maisie Shindo, MD, FACS
Professor, Otolaryngology
Thyroid and Parathyroid Division
Portland, Oregon
Reviewers xv
William W. Shockley, MD, FACS David J. Terris, MD, FACS

W. Paul Biggers Distinguished Professor Porubsky Professor and Chairman
Chief, Division of Facial Plastic and Reconstructive Surgery Surgical Director, MCG Thyroid/Parathyroid Center
Department of Otolaryngology/Head and Neck Surgery Department of Otolaryngology–Head and Neck Surgery
University of North Carolina School of Medicine Medical College of Georgia
Attending Physician, Department of Otolaryngology/Head and Augusta, Georgia
Neck Surgery
UNC Hospitals Ralph P. Tufano, MD, FACS
Chapel Hill, North Carolina Associate Professor, Department of Otolaryngology–Head
and Neck Surgery
James Sidman, MD Director of the Johns Hopkins Hospital Multidisciplinary
Director of Cleft and Craniofacial Programs Thyroid Tumor Center
Co-Director of Vascular Anomalies Program Director, Thyroid and Parathyroid Surgery
Department of Otolaryngology Johns Hopkins School of Medicine
Children’s Hospitals and Clinics of Minnesota Baltimore, Maryland
Professor of Otolaryngology and Pediatrics
University of Minnesota Joseph Valentino, MD
Minneapolis, Minnesota Professor, Department of Surgery
Division Of Otolaryngology–Head and Neck Surgery
C. Blake Simpson, MD University of Kentucky College of Medicine
Professor, Department of Otolaryngology–Head and Neck Chief of Head and Neck Surgery
Surgery Department of Surgery
Director, The University of Texas Voice Center Lexington Kentucky Veterans Medical Center
University of Texas Health Science Center at San Antonio Lexington, Kentucky
San Antonio, Texas
Isabel Vilaseca, MD, PhD
Catherine F. Sinclair, MD, FRACS Consultant, Otorhinolaryngology
Instructor/Fellow Head and Neck Surgery Hospital Clinic
Department of Surgery Associate Professor of Otorhinolaryngology
Division of Otolaryngology Head and Neck Surgery Department for Surgical Specialties
University of Alabama at Birmingham University of Barcelona
Birmingham, Alabama Barcelona, Spain
James D. Smith, MD Stephen J. Wang, MD, FACS

Professor Emeritus, Otolaryngology Head and Neck Surgery Associate Professor, Department of Otolaryngology–Head and
Oregon Health and Science University Neck Surgery
Portland, Oregon University of California–San Francisco
San Francisco, California
Timothy L. Smith, MD, MPH
Professor and Chief, Rhinology and Sinus Surgery Mark K. Wax, MD, FACS, FRCSC
Department of Otolaryngology–Head and Neck Surgery Professor, Otolaryngology–Head and Neck Surgery
Oregon Health and Science University Professor, Oral and Maxillofacial Surgery
Portland, Oregon Program Director
Director, Microvascular Reconstruction
Carl Henry Snyderman, MD Coordinator, Education, AAOHNS(F)
Professor, Department of Otolaryngology Department of Otolaryngology–Head and Neck Surgery
University of Pittsburgh Medical Center Oregon Health Sciences University
Pittsburgh, Pennsylvania Portland, Oregon
Robert A. Sofferman, MD Randal S. Weber, MD

Professor of Surgery and Chief Emeritus Professor and Chair, Head and Neck Surgery
Department of Surgery University of Texas MD Anderson Cancer Center
Division of Otolaryngology Houston, Texas
University of Vermont School of Medicine
Burlington, Vermont Richard J. Wong, MD
Associate Attending Surgeon, Department of Surgery
Jeffrey D. Spiro, MD Memorial Sloan-Kettering Cancer Center
Professor of Surgery, Division of Otolaryngology/Head and New York, New York
Neck Surgery
University of Connecticut School of Medicine Steven M. Zeitels, MD, FACS
Farmington, Connecticut Eugene B. Casey Professor of Laryngeal Surgery
Department of Surgery
Wolfgang Steiner, MD Harvard Medical School
Professor Emeritus, Department of Otorhinolaryngology–Head Director, Center for Laryngeal Surgery
and Neck Surgery Department of Surgery
University of Goettingen Massachusetts General Hospital
Goettingen, Germany Boston, Massachusetts
Preface
Learning how to do an operation can be a daunting they thought appropriate, whether to provide emphasis,
task, whether as a first-year resident preparing the night clarification, or alternate strategies. This commentary is
before a case never previously encountered or as a provided in essentially unedited form, interposed in the
surgeon in a busy practice faced with incorporating a original author’s text, because we thought that this
new technique or technology into his or her surgical would best simulate a “virtual conversation” taking
repertoire. This book acknowledges the realities of how place around an operation, such as one that would
this process occurs. Initially, “rote” learning of the steps occur at a surgical technique meeting session where a
involved may be all that can be expected. Over time, it panel is asked to discuss a given operation. We were
is hoped that an increased understanding of the logic surprised and gratified to see the enthusiasm with which
behind these steps and their sequence will be acquired, the commentators approached the task. Finally, at the
and this is where most surgical atlases stop. We know, end of many of the chapters, we have provided summary
however, that different surgeons perform the same oper- comments, when applicable, that seek to clarify common
ations in different ways, and these different techniques themes, reconcile significant conflicts, or emphasize
can work equally well. Although this can be confusing critical issues.
and disconcerting to early trainees as they work with Through the use of different fonts, color schemes,
different attending staff or preceptors, ultimately, being and paragraph structure, the publisher has preserved the
able to reconcile the success of these different approaches concept of the sequence of the writing process. This
requires a firm grasp of the unifying concepts behind allows the reader, depending on his or her knowledge
any procedure. Helping the reader reach this level while base or time constraints, to read (or reread) the opera-
still supporting the early phases of learning is the goal tion at the most appropriate level for his or her need at
of this book. that point in time. We think that it allows a logical
The book is designed to be read in the same way it sequence of knowledge acquisition, whether it be
is assembled. We selected authors with a known exper- rudimentary memorization, review of the steps, a more
tise in given procedures and asked them to break down in-depth understanding of the logic of these steps, or an
the operations into their component steps, much as they analysis of the guiding principles that underpin the
would direct an early learner the first time through the operation as a whole, through the commentary.
procedures in the operating room. We then asked the We hope the reader enjoys this approach as much as
authors to provide their logic, for both their technique we have enjoyed assembling it. We think that the disci-
and the sequence of these steps. This information was pline of the framework it provides is valid not only for
interposed into the initial “step sequence” in a sepa- the operations outlined here but also for a lifelong learn-
rately identifiable way. Key references are provided, ing process that will allow for the newer techniques and
where needed. technology that we all will and must confront over the
With the chapters assembled with their artwork, course of our professional lives.
each chapter was then sent to two to four surgeons James I. Cohen
with known expertise in the subject matter. They were Gary L. Clayman
asked to interject commentary into the chapter wherever Editors in Chief
xvii
SECTION A Adult Endoscopy
CHAPTER
Clinical Diagnostic Nasopharyngoscopy
1 Author Joshua S. Schindler
Commentary by Andrew N. Goldberg and Timothy L. Smith
Positioning Fiberoptic Nasopharyngoscopy

The procedure should be performed with the patient in The nasal cavity is treated with topical nasal deconges-
the seated position with the head supported from tant and local anesthetic using an aerosolizer. The physi-
behind. The chin should be in a neutral position with cian stands in front of the patient and directs the scope
the chin centered between the shoulders. into the nasal cavity (Figure 1-2A).
Although the procedure can be performed in any
position, secretion management is easiest with the head During fiberoptic nasopharyngoscopy, patients often
elevated. A headrest prevents withdrawal by the patient attempt to tilt the head backward to “assist” the
during the procedure. A centered chin prevents apparent entry of the scope into the nose but this generally
asymmetries in the nasopharynx from rotation of the increases the difficulty of passing the scope through
cervical spine. the nasal cavity. The head should be in a neutral
position. TLSmith
Indirect Nasopharyngoscopy
Nasopharyngoscopy may be performed transorally with Studies have failed to demonstrate a significant
a small mirror. The physician gently grasps the tongue patient benefit from topicalization of the nasal cavity.
and, using a head mirror or headlight, directs focused Despite this, we find that the decongestant spray (oxy-
light to the mirror placed just beneath and behind the metazoline or phenylephrine [Neo-Synephrine]) does
soft palate (Figure 1-1). facilitate placement of the fiberoptic scope. Anesthetic
(e.g., lidocaine, tetracaine [Pontocaine], mepivacaine
[Carbocaine]) should take effect within 90 seconds and
The patient’s saliva on the buccal mucosa can be
may be mixed with the nasal decongestant; 2% water-
used to defog the mirror prior to insertion in the
soluble lidocaine jelly also may be used and can facili-
nasopharynx. TLSmith
tate fiberoptic scope placement. We typically treat both
nasal cavities to allow placement of the fiberoptic scope
Although nasopharyngoscopy may be performed through either passageway.
this way, mirror nasopharyngoscopy yields a compara-
tively limited view of the nasopharynx. It is technically
challenging and cannot provide an adequate examina- For a right-handed examiner, standing in front of and
tion in all patients. We therefore defer mirror laryn- slightly to the patient’s right allows the examiner to
goscopy for flexible fiberoptic examination in most stand closer to the patient in a more comfortable
cases. position.
Although there is controversy over the utility of
In fact, I have not performed indirect topicalization in the nose, use of decongestant and
nasopharyngoscopy for years given the ready anesthetic is common practice.
availability and superior visualization of the Although anesthetics begin to take effect in
nasopharyngoscope. TLSmith 90 seconds, anesthesia is optimal between 5 and
3
4 UNIT I Benign Upper Aerodigestive Disease
FIGURE 1-1. Indirect mirror nasopharyngoscopy.
inspection of the choana, the eustachian tube orifice, the

10 minutes. Timing your topicalization and examination
torus tubarius, and the fossa of Rosenmueller on each
will increase comfort of the examination.
side. Midline structures including the adenoid pad, the
Warning the patient in advance that application of
roof of the nasopharynx, Passavant’s ridge and the pos-
topical anesthetic may make it feel difficult to swallow
terior mucosa of the soft palate should also be inspected.
or may make the front teeth feel numb allays some
Motion and closure of the soft palate should also be
patients’ anxiety if these sensations occur. Noting
tested by asking the patient to say “cake” or “kitty cat”
that the effects typically last less than an hour
(Figure 1-3).
similarly provides information that many patients
In most cases, all of these structures may be visual-
appreciate. ANGoldberg
ized through unilateral nasal cavity placement. Other
functional testing, such as Mueller’s maneuver to test
The fiberoptic scope is passed transnasally to the for pharyngeal airway collapse with inspiration, may be
nasopharynx. Continuous visualization is performed to performed with fiberoptic nasopharyngoscopy. The
determine the widest and most comfortable transnasal examiner should take note of relatively subtle asym-
approach (see Figure 1-2B). metries in the nasopharynx because many lesions in this
We prefer to use the floor of the nasal cavity to pass area are submucosal.
the fiberoptic scope because this is the least sensitive to
pain and is commonly the widest passage. If the bilateral
nasal floors are impassable, we approach the nasophar-
ynx between the middle meatus and septum. Although nasopharyngoscopy begins at the choana,
the opportunity to examine the nasal cavity during the
This approach is directly below the middle turbinate same examination should not be missed.
and commonly used in my experience. TLSmith Administration of topical anesthetic and decongestant
to both sides of the nose and examination of the nasal
cavity provides a complete endoscopic examination
Diagnostic nasopharyngoscopy examination begins with minimal additional morbidity. ANGoldberg
at the choana. A thorough examination includes
CHAPTER 1 Clinical Diagnostic Nasopharyngoscopy 5
Middle turbinate
Superior meatal passage

(“High road”)
Inferior turbinate
Nasal septum
Inferior meatal passage

(“Low road”)
FIGURE 1-2. A, Flexible fiberoptic nasopharyngoscopy. B, Fiberoptic

B view of anterior nasal cavity.
Nasopharynx roof
Torus tubarius
Adenoid pad
Fossa of
Rosenmueller
Uvula
Eustachian
tube
Soft palate
FIGURE 1-3. Nasopharynx view through flexible fiberoptic scope.
Suggested Readings
EDITORIAL COMMENT: Fiberoptic technology has
significantly improved the odds of complete Burkey BB, Ossoff RH: Endoscopy of nasopharyngeal cancer.
examination of the nasopharynx compared with Diagn Ther Endosc 1:63-68, 1994.
mirror examination alone—the issue is not whether Ritter CT, Trudo FJ, Goldberg AN, Welch KC, Maislin G,
the nasopharynx can be well seen with a mirror Schwab RJ: Quantitative evaluation of the upper airway
during nasopharyngoscopy with the Muller maneuver.
but rather that the technique requires considerable
Laryngoscope 109:954-963, 1999.
experience, and even with this is poorly tolerated
Strauss RA: Flexible endoscopic nasopharyngoscopy. Atlas
in the majority of patients. Oral Maxillofac Surg Clin North Am 15:111-128, 2007.
As pointed out the use of topical decongestant
with or without topical anesthetic is not mandatory
but probably preferred by most clinicians. The key
if it is used is to wait sufficiently for both
decongestion and anesthesia to take effect. Plan
your office visit/examination and patient flow
in such a way that the necessary time (5 to
10 minutes) is built in without rushing this. JICohen
CHAPTER
Diagnostic Clinical Pharyngoscopy
2 and Laryngoscopy
Author Joshua S. Schindler
Comments by Robert H. Maisel and Albert L. Merati
Positioning Telescopic Examination

Indirect laryngoscopy and pharyngoscopy should be Transoral laryngopharyngoscopy may also be performed
performed with the patient in the seated position with with a rigid angled telescope. The physician grasps the
the back straight and flexed forward about 20 degrees patient’s tongue and passes the telescope transorally to
from perpendicular. The chin should be in a “sniffing” the vallecula. The larynx may be visualized by then
position with the chin centered between the shoulders asking the patient to phonate while adjusting the tele-
and slightly elevated. scope to see the endolarynx (Figure 2-2).
This position may be used for all types of laryngos- Rigid, telescopic laryngopharyngoscopy offers one
copy (mirror, flexible fiberoptic, or rigid). The head of the best views of the posterior upper aerodigestive
flexion and extension may be adjusted to facilitate visu- tract. The telescopes may be magnified (up to 10×) and
alization of laryngeal and pharyngeal structures with provide unparalleled clarity. Most patients will tolerate
different visualization techniques. this procedure without anesthesia, but topical applica-
tion of local anesthetic (benzocaine/butyl aminobenzo-
ate/tetracaine [Cetacaine]) may be performed to diminish
Successful endoscopy begins with correct positioning
gagging. Relaxation of the jaw and tongue with retrac-
and verbal preparation of the patient. All the
tion by the examiner will prevent elevation of the base
endoscopic skill and topical anesthesia in the world
of tongue that prevents visualization. Asking the patient
can’t overcome a poorly positioned or ill-prepared
to smile widely facilitates elevation of the soft palate.
patient. This cannot be overemphasized. ALMerati
Both 70- and 90-degree telescopes are available to
achieve optimal visualization in the widest number of
Mirror Examination patients.
Transoral laryngopharyngoscopy may be performed

with a mirror. The physician gently grasps the tongue
and, using a head mirror or headlight, directs focused
Flexible Examination
light to the mirror placed onto or just beneath the Transnasal laryngopharyngoscopy may be performed
soft palate. The soft palate is gently elevated and the with a flexible laryngoscope. The procedure is per-
mirror is angled inferiorly to perform the examination formed as in nasopharyngoscopy (see Chapter 1). Once
(Figure 2-1). in the nasopharynx, the scope is passed through the
In contrast to nasopharyngoscopy, mirror laryngos- velopalatal closure while asking the patient to gently
copy can yield a magnificent view of the larynx and sniff (Figure 2-3).
pharynx without topical anesthesia. Procedures such as Flexible transnasal laryngopharyngoscopy may be
vocal cord injection and laryngeal or pharyngeal biopsy performed in all patients and is generally well toler-
may be performed with this technique if the patient ated. It affords the most access (including the subglottis
grasps his or her own tongue to free the physician’s and cervical trachea, in some cases) and allows for
second hand. Warming the mirror to body temperature both structural and functional examination of the
or applying a detergent-based defogging solution facili- larynx, oropharynx and upper portion of the
tates visualization. hypopharynx.
7
FIGURE 2-1. Indirect mirror laryngoscopy.
FIGURE 2-2. Indirect rigid telescope laryngoscopy.

CHAPTER 2 Diagnostic Clinical Pharyngoscopy and Laryngoscopy 9
FIGURE 2-3. Flexible fiberoptic laryngoscopy.
Posterior
Even in very experienced hands, there are patients in pharyngeal wall True vocal folds
whom flexible fiberoptic laryngoscopy is difficult,
nearly impossible, and even impossible. This is usually Piriform sinus
the result of a combination of the following: (1) patient
physical sensitivities such as an extreme gag reflex;
(2) poor preparation of the patient, that is, talking
through the examination, informing the patient about
the process, positioning, and anesthesia; (3) patient
psychologic preparation. Although they may
intrinsically be limited in their capacity to tolerate this
simple examination, many patients have become
“unexaminable” following a previous traumatic
examination. This latter situation is best handled by
addressing it directly, and doing so prior to any
attempt to examine the patient. ALMerati Epiglottis
Comprehensive flexible fiberoptic laryngoscopic

Base of tongue
examination should include examination of the base of
tongue, vallecula, epiglottis, aryepiglottic folds, glosso-
epiglottic fold, superior hypopharynx, posterior pha-
FIGURE 2-4. View of larynx through flexible fiberoptic
ryngeal wall, arytenoids, false vocal folds, true vocal laryngoscope.
folds, and immediate subglottis. Functional examina-
tion should include true vocal fold abduction and Flexible scopes are available to the operator in several
adduction (Figure 2-4). different sizes by diameter of tip cross section,
With the flexible endoscope in place, a number of allowing more patient comfort, pediatric examination,
techniques can be used to facilitate visualization. Pro- and suction or biopsy channel. The pediatric scope is
trusion of the patient’s tongue will often demonstrate 1.5 mm, the adult flexible scopes are 3.6 mm, and the
the vallecula and may show the lingual surface of the channeled scope is 6.1 mm in diameter. The video
epiglottis. Insufflation of the cheeks may be used to scope with “chip in tip” is 3.9 mm, and other scopes
open the pharynx in some patients and allow visualiza- have a tip diameter of 3.2 mm. Decision on which
tion of the hypopharynx. Alternatively, left and right scopes fit the internal anatomy is achieved actively
head turn usually allows inspection of the contralateral during the procedure. RHMaisel
piriform sinus—sometimes to the apex.
The glottis is generally quite easy to see in relaxed

voicing and respiration. Sniff can be used to demon- However, for the reasons mentioned, mirror
strate maximal vocal fold abduction and is useful in examination and rigid fiberoptic telescopes still
patients with laryngeal stenosis and true vocal fold have a place and can provide views not achievable
motion impairment. Some patients have pressed, hyper- with the smaller flexible telescopes. All techniques
functional voicing with closure of their false vocal folds require practice, a cooperative and well-prepared
during phonation, known as plica ventricularis. Visual- patient, and a structured approach to ensure
ization of the true vocal folds and glottic closure may that all necessary information is specifically
be obtained in such patients by asking them to phonate sought out.
on inspiration. A planned examination under anesthesia in no
Functional examinations, such as videostroboscopy way should be seen as a substitute for what can
and functional endoscopic evaluation of swallowing, be seen in the office but rather should be viewed
may also be performed using basic laryngopharyngos- as complementary to what is already known from
copy techniques. the office visit. In most circumstances with
modern technology the majority of information is
gleaned from the office examination; the clinician
should make a specific “checklist” of the unique
Video and still photo capture is possible for patient
additional information still needed and achievable
education during a consultation and can be archived
by examination under anesthesia before a decision
to compare with the direct laryngoscopic view and
to go forward with this is made. JICohen
subsequent office examination to permit objective
observation of the effects of the medication or speech
therapy. RHMaisel Suggested Readings
Hiss SG, Postma GN: Fiberoptic endoscopic evaluation of
swallowing. Laryngoscope 113:1386-1393, 2003
EDITORIAL COMMENT: The odds of success in Rosen CA, Amin MR, Sulica L, Simpson CB, Merati AL,
office-based comprehensive examination of the Courey MS, et al: Advances in office-based diagnosis and
upper aerodigestive tract have been greatly treatment in laryngology. Laryngoscope 119:S185-S212,
enhanced by fiberoptic technologies so that now 2009.
not only is visualization improved but a more Verikas A, Uloza V, Bacauskiene M, Gelzinis A, Kelertas E:
complete assessment of function is possible. Advances in laryngeal imaging. Eur Arch Otorhinolaryngol
266:1509-1520, 2009.
CHAPTER
Operative Pharyngoscopy
3 and Laryngoscopy
Commentary by Robert H. Ossoff, Clark A. Rosen, and Steven M. Zeitels
General Considerations The role of preoperative communication and planning

Direct laryngoscopy and pharyngoscopy are procedures with the anesthesia and nursing teams cannot be
fundamental to the practice of otolaryngology and overemphasized. This should include not only initial
essential components of a complete head and neck airway management strategies but also several backup
examination. The ability to obtain direct line-of-sight options. This sequence of airway “management
visualization of the entire upper aerodigestive tract is as options” should be determined preoperatively.
critical as it is challenging. Although flexible examina- Similarly, an intraoperative and postoperative airway
tion provides a tremendous amount of information and plan should be discussed and agreed on by the
may obtain tissue for biopsy, direct examination allows anesthesia, nursing, and surgical teams. This
the surgeon to palpate the tissue, to assess character discussion typically focuses on issues such as
istics of lesions such as depth and adherence to deeper endotracheal tube size and placement, use of jet
tissues, and visualize regions of the upper aerodigestive ventilation, placement of tracheotomy, and use of
tract that cannot be seen in the office (e.g., lateral extent apneic technique. This type of discussion should also
of the ventricle, the undersurface of the vocal folds, the ensure that emergency airway equipment, jet
piriform sinuses). ventilation equipment, heliox, and a Combitube are
Laryngoscopy and pharyngoscopy are somewhat available and agreed on by all members of the
unique among head and neck procedures in that they operative team. CARosen
are both diagnostic and therapeutic. As such, it is not
uncommon for the surgeon to identify unexpected
pathology or to find that the pathology is different than I am in complete agreement with the points raised by
that anticipated by previous clinical and radiographic Dr. Schindler and elaborated on by Dr. Rosen
examinations. This uncertainty mandates that the regarding preoperative and intraoperative
surgeon have broad experience in techniques and a wide communication. There is no such thing as an easy
array of instruments to manage whatever he or she finds “airway” case. RHOssoff
at the time of the procedure.
Of particular importance in the performance of
laryngoscopy is the ability of the surgeon to manage and In most situations the lesions of greatest concern to
maintain an adequate airway before, during, and after the otolaryngologist are malignancies of the larynx, oro-
the procedure. All laryngoscopy procedures should be pharynx, and hypopharynx, and evaluation for such
considered airway procedures. Before proceeding to the lesions should be performed during all direct laryngos-
operative suite, the surgeon should have the requisite copy procedures. That said, there are many reasons to
skill, support, and equipment necessary to manage the perform direct laryngoscopy including evaluation and
most difficult airway safely. Emergencies do happen and removal of masses, acquiring and maintaining an airway,
advance preparation is the only defense against cata removal of foreign bodies, improvement in glottic com-
strophe. This preparation includes a careful preopera- petence, assessment and management of scar tissue and
tive assessment of the patient’s airway anatomy and stenosis, and improving swallowing function. Although
respiratory requirements, an honest assessment of the many of these aims require different techniques and
surgeon’s skill, thorough discussion and close commu- instrumentation, the basic procedures of laryngoscopy
nication with supporting anesthesia and nursing staff, and pharyngoscopy should be performed in the same
inspection of the operative equipment for completeness fashion, order, and method in all patients to ensure that
and proper function, and multiple plans for managing the surgeon performs an adequate examination and
a difficult airway. does not overlook any unexpected pathology.
11
The usual and customary sequence of performing

laryngoscopy and pharyngoscopy also allows the
perioperative team to better support the surgeon.
RHOssoff
Equipment for Laryngoscopy

and Pharyngoscopy
Considerations on Scopes
Adequate instrumentation is essential to ensure a safe,
complete, and effective laryngoscopy procedure. Instru-
ments can be divided into two basic groups: (1) those
aimed at evaluation and exposure of the patient’s
anatomy and (2) those needed to perform the expected
procedure. Although it is important to plan ahead for FIGURE 3-1. The Holinger anterior commissure (AC)
laryngoscopy and have the equipment needed to perform hourglass laryngoscope.
the expected procedure, it is not uncommon to find
unexpected pathology and require additional equipment
for the evaluation and management of whatever the
surgeon finds. In addition, having instruments available
for alternate methods of both examination and treat-
ment is essential to prevent the added risk of future
procedures.
We maintain all of the necessary equipment in a
standardized location. Although a surgical tray or two
may be used to hold the equipment while not in use, we
strongly recommend a surgical cart with multiple
drawers that can be brought to the surgical suite. This
affords the surgeon immediate access to all of the equip-
ment that might be needed to perform the expected
procedure as well as any additional procedures that
may be required without contaminating multiple sets of
instruments. In addition, the cart allows organization
of the instruments in order to quickly determine if all FIGURE 3-2. The Dedo microlaryngoscope.
of the necessary equipment is available and ensure rapid
delivery of the necessary instruments to the surgeon if
necessary. variety of patients. Laryngoscopes and pharyngoscopes
come in many shapes and sizes designed to obtain
Access to an adequate and appropriate endoscopic
different views of the laryngeal anatomy in different
armamentarium cannot be overemphasized. Lack of
patients. Although a comprehensive discussion of laryn-
availability of proper instrumentation can lead to all
goscope design and options is well beyond the scope of
sorts of misadventures in the upper aerodigestive tract
this chapter, a brief description of some of the more
including less-than-favorable outcomes. RHOssoff
common scopes is warranted to allow familiarity and a
frame of reference for the reader.
After becoming familiar with the laryngoscopes
Diagnostic laryngoscopy and pharyngoscopy in their available at their institution, the reader is encouraged
purest form require only a scope, a suction, a light to learn about other brands and models by inspecting
source, and a tooth protector. Although this may seem laryngoscopes at vendor stands at meetings and obtain-
simple, the options for all of these items are vast. There ing catalogs from several of the manufacturers. It is
is significant debate over the most useful laryngoscopes important to remember that no single laryngoscope is
and technique, and preferences vary from institution to optimal for all patients and all procedures.
institution. Simply put, any technique and scope that Probably the two most commonly encountered
provides adequate exposure in a safe fashion is useful. laryngoscopes in the United States for adult procedures
The surgeon should have familiarity with many are the Holinger anterior commissure (AC) scope (Figure
options in order to obtain a successful result in a wide 3-1) and the Dedo microlaryngoscope (Figure 3-2).
CHAPTER 3 Operative Pharyngoscopy and Laryngoscopy 13
Although many surgeons are facile with these two strument use following introduction of the operating
models and can perform diagnostic procedures in nearly microscope in direct microlaryngoscopy. The shaft is
all patients, both scopes have limitations that make much wider and tapers only gently toward the tip. There
them unsuitable in some situations. is little anterior flare. Some models have bilateral light
Although they are commonly requested and described carriers and suction ports for aspirating smoke plumes
by name, each of these laryngoscopes actually comes in in laser-assisted laryngoscopy. Although this laryngo-
several different forms and may be available from more scope is tremendously useful because it yields wide
than one manufacturer. Despite subtle differences, the laryngeal exposure, it may not be suitable for patients
basic features are preserved. with an anteriorly positioned or high larynx.
The Holinger AC scope has a very narrow shaft and
a flared distal end to allow maximal exposure of the
anterior commissure. These features allow a monocular
view of the anterior-most surfaces of the larynx and The Dedo laryngoscope expanded the caliber of the
subglottis in even the most difficult to expose patients. Holinger design to accommodate the surgical
As such, this is an excellent scope to have available microscope and the 400-mm front lens; however,
for both diagnostic examinations and obtaining an the hourglass shape continued to partially restrict
airway in patients whose larynx is difficult to visualize. binocular stereoscopic microlaryngoscopic viewing.
Unfortunately, its advantages come at the cost of a very For this reason we introduced the Universal Modular
limited field of view and inability to afford binocular Glottiscope,2 which was designed specifically to
vision for microlaryngoscopy procedures or bimanual examine and perform glottic surgery. It provides a full
instrumentation. binocular glottal field, and the distal lumen is
conformed as a lancet arch to accommodate the inner
contours of the thyroid laminae, which is especially
It is important to note that the Holinger AC scope is valuable for treating glottic cancer. This feature
not appropriate for most operative procedures of the distracts the vestibular folds to provide enhanced
pharynx and larynx other than for viewing only. In viewing of the superior vocal fold region, a concept
most situations this laryngoscope should not be initially introduced by Jackson3 in the 1920s as
suspended and used for biopsy, given a lack of laryngostasis. Killian4 and Jackson3 both recognized
binocular vision, increased ability to be disoriented, decades ago that an “inverted V” distal contour
and poor exposure at the operative site in case of optimally exposed the glottis given its intrinsic
bleeding. CARosen shape. SMZeitels
Although a thorough discussion of all available

The Holinger laryngoscope 1 was introduced in 1960 laryngoscopes is not possible, it is useful to know that
in an era when the assistant functioned as the head there is an instrument designed to overcome almost all
holder to alter the position of the line-of-sight vector exposure problems in laryngoscopy and allow optimal
for the laryngoscopist.1 This allowed for distal viewing performance of different procedures. Procedure-specific
despite the narrow central hourglass waist. The narrow laryngoscopes are designed for visualization of the
central region was designed to accommodate the supraglottis, posterior commissure, anterior commis-
common restriction of large scope placement by the sure, and subglottis.
posterior floor of mouth along with the insertion of the
palatoglossus and palatopharygeus muscles with the
A primary advantage of bivalve laryngoscopes is that
tongue. The Holinger laryngoscope was designed for
the surgeon has substantially greater degrees of
performing visual examination and one-handed
freedom while angulating hand instruments. SMZeitels
surgery without magnification as it was introduced
prior to the era of microlaryngoscopy. SMZeitels
Other scopes are designed for evaluation of the
oropharynx and hypopharynx. Laryngoscopes have
numerous features such as multiple light carriers, suction
The Holinger AC laryngoscope can be suspended and ports, jet ventilation ports, and telescopic video ports.
used with telescopes and microlaryngeal instruments Some laryngoscopes have sliding channels to allow
in otherwise difficult to expose individuals. RHOssoff placement of an endotracheal tube and greater range of
motion for instruments, distending distal and proximal
tips to allow optimal exposure of the larynx and greater
The Dedo laryngoscope was designed in an effort instrument access, and removable handles to facilitate
to allow binocular visualization and bimanual in placement and suspension.
supraglottis, glottis, subglottis, or hypopharynx; trauma

I agree that the Holinger AC scope is a good “starting”
or burn to upper aerodigestive tract structures; stridor;
laryngoscope and can be important from a diagnostic
dysphagia with symptoms or findings suspicious for
perspective, and the Dedo laryngoscope is often a
lesion or stricture of the upper aerodigestive tract; throat
“workhorse” for simple pharyngoscopy and
pain without obvious source; need to obtain an ade-
laryngoscopy procedures. However, it is important to
quate airway; evaluation for second primary lesion with
note that neither of these laryngoscopes is appropriate
known upper aerodigestive tract malignancy; and
for high-quality detailed microlaryngoscopy
obtaining and maintaining a stable airway for endo-
procedures if a larger laryngoscope can be used.
scopic tracheobronchial procedures.
Multiple manufacturers make laryngoscopes larger
There are few contraindications to laryngoscopy
than the Dedo laryngoscope, and these laryngoscopes
and pharyngoscopy, but strict contraindications should
can be suspended above the area of interest and
include cardiopulmonary instability with a stable airway,
provide significantly greater exposure and operative
neck instability (e.g., fracture), and immobility of the
ease, thus increasing surgeon precision and improving
mandible precluding adequate jaw excursion.
operative outcome. The take-home point must be
Although operative endoscopy may be performed
emphasized that the largest possible laryngoscope
under sedative/local anesthesia, optimal control, preci-
that can be safely inserted and suspended above the
sion, and evaluation are attained under general anesthe-
operative site in question should be used, as opposed
sia. Judicious use of intermediate-length nondepolarizing
to a surgeon settling for the view obtained from the
paralytic agents can facilitate exposure and maintain an
Holinger AC scope or a Dedo laryngoscope. CARosen
immobile field.
Endotracheal intubation with as small a tube as
can be used for adequate ventilation (usually 5 to 6 Fr)
True laryngeal suspension4-7 requires a gallows that will facilitate the procedure if it can be performed safely
suspends the patient with the primary force being and without significantly disturbing the pathology of
exerted at the tongue base, supraglottis, and interest.
mandible. This is in contradistinction of what most
surgeons use, which are chest-support laryngoscope
holders/stabilizers that exert force on the maxilla. True The surgeon should habitually be present during
suspension force on the mandible as demonstrated by endotracheal intubation to observe as the anesthesia
Kirstein (written communication, 1897), Killian,4 and team places the endotracheal tube, noting the blade
Jackson9 allows for the largest-caliber speculum to be size and ease or difficulty with the exposure for
positioned. This is a key strategic goal because intubation. This ensures that the otolaryngologist is
optimizing laryngoscopic exposure frequently present at the time of airway establishment and
influences the precision of a surgical procedure. may predict the ease of placement of the operating
SMZeitels laryngoscope. CARosen
Having a selection of operative microlaryngoscopes is A Hunsaker jet-ventilation catheter can be valuable

essential. At this point in my career, I have drifted with laryngeal stenosis patients or when working in the
back to a more centrist position regarding scope periarytenoid and interarytenoid regions. SMZeitels
selection as it specifically relates to size of the scope.
By that I mean that I will choose a microlaryngoscope
that adequately exposes the surgical field but typically
not the largest scope. To me the key is adequate and The surgeon should be ready to take over the
good exposure, and the largest possible laryngoscope intubation if he or she senses any difficulty by the
is not always required to achieve that. RHOssoff anesthesia team. Traumatic intubation needs to be
minimized to prevent trauma to the delicate tissues of
the larynx. RHOssoff
Direct Laryngoscopy and

Pharyngoscopy with Close communication with anesthesia staff and prep-
or Without Biopsy aration for alternative means of ventilation are essential
to safe induction and intubation. Imaging studies should
Preoperative Considerations
be available during the procedure and reviewed with the
The indications for direct laryngoscopy and pharyngos- anesthesia staff prior to induction. It is the surgeon’s
copy are myriad and generally include abnormality responsibility to confirm availability and proper func-
or mass, noted or suspected, in the oropharynx, tion of all laryngoscopy equipment prior to induction.
Surgical instruments
Video cart
Assistant
Operative
table
Surgeon
OR
monitor
Operative
microscope
Anesthesia
Anesthetist
cart
FIGURE 3-3. Room configuration.
First, the anesthesiologist must have immediate

Before starting direct operative pharyngoscopy and access to intravenous lines and ventilating circuits. Typi-
laryngoscopy, the surgeon should confirm total muscle cally the patient should not be turned more than 90
paralysis with the anesthesia staff. No twitches on degrees away from the anesthesiologist and one arm
peripheral nerve monitoring ensures optimal relaxation should be available for blood pressure, oxygen satura-
prior to laryngoscope insertion and minimizes the tion, and emergency intravenous access. Multiple light
chance of injury to surrounding structures during the sources should be available and may be positioned in a
procedure. CARosen number of places around the surgeon with attention
paid to cables and obstruction. If a video cart is to be
used, it is often most convenient to place this at the
patient’s feet. The instrument cart should be placed in
The surgical suite is often small and, depending the room for rapid access to additional instruments by
on the procedure planned, may contain numerous pieces a noncontaminated circulating assistant.
of bulky, unwieldy equipment. Preoperative consider-
ation of the location of this equipment and its order
of use is essential to efficient use of operating room In my practice, the assistant is on the right-hand
time. Although many configurations work well, a simple side of the surgeon, given that most surgeons are
set of principles may allow the surgeon to configure any right-handed. CARosen
available room rapidly (Figure 3-3).
With wet gloves to facilitate examination, digital palpa-

Operative Steps tion of the lips, gingivolabial and gingivobuccal sulci,
floor of mouth, anterior tongue, and retromolar trigones
should be performed.
STEP 1. Position the patient with the head as close as
Deeper palpation of the soft palate, tonsils, posterior
possible to the head of the bed.
pharyngeal wall, base of tongue, and vallecula should
be performed to assess for submucosal lesions not
appreciated during office examination. The lingual and
STEP 2. Induce general anesthesia as per management
palatine tonsils are often involved in cases of occult
plan with anesthesia staff.
malignancy, and palpation is surprisingly sensitive in
In most cases induction of general anesthesia and endo- identifying such lesions if performed carefully. In cases
tracheal intubation may be performed by qualified anes- of laryngeal cancer, the preepiglottic space and base of
thesia staff prior to performing upper airway endoscopy. tongue can often be palpated for signs of invasion.
Once intubated, the tube is taped to the left lower lip The long finger should be used to palpate the pala-
and corner of mouth (for a right-handed surgeon). toglossal folds and piriform sinuses to the level of the
hyoid bone if possible. Also, any discrete suspicious
masses should be biopsied with cup forceps either
After the anesthesia team has successfully intubated
through the laryngoscope or by direct visualization.
the patient, the surgeon should ensure that the
Once oropharyngeal examination is completed, the
endotracheal tube is placed to the left side of the base
neck may be carefully palpated with the patient under
of the tongue prior to taping the endotracheal tube
general anesthesia to feel for lymphadenopathy, particu-
at the left corner of the mouth. Given that most
larly deep to the sternocleidomastoid muscles.
intubations are done with the right hand, this naturally
places the endotracheal tube on the right side of the
base of the tongue, and for the right-handed surgeon,
this places the endotracheal tube in a “competing” It is very important to perform digital and bimanual
position for direct pharyngoscopy and laryngoscopy. palpation of the structures of the oral cavity,
The most effective way to reposition the endotracheal oropharynx, and hypopharynx. RHOssoff
tube to the left base of the tongue is not to use a
tongue blade, but instead to use a gloved index finger,
manually placing the endotracheal tube to the left
aspect of the patient’s base of tongue prior to STEP 5. Prepare the patient’s head and oral cavity for
securing the tube. CARosen direct laryngoscopy and pharyngoscopy.
Preparation for direct laryngoscopy and pharyngoscopy

begins with dental protection and head positioning.
When performing laser-assisted operative Standard positioning for unassisted laryngoscopy places
microlaryngoscopy, the tube should not be taped so the patient’s neck flexed and atlanto-occipital joint
that it can be rapidly removed should an airway fire extended (Figure 3-5).
occur. RHOssoff If the patient has maxillary dentition, a Silastic or
rubber tooth protector is applied. If the maxillary denti-
tion is absent, a saline-soaked gauze or towel may be
STEP 3. Turn the head of the bed toward the surgeon used. In cases in which the maxillary dentition is poor
and drape the operative field. or loose, extreme caution must be used. Dental impres-
The eyes are carefully taped closed and protected to sion putty may be placed in the tooth protector to help
prevent corneal abrasions or other injuries. Plastic eye maintain support if some of the dentition is absent or
shields are available, but gauze eye pads are generally suspect.
sufficient. Typically these are soaked in water prior to
application to maintain safety in the event the laser is Saline-soaked gauze can often cause significant
later used. mucosal trauma to the edentulous alveolar ridge. A
The arm opposite the anesthesiologist is padded and superior alternative is to use a small piece of high-
tucked and the patient is draped in a clean fashion such density foam such as is found in otologic or
that the ventilator circuit can be seen and monitored by neurosurgical head rests. A strip of high-density foam
the anesthesiologist. (approximately 1-2 cm × 3-4 cm × 0.5 cm) can be
placed inside a small plastic bag and then placed
between the laryngoscope and the alveolar ridge.
STEP 4. Perform a careful bimanual examination while CARosen
the patient is under general anesthesia (Figure 3-4).
Pre-epiglottic
space
FIGURE 3-4. Bimanual examination.
laryngoscope against the teeth and uses them as a

Rolling a wet surgical sponge and placing it between
fulcrum to raise the distal tip of the laryngoscope into
the maxillary alveolus and labial surface of the upper
the base of tongue. Proper technique applies anterior
lip as well as using another to protect the maxillary
pressure against the base of tongue with the laryngo-
alveolar ridge will usually protect the patient’s tissues
scope, without using it or the teeth as a fulcrum, and
in edentulous patients, in my experience. RHOssoff
keeps the proximal end of the laryngoscope off of the
teeth. One usually knows that the technique is correct
when the patient’s head comes off the table.
Contrary to popular anesthesia and otolaryngology
teaching, substantial pressure may be applied to the
maxillary dentition so long as the pressure is applied
gradually and directly into the maxilla over stable teeth. One method to reduce the risk of dental injury during
Any rapid acceleration in the anteroposterior dimension laryngoscopy is to ensure the use of proper upward
can lead to dental injury or loss. force by monitoring the surgeon’s arm muscle use
With a simple set of basic precautions, the skilled or activation. Inappropriate “fulcrum” use of the
surgeon can obtain excellent direct visualization of laryngoscope involves bicep muscle use and suggests
nearly all regions of the oropharynx, larynx, and hypo- that the surgeon is not providing the appropriate
pharynx. Of greatest concern is injury to the teeth. forces on the laryngoscope to achieve exposure.
Although the tooth protector helps reduce the likeli- In contrast, to achieve the appropriate upward
hood of injury, damage to the dentition can still occur and forward force on the laryngoscope during
through carelessness. pharyngoscopy and laryngoscopy, significant tricep
Most commonly, injuries occur when the surgeon and deltoid muscle activation should be used. This is
attempts to inspect anterior structures and the wrist especially helpful when training and monitoring
flexes to reduce the angle between the line of the scope students of laryngoscopy. CARosen
and the floor. This places the proximal end of the
Direction of scope advance

Direction of force
FIGURE 3-5. Patient positioning for laryngoscopy and pharyngoscopy.
Proper head positioning for direct laryngoscopy is

To optimize exposure of the pharynx and larynx for
famously controversial and hotly debated among laryn-
direct examination, the basic principle of neck flexion
gologists. In general, head position is largely dependent
and head extension is not controversial and is an
on the patient’s anatomy and the region the surgeon
essential tenet for pharyngoscopy and laryngoscopy.
wishes to inspect. If an operative table with adjustable
Neck flexion is easily achieved using an elevated head
head position is used, a shoulder roll is generally not
pillow, with or without upward rotation of an
required.
articulated head of the operating table. Head
The examination may begin in the “sniffing” posi-
extension can be achieved during laryngoscopy
tion with the atlanto-occipital joint extended and the
(especially during suspension of the laryngoscope).
neck gently flexed. This position is suitable for careful
Any unfavorable angle of the suspended laryngoscope
inspection of the oropharynx and hypopharynx. Often
for microlaryngoscopy can be overcome easily by
the larynx may also be exposed adequately in this
placing the operating room table in Trendelenburg
position.
position or using articulated eyepieces of the
Greatest anterior exposure of the larynx with little
microscope. CARosen
or no dental pressure can be obtained with the neck
flexed and the atlanto-occipital joint flexed (Figure 3-6).
Raising the head of the operating table facilitates this
positioning. Although this view is excellent for diagnos-
tic examinations, it is often cumbersome for the surgeon
because the laryngoscope is pointed near vertically and In contrast, the distal hypopharynx and cervical
the patient cannot be placed in suspension in this posi- esophagus can be visualized most easily with both the
tion easily. atlanto-occipital joint and neck extended (Figure 3-7).
Direction of force
FIGURE 3-6. Greatest anterior exposure of the larynx with little or no dental pressure can be
obtained with the neck flexed and the atlanto-occipital joint flexed.
This position is often used for rigid esophagoscopy and The surgeon may need to adjust his or her body and
is readily obtained by lowering the head of the bed. head position to obtain direct line of sight down the
laryngoscope. Additional extension of the atlanto-
occipital joint and neck is improper and may lead to
dental injury as the laryngoscope contacts the teeth.
Remarkably, the sniffing position is widely espoused

Reverse Trendelenburg position adjustments typically
as the optimal position for exposure of the glottis and
allow for more comfortable head and neck position of
therefore intubation. In fact, flexion of the neck and
the surgeon. SMZeitels
atlanto-occipital joint (see Figure 3-6) provides optimal
viewing in a difficult laryngoscopic exposure, which
was recognized by Johnson10 a century ago.11,12
Endotracheal intubation13,14 was done approximately The surgeon must be aware of his or her body, head
15 years after the conventional introduction of direct and neck alignment. Great care should be exercised
laryngoscopy, and anesthesiologists copied the to avoid sticking one’s chin out too far or extending
surgeons’ sniffing position using similar viewing one’s neck too much. Careful positioning by the
vectors from the head of the bed. However, surgeons surgeon is essential to avoid acquiring long-term
required this viewing vector to perform substantial cervical spine degenerative changes. Do not be afraid
instrumentation of soft tissues while anesthesiologists to ask your assistant, nurse, or other member of the
could easily intubate patients in flexion-flexion position operative team if your “head is situated over your
(see Figure 3-6). SMZeitels shoulders.” RHOssoff
Direction of scope advance
FIGURE 3-7. The distal hypopharynx and cervical esophagus can be visualized most easily
with both the atlanto-occipital joint and neck extended.
Injuries to the pharyngeal mucosa and tongue can The importance of orientation should contribute to
occur through aggressive manipulation of the laryngo- the surgeon’s decision on which laryngoscope to use
scope. The best means to avoid these injuries is to because small scopes allow only a limited view of criti-
know the location of and maintain precise control over cal landmarks. In general, the surgeon should choose
the distal tip of the laryngoscope. It is not uncommon the largest laryngoscope that can be used to evaluate all
for the surgeon to be inspecting mucosa, but not be portions of the anatomy.
entirely certain where the mucosa is within the orophar-
ynx or hypopharynx. The natural reaction is to start
STEP 6. Perform oropharyngeal examination.
looking side to side and deeper to see if more landmarks
come into view to allow orientation. This tendency must Endoscopic evaluation typically begins with examina-
be avoided and the surgeon should gently withdraw the tion of the oropharynx (Figure 3-8). For a right-handed
laryngoscope until known anatomic structures come surgeon, pharyngoscopy and laryngoscopy begin with a
into view. Once reoriented to the position of the distal scissoring motion of the left thumb and forefinger to
tip of the laryngoscope, the surgeon may then advance open the jaw. The structures that should be identified
the scope carefully and attempt to identify the next discretely and carefully inspected include the soft palate,
landmark. Useful landmarks include the uvula, the epi- the tonsils, the palatoglossal folds, the base of tongue
glottis, the arytenoids, and the endotracheal tube itself. and vallecula, the lingual surface of the epiglottis, the
Poorly oriented attempts to perform laryngoscopy will lateral pharyngeal walls, the posterior pharyngeal walls,
lead to mucosal injury and bleeding, which only com- the walls and apex of the piriform sinuses, the postcri-
pounds the difficulty of the examination. coid mucosa, the esophageal introitus, the laryngeal
Posterior
pharyngeal
wall
Uvula
FIGURE 3-8. Examination of the oropharynx.
surface of the epiglottis, the aryepiglottic folds, the ary- FIGURE 3-9. View of the uvula and soft palate, as well as the
tenoids, the interarytenoid space, the false vocal folds, posterior pharyngeal wall.
the ventricles, the true vocal folds, and the immediate
subglottis.
The surgeon should develop his or her own methodi-
cal system that evaluates all of the anatomy and is
repeated in the same order and manner with every
examination to ensure that all areas of the anatomy are Vallecula
inspected thoroughly. The following is one method for
inspecting all of these structures.
The scope is inserted with the right hand and
the surgeon immediately begins the process of orienta-
tion. The surgeon should pay careful attention to the
lower lip and corner of mouth as he or she passes the
laryngoscope because it easy to pinch between the teeth
and the scope. Insertion in the midline rapidly yields a
Epiglottis
view of the uvula and soft palate (Figure 3-9). The pos-
terior pharyngeal wall may be visualized at this point.
In returning the laryngoscope to the uvula, the surgeon
may trace the soft palate laterally to the right tonsillar
fossa. At the inferior pole of the tonsil, the surgeon may
proceed to the palatoglossal fold and base of tongue. As Posterior
the surgeon draws the tip of the scope medially, the pharyngeal
wall
vallecula and lingual surface of the epiglottis come into
view and may be inspected (Figure 3-10). The same
structures on the left may be visualized as the surgeon FIGURE 3-10. The vallecula and lingual surface of the
draws the scope to the left palatoglossal fold and infe- epiglottis come into view.
rior tonsil pole. As the surgeon draws the scope up the
left tonsillar fossa and, palate the uvula again comes
into view. There is a substantive time delay (about 20 minutes)
Some patients release copious saliva following induc- between the administration of glycopyrrolate and
tion of anesthesia. If this causes any difficulty with decreased salivation; therefore, this medicine should
visualization, the surgeon or anesthesia staff may admin- be given preoperatively for patients undergoing direct
ister a small dose of glycopyrrolate (Robinul). Typically pharyngoscopy and/or laryngoscopy, unless there is a
0.2 mg is effective. Glycopyrrolate can cause significant medical contraindication. CARosen
urinary retention, particularly in older men.
STEP 7. Perform hypopharyngeal examination.
With the uvula in view, the distal tip of the laryngoscope

is pressed into the tongue and tongue base. This should
bring the tip of the epiglottis into view with little or
no rotation of the laryngoscope. Careful direction of the
laryngoscope laterally will demonstrate the palatoglos-
sal fold. Keep the proximal end of the laryngoscope off
the teeth; the scope may be gently passed into the supe-
rior aspect of the piriform sinus.
To facilitate the examination the surgeon may direct
the shaft of the laryngoscope into the lingual sulcus, Apex of
thus displacing the tongue away from the side being piriform
Arytenoid sinus
inspected. This usually allows continued anterior
cartilage
passage of the laryngoscope without rotation of the
laryngoscope. As the piriform sinus is entered, the
surgeon will note that there are no landmarks in this Lateral
cone of mucosa leading to the apex. This is an easy pharyngeal
wall
region to lose orientation.
The hyoid bone laterally and the pharyngoepiglottic FIGURE 3-11. The apex of the piriform sinus.
fold anteriorly demarcate the oropharynx from the
hypopharynx, which can be helpful in defining and
mapping the geography of cancer in this region. palpated with a suction or blunt probe to confirm
The pharyngoepiglottic fold is the surface mucosal mobility, if indicated.
structure overlying the hyoepiglottic ligament.
SMZeitels
If arytenoid joint fixation and the subsequent diagnosis
of arytenoid ankylosis and/or dislocation is a
Gentle passage of the scope should continue to preoperative clinical concern, then during the direct
yield a potential space that ends in a blind pouch laryngoscopy, it is best to perform palpation of the
(Figure 3-11). This is the apex of the piriform sinus and arytenoids and subsequent cricoarytenoid joints either
may be confirmed by gentle palpation of the distal tip as an awake, in-office procedure, or before the
of the scope medially against the cricoid cartilage. The endotracheal tube is in place and/or the laryngoscope
esophageal introitus should be viewed with slight medial is suspended. Optimal visualization of the posterior
observation and confirms orientation. As the scope is glottis and the arytenoids should be achieved prior to
drawn medially, the postcricoid mucosa and posterior an endotracheal tube being inserted. Each arytenoid
hypopharyngeal wall may be inspected. Once the exam- should be independently palpated just anterior to the
ination is completed, the laryngoscope may be with- vocal process of the arytenoid cartilage. One should
drawn to the uvula and the sequence may be repeated be looking for decreased motion or “stiffness” of the
on the opposite side. cricoarytenoid joint during lateral traction applied to
the arytenoid. In addition, careful examination of the
posterior commissure should be done during this
STEP 8. Perform laryngeal examination.
maneuver to fully evaluate the possibility of posterior
From the uvula, the laryngoscope is again pressed into glottic stenosis (a common cause of bilateral vocal
the tongue to visualize the tip of the epiglottis. Rotation fold motion impairment). CARosen
of the tip of the laryngoscope superiorly and gentle
advancement allows passage of the tip posterior and
superior to the tip of the epiglottis. This allows inspec- The interarytenoid space should be inspected. If the
tion of the aryepiglottic folds and some of the laryngeal endotracheal tube is taped to the patient’s left lower lip,
surface of the epiglottis. The surgeon should note that the surgeon should inspect the interarytenoid space
the laryngeal surface of the epiglottis is parallel to the from the right arytenoid cartilage. With this cartilage in
tip of the laryngoscope and complete inspection of this view, the scope tip should be directed posteriorly and
region often requires an angled telescope. placed behind the endotracheal tube. The tip may then
The aryepiglottic folds should be followed on both be advanced inferiorly and the interarytenoid space will
sides to the arytenoid cartilages. These may be gently come into view as the endotracheal tube is moved gently
False vocal fold
Interarytenoid
space
True
Paraglottic vocal
mass fold
Arytenoids
FIGURE 3-12. The interarytenoid space comes into view. FIGURE 3-13. False versus true vocal folds.
into the anterior glottis (Figure 3-12). The immediate

To further improve anterior exposure during direct
posterior subglottis, often to the level of the first or
laryngoscopy, the clinician should ensure that the
second tracheal ring, may also be viewed from this
patient’s head and neck are positioned in neck flexion
position.
and head extension. Also consider applying gentle
anterior neck downward pressure in the area of the
upper trachea and/or cricoid to maximize anterior
This is the technique that I use to visualize the
commissure visualization during laryngoscopy and
posterior commissure, arytenoids and vocal process
microlaryngoscopy. CARosen
area. RHOssoff
Withdraw the scope to the epiglottis, maintaining the With the anterior commissure in view, the ventricles
tip of the scope inferior to the tip of the epiglottis. may be carefully inspected by pressing the false
Applying pressure into the base of tongue with the shaft folds laterally with the tip of the laryngoscope
of the laryngoscope will gently lift the patient’s head (Figure 3-13).
from the operating table. The false vocal folds should
come into view. These may be inspected and the vocal The distal aperture of most tubular laryngoscopes
processes should also be seen. (through 1960) is round posteriorly to expose the
Continued gentle application of pressure into the interarytenoid region (see Figure 3-12) because
base of tongue should yield a view of the vocal folds they were designed before the era of endotracheal
and anterior commissure. If this region is difficult to tube placement during surgical laryngoscopy.
expose, the surgeon may try elevating the head of the Laryngoscopes such as the Jako,15 Kleinsasser,16 and
operating table 4 to 7 cm, applying gentle posterior Dedo17 unnecessarily adopted that feature from earlier
pressure to the cricoid cartilage, or switching to a designs. Davis and associates18 clearly demonstrated
smaller laryngoscope. Sometimes the surgeon must that glottic cancer resections often failed in the
make all of these changes in order to obtain an adequate anterior commissure and posterolateral paraglottic
view. One of the most common mistakes is to pass the region due to limitations in laryngoscopic exposure
laryngoscope tip too deep, which prevents full view of from the circular-oval laryngoscope speculum.
the anterior commissure. As a rule, if visualization is However, the optimal shape of a distal laryngoscope
poor, the surgeon should first attempt to improve the lumen to expose the neoplasm in Figures 3-12 and
exposure by gently withdrawing the laryngoscope before 3-13 is triangular.2 SMZeitels
advancing it.
Complete examination of the ventricular mucosa If biopsy is indicated, the lesion and surrounding
requires a sharply angled telescope (usually 70 degrees). mucosa should be treated with topical 1 : 10,000 epi-
nephrine for 2 to 3 minutes. Once vasoconstriction is
initiated, the surgeon may proceed with biopsy.
Most of the lesions of the oropharynx, larynx, and
Use of telescopes (5 mm diameter, 30 cm in length) hypopharynx that require biopsy for diagnostic pur-
during direct laryngoscopy and microlaryngoscopy poses are mucosal and are amenable to simple biopsy
is essential and should be a routine part of all with cup forceps between 2 and 4 mm in diameter.
pharyngoscopy and laryngoscopy procedures, most Biopsy involves pressing the open forceps into the lesion,
notably after the laryngoscope has been suspended. closing the jaws, and rapidly withdrawing the forceps
Zero-, 30-, and 70-degree telescopes provide a with a tearing action (see Figure 3-14). In most cases
“three-dimensional” view of many areas of the larynx several biopsies should be obtained to ensure adequate
and pharynx that are difficult to visualize with direct tissue for diagnosis.
laryngoscopy and binocular microlaryngoscopy. If the lesion appears to be submucosal, additional
These areas include the posterior commissure, the biopsies of the submucosa may be taken following
infraglottis, subglottis, anterior commissure, and the initial removal of the overlying mucosa.
laryngeal ventricles. The use of angled telescopes If the lesion is noted within the palatine tonsil, strong
through a suspended laryngoscope provides the consideration should be made to unilateral tonsillec-
surgeon important staging and “mapping” information tomy in order to ensure adequate tissue for biopsy and
that complements and supplements the information adequate postprocedure hemostasis. Although unilat-
obtained from binocular, high-powered eral tonsillectomy results in oropharyngeal wall asym-
microlaryngoscopy. CARosen metry which is annoying in subsequent surveillance for
malignancy, routine removal of the opposite tonsil is
unnecessary and increases postoperative pain and risk
of bleeding.
Although biopsy in most regions is safe, special
I completely agree that today telescopic evaluation
attention should be paid to lesions of the membranous
using 0-, 30-, and 70-degree telescopes is an integral
vocal fold. Superficial lesions of the true vocal fold that
part of diagnostic and therapeutic microlaryngoscopy.
are worrisome for malignancy should be biopsied.
I also routinely use these same telescopes to monitor
Because limited lesions may be treated with micro-
operative progress as needed and to evaluate my
surgery or radiation therapy for definitive management,
results following completion of the case. RHOssoff
the surgeon should pay very careful attention to biopsy
technique to avoid biopsy of any normal tissues.
Although bulky tumors may be biopsied with large-cup
forceps without magnification, proper evaluation and
Inspection of the immediate subglottis may be per-
biopsy of small lesions of the vocal folds is best per-
formed through the vocal folds or the laryngoscope may
formed with an operating microscope and microlaryn-
be gently passed through the vocal folds for improved
geal instruments to minimize the chance of permanent
visualization. Again, angled telescopes may be very
dysphonia following definitive management.
useful to view the entire mucosa of the subglottis.
Excessively deep biopsies may violate the vocal liga-
ment, leading to sulcus formation. Indiscriminant vocal
fold “stripping” should be condemned because it can
STEP 9. Biopsy suspicious pharyngeal and laryngeal
lead to excessive loss of the lamina propria and pro-
lesions (Figure 3-14).
found dysphonia. Biopsy or stripping near the anterior
If any lesions are encountered during the examination, commissure can also lead to anterior glottic web forma-
they should be noted and, after the entire examination tion and should be performed with adequate magnifica-
is completed, the lesion(s) should be viewed again for tion and great care.
consideration of biopsy.
An operative diagram of the larynx should be used in

the operating room to document lesions seen during It is also important to note that there is often a role for
pharyngoscopy and laryngoscopy and location of a microflap approach for removal of vocal fold lesions
biopsies. Preferably this is a standardized diagram that allows for optimal and maximal precision of tissue
that is placed in the medical record. CARosen removal and orientation of the specimen. CARosen
FIGURE 3-14. Biopsy.
Today proper care and respect for the tissues of the

vocal folds represents the standard of care. Use of the STEP 10. At the conclusion of laryngoscopy, treat the
operating microscope with mid to high magnification larynx with topical anesthetic to reduce the chance of
similar to otologic microsurgery of the middle ear is laryngospasm.
the expectation. The microflap approach can be used This can be easily accomplished with several milliliters
with good confidence and is ideal to manage of 4% lidocaine solution sprayed onto the vocal folds.
premalignant and superficial malignant lesions of the
vocal folds. Vocal fold stripping is of historical
significance only and should not be used as a
technique for mucosal removal. RHOssoff STEP 11. Remove the laryngoscope and the dental
protector.
STEP 12. Suction the patient’s oral cavity and orophar- 4. Killian G: Die Schwebelaryngoskopie und ihre praktische
ynx clear of blood and secretions. Verwertung. Vienna, 1920, Urban & Schwarzenberg.
5. Grundfast KM, Vaughan CW, Strong MS, De Vos P: Sus-
pension microlaryngoscopy in the Boyce position with a
STEP 13. Return the patient to the anesthesia staff for new suspension gallows. Ann Otol Rhinol Laryngol
87:560-566, 1978.
extubation.
6. Killian G: Die Schwebelaryngoskopie. Archr Laryngol
Rhinol 26:277-317, 1912.
In order to prevent laryngospasm, extubation should 7. Zeitels SM, Burns JA, Dailey SH: Suspension laryngos-
be delayed until the patient is awake and following copy revisited. Ann Otol Rhinol Laryngol 113:16-22,
commands. 2004.
8. Reference deleted in proofs.
9. Jackson C: Position of the patient for peroral endoscopy,
Suggested Readings in peroral endoscopy and laryngeal surgery. St. Louis,
1915, Laryngoscope Co, pp 77-88.
Benjamin B, Lindholm CE: Systematic direct laryngoscopy: the
10. Johnston RH: Some original endoscopic methods. Laryn-
Lindholm laryngoscopes. Ann Otol Rhinol Laryngol 112(9
goscope 23:607-617, 1913.
Pt 1):787-797, 2003.
11. Hochman II, Zeitels SM, Heaton JT: An analysis of the
Friedrich G, Kiesler K, Gugatschka M: Curved rigid laryngo-
forces and position required for direct laryngoscopic
scope: missing link between direct suspension laryngoscopy
exposure of the anterior vocal folds. Ann Otol Rhino
and indirect techniques? Eur Arch Otorhinolaryngol
laryngol 108:715-724, 1998.
266(10):1583-1588, 2009.
12. Hochman II, Zeitels SM: Exposure and visualization of
Hochman II, Zeitels SM, Heaton JT: Analysis of the forces
the glottis for phonomicrosurgery. Op Tech Otolaryngol
and position required for direct laryngoscopic exposure of
Head Neck Surg 9:192-195, 1998.
the anterior vocal folds. Ann Otol Rhinol Laryngol
13. Elsberg CA: Clinical experiences with intratracheal insuf-
108(8):715-724, 1999.
flation meltzer, with remarks upon the value of the method
Zeitels SM: Atlas of phonomicrosurgery and other endolaryn-
for thoracic surgery. Ann Surg LII:23-29, 1910.
geal procedures for benign and malignant disease. San
14. Jackson C: Anesthesia for Peroral Endoscopy. Peroral
Diego, 2001, Singular, pp 23-36.
Endoscopy and Laryngeal Surgery. St. Louis, 1915, Laryn-
goscope Co, 54-72.
15. Jako GJ: Laryngoscope for microscopic observation,
Suggested References of Historical Interest surgery, and photography. Arch Otolaryngol 91:196-199,
Provided by Dr. Zeitels 1970.
16. Kleinsasser O: Microlaryngoscopy and endolaryngeal
1. Holinger PH: An hour-glass anterior commissure laryn- microsurgery. Philadelphia, 1968, Saunders.
goscope. Laryngoscope 70:1570-1571, 1960. 17. Dedo HH: A fiberoptic anterior commissure laryngoscope
2. Zeitels SM: A universal modular glottiscope system: the for use with the operating microscope. Trans Sect Otolar-
evolution of a century of design and technique for direct yngol Am Acad Ophthalmol Otolaryngol 82:ORL91-92,
laryngoscopy. Ann Otol Rhinol Laryngol 108(Suppl 179): 1976.
1-24, 1999. 18. Davis RK, Jako GJ, Hyams VJ, Shapshay SM: The ana-
3. Jackson C, Tucker G, Clerf LH: Laryngostasis and the tomic limitations of CO2 laser cordectomy. Laryngoscope
laryngostat. Arch Otolaryngol 1:167-169, 1925. 92:980-984, 1982.
CHAPTER
Operative Esophagoscopy and
4 Percutaneous Gastrostomy
Commentary by Nasir I. Bhatti, Robert G. Martindale, and John R. Saunders Jr.
STEP 3. With the scope positioned just over the piriform

Transnasal Esophagoscopy sinus, the patient is asked to swallow forcefully. The
scope is gently passed into the cervical esophagus
STEP 1. Unsedated, thin-caliber esophagoscopy is per- through the upper esophageal sphincter (UES).
formed under local anesthesia alone. The nasal cavity
Gagging is expected and typically modest.
is prepared with topical nasal decongestant (e.g.,
oxymetazoline, phenylephrine) and local anesthetic (e.g.,
lidocaine, tetracaine [Pontocaine]) as in flexible laryn-
As in all passages of endoscopes this should be done
goscopy; 2% lidocaine water-based lubricant is then
under direct vision particularly because the passage
applied liberally to the nasal cavity on a cotton-tipped
through the lower esophageal sphincter (LES) can be
applicator.
somewhat tortuous. JRSaunders
It is preferable if the patient fasts before the procedure
for a brief period, although I have not encountered
problems if the patient has not done this. The surgeon
Pharyngeal anesthesia may make the patient very
is performing esophagoscopy, not gastroscopy, and the
uncomfortable and may give a false but alarming
esophagus should be devoid of food that could obstruct
sensation of not being able to breathe! NIBhatti
visualization.
The application of the lidocaine in this manner allows

STEP 4. Once in the cervical esophagus, the scope is
the operator to assess which nares will be most
gently passed to the stomach.
optimal to pass the endoscope. JRSaunders
I instruct the patient not to eat solid food for at least 4 STEP 5. The stomach is gently inflated and inspected to
to 6 hours before the procedure. NIBhatti a limited degree unless the 100-cm scope is used. Ret-
roflexion of the scope allows visualization of the dia-
phragmatic hiatus and Z-line.
STEP 2. The patient is positioned in a chair with the head
Patients tolerate unsedated, transnasal esophagoscopy
comfortably supported. A 60- or 100-cm flexible esopha-
extremely well. Although nasal anesthesia is essential
goscope is passed transnasally along the floor of the
to the procedure, pharyngeal and hypopharyngeal
nose (Figure 4-1).
anesthesia often complicates the procedure because
As a right-handed individual, I prefer to hold the scope patients find it difficult to manage their own secretions.
in my right hand and advance the scope with my left. In some circumstances, pharyngeal application of
If bony obstruction prevents passage along the floor, the benzocaine/butyl aminobenzoate/tetracaine (Cetacaine)
“middle road” just medial to the middle meatus entrance may be used to diminish a strong gag reflex.
may be used. The scope is passed to the nasopharynx Patients should be warned and prepared for the
and then to the oropharynx. gagging that occurs with passage of the scope through
the UES. With a gentle touch this is limited or absent
Because most transnasal scopes are designed for and, once the scope is in the cervical esophagus, usually
right-handed operators, they function better by holding extinguishes quickly.
the endoscope with the left hand to manipulate
the flexion or retroflexion dial with the left thumb, Patients should be encouraged to belch any
freeing the right hand to rotate and direct the excess air that is insufflated during the
scope. JRSaunders procedure. JRSaunders
27
FIGURE 4-1. Transnasal esophagoscopy.
STEP 6. After briefly examining the stomach, the stomach STEP 7. The scope is gently withdrawn through the
is suctioned free of air and the scope is withdrawn remainder of the esophagus, noting structural and
through the diaphragmatic hiatus to view the gastro- mucosal abnormalities. Once withdrawn into the hypo-
esophageal junction. Biopsies for lesions or Barrett’s pharynx, the scope may be withdrawn completely.
esophagus may be taken through the working channel.
The mucosa of the UES and lower hypopharynx cannot
Several passes are often necessary to adequately visual- adequately be assessed with a flexible endoscope, and
ize the entire gastroesophageal junction, or Z-line. Biop- thus if a lesion is suspected in this area, sedated rigid
sies of the esophagus in the absence of sedation are laryngoscopy and esophagoscopy are indicated to ade-
challenging because of the constant peristalsis, and the quately view this region.
surgeon must ensure adequacy of the specimen. Often,
grasping the tissue with the forceps and pulling back
and forth under direct visualization will allow determi-
nation if the area to be biopsied has been captured in
Operative Flexible Esophagoscopy
the forceps. Lesions in the cervical esophagus are even
more challenging because this region is more sensitive STEP 1. Under general anesthesia flexible esophagos-
to pain than is the distal esophagus. copy is performed by grasping the patient’s jaw and
lifting anteriorly. The scope is then placed transorally
I haven’t found this to be a problem. The main with a gentle inferior curve. With the scope draped over
problem is the extremely small sample that can the surgeon’s shoulder, the surgeon gently passes the
be biopsied with each pass of the biopsy flexible esophagoscope gently into the hypopharynx
forceps. JRSaunders and through the UES. This is done blindly by palpation
(Figure 4-2).
CHAPTER 4 Operative Esophagoscopy and Percutaneous Gastrostomy 29
Jaw
lifted
FIGURE 4-2. Transoral flexible esophagoscopy, with the patient under general anesthesia.
Operative flexible esophagoscopy can be performed

In our resident training program we have the attending
with either sedative or general anesthesia. For the head
staff pass the scope as the resident steers the
and neck surgeon, this is usually performed under
endoscope. It seems that about half the time the scope
general anesthesia because of lesions in the oropharynx,
can be easily passed as previously described; other
hypopharynx, larynx, or esophagus and the difficulties
times the opening through the UES should be visualized
in assessing these areas adequately with flexible
before the scope is passed through. JRSaunders
techniques.
If the surgeon encounters resistance to passage, the
scope is withdrawn 1 to 2 cm, rotated 5 degrees in If the surgeon/operator has performed direct operative
either direction, and repassed. laryngoscopy and has used a shoulder roll, it should
Entering the cervical esophagus with a flexible scope be removed to facilitate entry into the upper
under general anesthesia is one of the initial challenges esophageal sphincter. Dilation in the case of previous
of esophagoscopy. With practice it becomes very easy radiation can be risky, and extreme caution and
to place the scope by this method and it is very fast. significant experience in esophageal endoscopy are
Many head and neck cancer patients have strictures and warranted. Pulling the mandible forward as depicted in
altered anatomy in this region. This can complicate Figure 4-2 is often necessary. NIBhatti
passage of the scope and may prove to be impossible
without visualization. In such cases, a Miller or Macin-
STEP 2. The surgeon passes the scope to the stomach
tosh laryngoscope from the anesthesia department can
and gently inflates it.
facilitate opening the hypopharynx and passing the
scope under direct visualization into the cervical esoph- STEP 3. Once the scope is well into the midportion of
agus. In some cases, dilation is necessary before the the stomach lumen, retroflexion of the scope allows
scope can be placed. visualization of the diaphragmatic hiatus and Z-line.
Esophagus in line
with oral cavity
Tooth
protector
Neck
extended
FIGURE 4-3. Positioning for rigid

esophagoscopy.
STEP 4. The stomach is inspected as required and on The surgeon must keep a lumen in view while advancing
completion suctioned to remove excess insufflated gas. the scope (Figure 4-5).
Rigid esophagoscopy is tremendously valuable for
evaluation of lesions in the hypopharynx and their
STEP 5. Visualization of the esophagus is done while
extension into the cervical esophagus. It is a particularly
withdrawing the scope.
dangerous technique in inexperienced hands, however.
Finger controls help keep the scope centered in the It is very easy to pass the scope through a stricture,
esophagus and allow visualization of all mucosal neoplasm, or Zenker’s diverticulum into the mediasti-
surfaces. num. Unrecognized, such injuries can be fatal. Prompt
Biopsies may be taken though the 2.3-mm working management of such complications with cessation of
port. Once passed through the UES into the hypophar- oral intake, enteral bypass (feeding tube) placement,
ynx, the scope is withdrawn. and mediastinal drainage is critical. Proper positioning
and depth of anesthesia are also important to help
prevent serious complications.
Rigid Esophagoscopy
STEP 1. Rigid esophagoscopy is performed transorally The rigid esophagoscope should ideally be advanced
under general anesthesia with the patient completely by traction using the thumb on the undersurface of the
relaxed. A tooth protector is placed on the maxillary scope. Rotating the patient’s head from side to side
dentition and the neck is extended to bring the esopha- can facilitate visualization of the lumen. JRSaunders
gus in line with the oral cavity (Figure 4-3).
STEP 2. The scope is passed into the hypopharynx and As otolaryngologists become more and more familiar
then into the cervical esophagus. with flexible esophagoscopy, experience with rigid
esophagoscopy is diminishing. Extreme caution is
therefore advised to avoid passing a rigid
STEP 3. With gentle elevation of the tip of the scope and esophagoscope into the mid- and especially lower
protection of the maxilla with the thumb or forefinger, esophagus. Asking the anesthesiologist to help with
the scope is gently passed through the cervical esopha- muscle relaxation is always helpful. NIBhatti
gus (Figure 4-4).
Prior to placement of a percutaneous gastrostomy,

the surgeon should inspect the entire upper gastrointes-
tinal (GI) tract to at least the first portion of the duo-
denum. This is important to exclude pathology in these
sites and to understand the position and geometry of
the pylorus and lesser curvature of the stomach.
Percutaneous procedures should be considered with
extreme caution in patients with previous abdominal
surgery and obesity. Relative contraindications include
ascites and the presence of malignant lesions of the
esophagus, stomach, or duodenum.
During gastrostomy placement the greatest danger is
malposition of the tube with placement into or through
the colon, small bowel, or liver edge. Thus patients with
previous intraabdominal surgery should be considered
for referral for possible open gastrostomy placement.
Patients with prior surgery for ventral hernia repairs

with synthetic mesh are especially at risk. Passing the
gastrostomy tube through synthetic mesh will have a
disastrous result of abdominal wall infection and
fasciitis. RGMartindale
A single dose of a broad-spectrum antibiotic

is given prior to the procedure (see Jafri et al,
2007). JRSaunders
FIGURE 4-4. Initiating rigid esophagoscopy.

STEP 2. The scope is passed to the stomach and through
the pylorus to exclude malignant or dangerous pathol-
ogy (e.g., advanced duodenal ulcer) that might require
additional treatment or be a contraindication to gastros-
tomy placement.
STEP 4. The scope is advanced only to the mid- or upper
portion of the distal third of the esophagus.
It becomes increasingly difficult (and dangerous) to pass In addition to the malignant lesions noted, patients
it to the distal esophagus. Biopsies may be taken directly with portal gastropathy will have large venous
or with the use of an operating telescope. structures noted in the submucosa. RGMartindale
STEP 5. The rigid esophagoscope is gently withdrawn

STEP 3. With the stomach inflated, an assistant palpates
under direct visualization.
the epigastrum just inferior to the costal margin with a
single finger (Figure 4-6).
Percutaneous Gastrostomy This palpation should be seen endoscopically as a dis-

crete projection into the anterior stomach wall. Transil-
lumination of the skin around the depression may be
STEP 1. Begin percutaneous gastrostomy tube place-
performed in a darkened room. Placement of the gas-
ment by performing flexible esophagogastroduodenos-
trostomy tube too close to the pylorus can allow natural
copy.
passage of the balloon or bolster into the duodenum and
Percutaneous gastrostomy placement is a valuable skill lead to gastric outlet obstruction.The procedure may be
for a head-and-neck surgeon. With proper patient selec- aborted in favor of open gastrostomy tube placement if
tion and attention to technique, it is extremely safe. visualization of stomach anatomy is not perfect.
View
through
scope
Thumb serves
as fulcrum
FIGURE 4-5. Advancing rigid esophagoscope.
ENDOSCOPIC
VIEW
Flexible
gastrostomy
Liver
Stomach
(inflated)
Scope
FIGURE 4-6. Palpating for suitable position for gastrostomy.

Mid-clavicular
line
Xiphoid
process Anterior
axillary
line
Diaphragm
Costal
margin
Selection
of site
FIGURE 4-7. Site selection for

percutaneous gastrostomy.
We like to start from lateral to medial until the area Otolaryngologists with limited experience should
of maximum indentation is found. For questionable ensure seeing transillumination of the abdominal wall.
sites, the Ponsky technique of passing a needle This will reduce the risk of misplacement of the tube
with an attached saline-filled syringe through the into the colon. NIBhatti
puncture site until it is visualized in the stomach,
without other air entering the syringe, signifying entry
through another gas-filled viscus, can be helpful STEP 4. While keeping the stomach inflated, the assis-
(see Ponsky, 1998). Patients who have had prior tant chooses a site two fingerbreadths below the costal
gastric resection may have gastric remnants that margin between the xiphoid process and the anterior
are too small to be insufflated to the abdominal wall. axillary line on the left (Figure 4-7).
They may have a retro-colic anastomosis, making
Endoscopically, the point should be lateral to the
the Ponsky syringe technique an important
lesser curvature so as to prevent migration of the gas-
addition. JRSaunders
trostomy tube through the pylorus.
If a combination tube of gastrostomy and jejunostomy

may be needed, the tube should be placed near the
antrum to allow easy placement of the jejunostomy
Using a single finger to palpate the epigastrium cannot portion of the combination tubes. RGMartindale
be overstated. If a large portion of the anterior wall of
the stomach depresses with the finger palpation,
the surgeon should continue to search the anterior STEP 5. The abdomen is prepped and draped in sterile
abdominal wall for a point where the stomach is easily fashion. A 1-cm vertical incision is made at the site on
noted to see projection onto the stomach wall with the anterior abdominal wall.
even mild pressure. This will minimize the potential
of passing a needle through the liver edge or The size of the incision is much more important than
colon. RGMartindale the orientation. JRSaunders
Wire
Needle
catheter
Snare
in place
FIGURE 4-8. Passing guidewire for percutaneous gastrostomy.
STEP 6. With the stomach fully inflated, a needle cath- STEP 8. The scope, snare, and wire are brought out
eter is passed into the stomach. through the mouth and a gastrostomy pull-type tube
secured to the wire (Figure 4-8).
An additional method to “test” for appropriate
During the procedure, gentle insufflation of the stomach
approximation of the anterior abdominal wall and
with complete effacement of the normal rugae helps
stomach is to place a 1.5-inch 21- or 23-gauge needle
ensure that the stomach “floats” up to the anterior
through the anterior abdominal wall and evaluate the
abdominal wall and displaces other organs that may be
location and angle of entry of needle into the stomach.
between it and the peritoneum.
After this is confirmed, the larger 12- or 14-gauge
Good visualization and control of the wire during
needle catheter is placed. RGMartindale
the procedure are also critical to prevent injury to the
stomach.
STEP 7. A wire is passed through the catheter and
grasped with a snare through the gastroscope. Too much air insufflation can push air into the jejunum
The surgeon should be aware that there are different and interfere with gastric apposition to the abdominal
kits and methods to gastrostomy tube placement (avail- wall. JRSaunders
ability may vary substantially from institution to institu-
tion). The Ponsky pull technique is described, but push
STEP 9. The wire is then withdrawn from the abdomen
techniques are common as well. It is the surgeon’s obli-
side, pulling the gastrostomy tube through the mouth
gation to full understand what kits are available and
and through the esophagus (Figure 4-9).
how these tubes are placed.
STEP 10. The gastrostomy tube is secured at the abdom-

inal wall between 2 and 4 cm from the skin depending
Other commercially available choices for gastrostomy on the girth of the patient (Figure 4-10).
tube placement kits include the technique of
T-fasteners used to pexy the stomach to the anterior The tube should be secured snugly, but not tightly
abdominal wall. The Seldinger technique is then used against the skin to prevent necrosis and “buried bumper
to place the gastrostomy tube by first passing a syndrome.”
needle, followed by a guidewire. Dilators are then
passed over the wire, followed by the tube, with a We don’t secure the tube in any way and prefer it to
balloon to secure it in the stomach. NIBhatti have some play rather than to be snug. JRSaunders
FIGURE 4-9. Pulling gastrostomy into stomach wall.
Keeping the tube exiting the abdomen at a 90-degree

angle will help prevent mucosal and skin necrosis.
When the tube is allowed to hang to one side or the Xiphoid
other, the internal bolster places excessive pressure
on the mucosa and causes pressure necrosis, leading
to leakage and increased risk of infection. The tube
can be easily kept at a 90-degree angle by placing a
Kerlix or small face towel placed at the base of the
tube. RGMartindale
STEP 11. The tube is attached to a straight drainage bag

and the gastroscope removed.
Although feeding may begin immediately after place- Costal

ment, we find that many patients do not tolerate feeding margin
shortly following the procedure and we prefer to “rest”
FIGURE 4-10. Securing gastrostomy tube to abdominal wall.
the stomach and GI tract by connecting the new gas-
trostomy tube to a straight drainage bag for 24 hours
Postoperative Considerations for
before feeding.
Percutaneous Gastrostomy
Late complications are rare following percutaneous gas-
We allow administration of enteral medication in small
trostomy placement. Subdiaphragmatic air following
volumes (<50 mL) immediately after tube
the procedure is common on chest x-ray and should not
placement. NIBhatti
cause alarm.
The air can be noted under the diaphragm for

We generally wait for the return of normal bowel approximately 4 to 5 days, and if present over
sounds at 1 to 24 hours before initiating 5 days, concern of gastric leakage should
feeding. JRSaunders increase. RGMartindale
Rebound tenderness, fever, bowel obstruction, and incredibly rare. Although direct contact and transfer of
vomiting should be evaluated very carefully following tumor cells has been suggested as a mechanism, other
the procedure for perforation of the large or small data suggest that hematogenous spread of malignancy
bowel. Leakage around the gastrostomy after resuming with subsequent seeding of the gastrostomy wound may
feeding is typically the result of gastric stasis rather than play a greater role. We do not consider the presence of
breakdown of the gastrostomy site. Stimulation of the upper aerodigestive tract malignancy a contraindication
stomach motility prokinetic agents may be helpful. to gastrostomy tube placement or the use of “pull-type”
tubes, such as those described in the technique described
We recommend that patients rotate their tubes 360 earlier.
degrees daily. This helps ensure that the mushroom
end of the tube has remained in the stomach rather
than being extruded into the tract. If there is a
EDITORIAL COMMENT: Changes in technology
question regarding this, the bumper can be withdrawn,
(thin caliber esophagoscopes that can be passed
and the tube should easily move back and forth into
transnasally) and procedures (percutaneous versus
the stomach. Gastrografin tube studies can be
open gastrostomy) have greatly expanded the
misleading for tubes that are partially extruded but still
head-and-neck surgeon’s role and capability in the
in communication with the gastric lumen. Extruded
field of esophagology. A familiarity with each of
tubes are generally easily removed using topical
the techniques is important, and they should be
lidocaine gel and replaced with a balloon gastrostomy
seen as complementary rather than competitive
tube in an office setting. JRSaunders
with respect to the more traditional rigid
esophagoscopy and open gastrostomy, which still
have a role. Most of the serious problems that
Pain at the gastrostomy site should be evaluated
arise from these procedures can be traced to
carefully. Buried bumper is a common etiology. The
trying to push a given approach beyond its safe
occurrence is most common when the gastrostomy
limitations rather than choosing an alternate
tube is pulled too tightly to the abdominal
one. JICohen
wall. RGMartindale
Erythema and local skin excoriation around the gas-

trostomy site is common and often best treated with Suggested Readings
gentle loosening of the skin flange. Antibiotics with Ghogomu NT, Kallogjeri D, Nussenbaum B, Piccirillo JF:
activity against gram-positive cocci (e.g., cephalexin) Iatrogenic esophageal perforation in patients with head and
may be useful for erythema consistent with cellulitis neck cancer: evaluation of the SEER-Medicare database.
around the site. Yeast organisms are also a common J Otolaryngol Head Neck Surg 142:728-734, 2010.
cause of erythema under the skin flange, particularly in Jafri NS, Mahid SS, Minor KS, Idstein SR, Hornung CA,
patients who have regular leakage of tube feed around Galandiuk S: Meta-analysis: antibiotic prophylaxis to
the flange. Skin barriers and antifungal creams may be prevent peristomal infection following percutaneous endo-
helpful in managing such problems. scopic gastrostomy. Aliment Pharmacol Ther 25:647-656,
2007.
Ponsky JL: Transilluminating percutaneous endoscopic gas-
The routine cleaning of the peritube site with mild trostomy. Endoscopy 30:656, 1998.
soap and warm water will prevent most gastrostomy Postma GN: Transnasal esophagoscopy. Curr Opin Otolaryn-
tube site irritations and skin problems. RGMartindale gol Head Neck Surg 14:156-158, 2006.
Schrag SP, Sharma R, Jaik NP, Seamon MJ, Lukaszczyk JJ,
Martin ND, et al: Complications related to percutaneous
Seeding of the gastrostomy tube site with upper endoscopic gastrostomy (PEG) tubes. A comprehensive
aerodigestive tract cancer has been reported, but is clinical review. J Gastrointestin Liver Dis 16:407-418, 2007.
CHAPTER
Operative Bronchoscopy
Commentary by Seth M. Cohen, Paul W. Flint, and Tanya K. Meyer
General Preoperative Considerations In an average adult patient, assuming adequate

For either flexible or rigid bronchoscopy, the surgeon preoxygenation, after cessation of respiration there is
should have all available information in the room prior approximately 3 minutes until desaturation, 6 minutes
to starting the procedure. In common cases, such as until asystole, and 11 minutes until brain death (this
upper aerodigestive tract tumors and airway stenosis, varies by the age of the patient and comorbidities).
computed tomography (CT) scans of the area of concern Thus it is critical to be prepared for contingency plans
can be critically important in assessing the extent of a in case of failure of the primary airway plan before
given lesion. the patient enters the operating room (OR). If the
Unlike pulmonologists, otolaryngologists must contingency plan for securing the airway is a fiberoptic
perform bronchoscopy at times when most indications intubation, that fiberoptic scope should be in the OR,
mandate general anesthesia. This means that manage- and the optics, light source, and suction should be
ment of the airway throughout the procedure is of para- tested before the patient arrives. If the contingency
mount importance and the primary responsibility of the plan is a tracheotomy, the tracheotomy tray needs to
otolaryngologist. Preoperative assessment of the patient’s be open with the appropriate blade loaded on the
oral, pharyngeal, laryngeal, and tracheobronchial scalpel. There is no time to search for equipment
anatomy through physical examination, indirect laryn- when the operative team is moving from the primary
goscopy, and radiographic imaging is critical to safely to the contingency airway plan.
maintaining ventilation during the procedure. It is important to ensure proper positioning of the
The surgeon must consider the relative pulmonary patient on the OR table prior to the start of anesthesia.
health of each patient to understand how that patient Make sure that the head of the bed can flex superior
will tolerate periods of inadequate ventilation. In and inferior to facilitate placing the patient in the
many cases the pathology may not allow intubation or proper “sniffing” position for optimal laryngeal
even adequate bag-mask ventilation, and the surgeon exposure. Also make sure that the patient is
must be prepared for multiple contingencies. Although positioned at the very head of the table so that the
a careful appraisal of the surgeon’s comfort, skill, surgeon or anesthesiologist does not have to reach an
and available equipment for direct laryngoscopy (see additional distance to manipulate the airway. TKMeyer
Chapter 3) is essential, bronchoscopy can add addi-
tional challenges to ventilation that must be considered
prior to inducing general anesthesia. In some cases, stabilization of the airway with an
It is vitally important that the surgeon meet with the awake tracheotomy under local anesthesia prior to
anesthesiologist prior to induction to review the plan induction of general anesthesia is the safest way to
for managing the airway. Although this management proceed with airway evaluation.
should be considered the responsibility of the surgeon,
there are a number of airway measures with which the
anesthesiologist is more familiar that can be life-saving It is useful to calculate the maximal dose and volume
in emergencies. allowed for lidocaine for each patient. During flexible
bronchoscopy in a sensitive patient, it is possible to
One of the most important steps in operative airway get near the toxic lidocaine dose, especially if the
management is preoperative planning including 4% topical lidocaine is used. It may be safer to
discussions with anesthesia and having multiple plans use 1% or 2% plain lidocaine preparations in these
for airway management. SMCohen cases. TKMeyer
37
Flexible Bronchoscopy Preoperative TABLE 5-1 Equipment for Flexible Bronchoscopy

Considerations • Bronchoscope
Otolaryngologists most commonly perform flexible • Swivel adapter (Bodi connector)
• Silicone lubricant
bronchoscopy with the patient intubated because the
• Anti-fog solution
procedure is usually part of a comprehensive panendos- • Biopsy forceps
copy of the upper aerodigestive tract. Because of this it
is important to discuss the intubation with the anesthe-
siologist prior to induction. The necessary diameter of
STEP 2. Pass the bronchoscope through the endotra-
the endotracheal tube depends on the bronchoscope
cheal tube to the distal tip (Figure 5-1).
used and the intent of the procedure. Most diagnostic
procedures can be done with a 5.1-mm bronchoscope It is helpful to suction the endotracheal tube prior to
and 2-mm cup forceps for biopsies. These will easily fit advancing the bronchoscope to avoid collecting mucus
down a 7-mm endotracheal tube and even a 6.5-mm at the tip. If the scope becomes fogged or covered with
tube. Therapeutic procedures, such as those performed mucus, simply wipe the scope tip gently across the
for removal of large mucous plugs, dilation, or stent carina to clear the tip. Lavage of 2 to 3 mL of respiratory-
placement, require a 7-mm bronchoscope with a 2.8-mm grade sterile saline may also help.
working channel. These tubes fit best down a 7.5- to For most diagnostic procedures the surgeon should
8-mm endotracheal tube. Coordinating intubation with avoid the urge to suction patches of mucus. These can
the anesthesiologist is helpful to avoid delays for tube clog smaller scopes and simply prolong the procedure.
changes.
STEP 3. Pass the scope to the carina and into the right
It is useful to “test” the sizing by making sure the
mainstem bronchus. View the visible portions of the
chosen bronchoscope fits through the endotracheal
lower airway.
tube or laryngeal mask airway. Make sure that you
have enough room for ventilation around the
Use a combination of finger and wrist action for direc-
bronchoscope. TKMeyer
tional control of the distal tip of the scope. The surgeon
should stand tall and keep the scope as extended and
Rigid Bronchoscopy Preoperative straight as possible. This allows the surgeon to “dance”
using wrist rotation of the bronchoscope. Doing so is
Considerations critical to add the third degree of freedom at the tip of
Rigid bronchoscopy is substantially different from flex- the scope and allow atraumatic advancement into all air
ible bronchoscopy and is almost never performed in the passages. If the scope is not extended, rotation of the
absence of general anesthesia. In order to perform rigid body of the scope will only result in coiling of the cable
bronchoscopy, the surgeon must obtain direct line- rather than movement of the tip.
of-sight access to the lower airway. Although this is
often easy in children because of their anatomy and
To further maintain visual orientation, it is helpful for
particularly pliable tissues, obtaining line-of-sight access
the surgeon to turn slightly and face the side being
in adults can be difficult. As such, the surgeon may
examined. PWFlint
consider a variety of methods to view and manipulate
the lower airway, some of which do not even require a
rigid bronchoscope. Regardless of what method the Comprehensive bronchoscopy will inspect the mid
surgeon uses, having a full complement of equipment and distal trachea, the carina, and bronchi including the
used for direct laryngoscopy is often useful. right upper lobe, right bronchus intermedius, right
middle lobe, right lower lobe, left upper lobe, left lingua,
and left lower lobe. To enable the scope to pass,
It is essential to make sure that all equipment that may each segment should be noted and inspected for lesions.
be needed is available and working. Lighting for The proximal trachea is better visualized by direct
scopes and suction need to be checked prior to the laryngoscopy/tracheoscopy without an endotracheal
patient entering the OR. SMCohen tube in place using a rigid telescope (see Chapter 3).
Flexible Bronchoscopy During the examination, apply frequent suction in all

areas inspected to assess for tracheomalacia.
Collapse of anterior and lateral walls identifies
STEP 1. Attach the swivel adaptor to the endotracheal segments with loss of cartilaginous support. PWFlint
tube ( Table 5-1).
CHAPTER 5 Operative Bronchoscopy 39
FIGURE 5-1. Flexible fiberoptic bronchoscopy through an endotracheal tube.
Having a standard evaluation algorithm can help Flexible bronchoscopy can also be easily performed
ensure that all areas are inspected. SMCohen under general anesthesia using a laryngeal mask airway
(LMA) and spontaneous ventilation. The patient is
induced and the LMA is placed by the anesthesia team.
STEP 4. Biopsy suspicious lesions by passing the forceps The swivel adapter is placed. The bronchoscope is
through the working channel of the scope. introduced through the LMA. At the glottis, topical
lidocaine can be given to prevent laryngospasm and
Most lesions in the lower airway can be biopsied. coughing. Additional topical lidocaine can be given in
Although there can be a concern about creating a bron- the trachea—be careful to monitor total dose given.
chopleural fistula or pneumothorax, these problems are With this technique, vocal fold motion, the status of the
rare with intraluminal lesions. The surgeon should exer- subglottis, the dynamic stability of the trachea with
cise caution biopsying lesions that appear to be outside respiration and cough (tracheomalacia), and the lower
of or through the cartilaginous lumen as well as particu- airways can all be assessed and manipulated. TKMeyer
larly vascular lesions.
A
FIGURE 5-2. A, Rigid bronchoscope insertion to larynx.
TABLE 5-2 Equipment for Rigid Bronchoscopy Ventilation may be performed with intermittent removal
• Rigid bronchoscope and replacement of an endotracheal tube through the
• Light source laryngoscope (intermittent apneic technique) or via jet
• Suction ventilation. The jet ventilator is often the most efficient
• Anesthesia circuit adapter (Jolly tube) because it allows the surgeon to work with no endotra-
• 45-cm Hopkins rod telescope cheal tube in the way and maintain ventilation. Again,
• Macintosh (or other) laryngoscope (if needed)
a rigid 45-cm Hopkins rod telescope is useful for visual-
izing the airway.
Equipment for Rigid Bronchoscopy Rigid Bronchoscopy

(Table 5-2)
Bronchoscopes come in different sizes and lengths. In STEP 1. Place the bronchoscope in the oropharynx with
most situations a 40-cm bronchoscope is the appropri- the longer end of the beveled tip directed anteriorly.
ate length. A normal adult male airway will usually
accommodate a 9-mm-diameter scope easily. Smaller
STEP 2. Pass the scope behind the epiglottis and identify
patients, airway stenosis, and unusual anatomy may
the glottis (Figure 5-2A).
necessitate the use of smaller scopes.
In many cases a rigid bronchoscope is not necessary The bronchoscope has a tiny distal aperture given its
or desirable. In such cases the surgeon can establish the length, and it can often be challenging to identify the
airway with a laryngoscope and suspension apparatus. glottis.
FIGURE 5-2, cont’d. B, Use of a Macintosh laryngoscope to place rigid bronchoscope.
If secretions are a problem—which are cumbersome longer end is adjacent to the epiglottis when exposing
to suction from a 40-cm bronchoscope—the anesthetist the larynx. Before passing through the glottic aperture
may administer glycopyrrolate (Robinul) to reduce the bevel is rotated to better view the airway as the
these. surgeon passes the scope through the glottis.
A sturdy tooth protector is often helpful to prevent
dental injury.
If the glottis cannot be easily identified, the surgeon
Rotating the bevel is helpful to atraumatically lateralize
may use a Macintosh or similar laryngoscope to expose
one vocal fold to facilitate passage through the
the glottic aperture and place the rigid bronchoscope
glottis. SMCohen
(see Figure 5-2B).
A small amount of water-based lubricant on the
outside of the bronchoscope can facilitate passage
through the lower airways. Head position may change during this part of the
procedure. It is often easiest to see the glottis with
the neck slightly flexed, as in direct laryngoscopy.
STEP 3. Rotate the bronchoscope 180 degrees to Once the glottis is exposed, the airway will angle
advance the scope into the cervical trachea (Figure 5-3). more anteriorly and the surgeon may need to extend the
neck substantially to safely advance the bronchoscope.
The beveled end of the scope facilitates exposure A shoulder roll is rarely necessary if the head of the bed
throughout the procedure. Like a laryngoscope, the can be lowered to flex the neck.
Rotate 180 degrees
FIGURE 5-3. Rotate rigid bronchoscope to pass through glottis.
STEP 4. Attach the proximal glass, ventilator adapter, The rigid bronchoscope can be extremely dangerous
and the anesthesia circuit to initiate ventilation. if it is not carefully advanced through the airway. The
junction of the membranous tracheal wall with the car-
Most rigid bronchoscopes have side holes that extend tilaginous rings of the tracheal is particularly easy to
about 5 cm up from the tip. Because of this the surgeon separate and cause a bronchopleural fistula. The surgeon
cannot effectively ventilate with positive pressure from must always see an open lumen before advancing the
the anesthesia circuit until the scope tip is about 5 to scope and may need to rotate the scope slightly in order
6 cm below the glottis. to take advantage of the beveled end.
Be aware that small-diameter bronchoscopes may
leak substantially through glottic apertures of normal
caliber. Effective ventilation is not possible unless the The left hand is used to advance the scope (see
scope is closely sized to the airway lumen. Figures 5-2A and 5-3) in controlled increments while
guiding with the right hand, thus minimizing the risk of
injury. PWFlint
STEP 5. Carefully advance the bronchoscope to the
carina.
STEP 6. Rotate the patient’s head to gain access to the
bronchi (Figure 5-4).
With the bronchoscope in the cervical trachea, the
surgeon “threads” the airway onto the bronchoscope by Turning the head allows the surgeon to angle the scope
gently advancing the scope through the open lumen. into the right and left airways, using the glottis as the
Right
mainstem
bronchus
Chin
to left
FIGURE 5-4. Turn patient’s head to the contralateral side to obtain straight line access to the
bronchus.
pivot point. To view the right mainstem bronchus, the unencumbered access to the entire lower airway from
surgeon should turn the patient’s head to the left and the vocal folds to the lower lobe takeoffs. Without an
vice versa. endotracheal tube or rigid bronchoscope, the surgeon
has much more room to manipulate instruments and
work in several areas of the lower airway without
STEP 7. Biopsy suspicious lesions using a 2- to 4-mm adjusting the airway. The surgeon should use the largest
cup forceps. laryngoscope that will allow visualization of the glottis
and jet ventilation. I prefer the Lindholm laryngoscope
when possible, but the Dedo laryngoscope will also
Bronchoscopy Without a Rigid work effectively.
Bronchoscope
STEP 1. Perform suspension laryngoscopy and expose In select patients, total intravenous anesthesia (TIVA)
the glottic aperture. can be used to allow spontaneous ventilation. This
works better in younger, thin patients without
This is often the most useful way to perform airway pulmonary disease. TKMeyer
evaluation and intervention. It affords the surgeon
FIGURE 5-5. Rigid telescope through laryngoscope for airway inspection.
STEP 2. Establish jet ventilation.

For this procedure, 100% oxygen may be used, and
Establishing jet ventilation can be tricky to those unfa- as long as nothing that can burn is placed in the airway,
miliar with the technique. Many laryngoscopes have a there is no risk of laser or electrical fire.
side channel to allow attachment of a jet ventilator and At no time should the proximal end of the laryngo-
direct the air to the tip of the scope. Some laryngoscopes scope be substantially obstructed, to avoid the risk of
require small attachments for this. The “Hunsaker” barotrauma.
needle may also be used. The surgeon should wear eye protection during jet
ventilation.
Keep in mind that the procedure may also be
performed under brief apneic conditions without the
use of jet ventilation. PWFlint STEP 3. Perform bronchoscopy with a 45-cm by 5-mm
0- or 30-degree Hopkins rod telescope (Figure 5-5).
The surgeon should monitor for chest rise and fall

to assure adequate ventilation and not simply oxy A 70-degree telescope may also be useful. SMCohen
genation. Usually 20 to 30 mm Hg pressure is adequate
for effective ventilation. In obese patients, reverse
Trendelenburg position may be helpful to improve The surgeon may need to adjust the patient’s head posi-
ventilation. tion and laryngoscope position to attain line-of-sight
A suspension table (Mustard, Mayo, etc.) should access through the trachea and bronchi. Use of a
always be used for jet ventilation because using the 30-degree endoscope may preclude the need to take the
patient’s chest as the suspension surface may prevent patient out of suspension and turn the head for visual-
adequate ventilation. ization of the bronchi.
STEP 4. Biopsy suspicious lesions under close visual STEP 2. Dilate the stenosis using a continuous radial
ization using the telescope and 2- to 4-mm cup expansion (CRE) balloon (Figure 5-6).
forceps.
The balloon is inflated to dilate the stenosis and subse-
When the procedure is completed, the surgeon may quently removed. The procedure may be repeated with
place a No. 6 endotracheal tube through the laryngo- a larger balloon, if desired. There is no great science for
scope, withdraw the scope over the tube, and emerge determining how much to dilate the patient’s airway
the patient from general anesthesia at the discretion of stenosis. The risk, of course, is airway disruption with
the anesthesiologist with a secure airway. bronchopleural fistula and subcutaneous or mediastinal
emphysema. Soft stenoses with cartilaginous collapse
can often be dilated widely (18 to 20 mm), but will
Interventional Bronchoscopy with relax back to at least partially obstructed shortly fol-
Tracheal Balloon Dilation lowing the procedure. Firm, fixed stenoses may be at
greater risk of disruption during dilation. I have become
STEP 1. The surgeon should perform suspension more aggressive with dilating these with time and will
laryngoscopy and bronchoscopy with jet ventilation generally dilate to about three times larger than the
and a 45-cm Hopkins rod telescope as described stenotic aperture. Most will accept dilation with a 15-
previously. to 18-mm balloon. Serial dilation in ever-increasing
diameters of balloon from the original stenosis does not
Rigid bronchoscopy can also be performed, but ventila- seem to yield any advantage over simply using the final
tion and visualization are both compromised as a result 15- to 18-mm balloon.
of the bronchoscope. Other methods of dilation, including serially increas-
Jet ventilation can be used effectively with even the ing semirigid bougies, Jackson laryngeal dilators, and
smallest airways (3 to 4 mm) and allows the greatest rigid bronchoscopes, may be used for simple dilation. I
flexibility with instrumentation. prefer the CRE balloons because they inflate within the
The stenosis should be inspected for position relative airway and do not have the limitation of passing through
to the vocal folds and length (both in cm). It may also the glottis. I would not try to pass an 18-mm bougie
be palpated for rigidity. Tracheal stenoses come in many through the glottis. The CRE (controlled radial expan-
varieties. Cartilaginous collapse from previous trache- sion) balloons are also gentle on the surrounding mucosa
otomy is often “A-shaped” in configuration. In my and may limit further airway injury.
experience, these are rarely ameliorated with dilation
for long and typically require resection because they New noncompliant balloons are available for tracheal
lack structural support for durable dilation. Membra- dilation. I prefer to make radial incisions through areas
nous stenoses have normal and stable cartilaginous with a large “shelf” of stenosis prior to balloon dilation
rings surrounding a circumferential fibrous and mucosal with a noncompliant balloon. I typically use a 10-
band in the airway. In the trachea, these are more or 14-mm balloon. Adjuvant treatments such as
common in inflammatory disorders, such as Wegener’s mitomycin C may be applied after dilation. SMCohen
granulomatosis, and less severe endotracheal tube inju-
ries. These are generally quite amenable to simple dila-
tion. More comprehensive, and possibly more durable
Following dilation, redundant tissue extruding into the
treatment, may be afforded by using radial incisions cut
airway may be removed using laser ablation or
with a laser or definitive resection.
excised with a 27.5-cm microdebrider with a 4-mm
Tricut blade. PWFlint
Biopsy of the stenosis is important to facilitate Once completed, the surgeon should be able to place
diagnosis. SMCohen a No. 6 endotracheal tube without difficulty, remove the
laryngoscope, and return the patient to the anesthesiolo-
gist for emergence.
As discussed under flexible bronchoscopy, it is Tracheal balloon dilation can additionally be performed
important to identify tracheomalacia. In this situation, using flexible bronchoscopy through an LMA with
pass a rigid telescope and suction through the spontaneous ventilation. It is important to check the
glottic aperture and apply suction. Collapse of anterior length of the bronchoscope in relation to the balloon
and lateral wall identifies segments with loss of catheter. Some flexible bronchoscopes allow
cartilaginous support. PWFlint introduction of the balloon catheter through the
Insertion
Inflation
FIGURE 5-6. Balloon dilation of

tracheal stenosis.
working channel. Other bronchoscopes either do not Postoperative Considerations

have a working channel that is large enough, or the
balloon catheter is not long enough to pass entirely Bronchoscopy is most commonly performed as an out-
out of the working channel. It is important not to patient procedure. Even in cases of airway stenosis, the
inflate the balloon in the channel or the scope will be surgeon should be confident that the airway is larger
severely damaged. If there is a length discrepancy, a than it was before the patient arrived.
guidewire can be introduced through the working Postoperative chest x-ray is not typically necessary.
channel and into the distal tracheobronchial tree. The Rarely, patients with substantial airway compromise
bronchoscope is removed leaving the wire in place. can develop postobstructive pulmonary edema follow-
The balloon is introduced over the wire, and the ing airway interventions. Hypoxemia in the postope
bronchoscope is reintroduced alongside the balloon rative period with continued supplemental oxygen
for visual confirmation of placement. The balloon can requirement and diffuse rales in the chest are character-
be inflated to allow dilation and then deflated to allow istic. Chest x-ray will demonstrate diffuse pulmonary
ventilation. TKMeyer edema. This typically resolves with diuretics in 24 to
48 hours, but may require hospitalization. In rare
circumstances, reintubation with positive pressure ven- tracheoplasty using combined laser and balloon dilation.
tilation and slow wean may be necessary. Laryngoscope 117:2159-2162, 2007.
Hemoptysis is common following bronchoscopy, but Daumerie G, Su S, Ochroch EA: Anesthesia for the patient
rarely of consequence. Large-volume hemoptysis should with tracheal stenosis. Anesthesiol Clin 28:157-174, 2010.
Gaissert HA, Burns J: The compromised airway: tumors, stric-
prompt close observation and consideration of repeat
tures, and tracheomalacia. Surg Clin North Am 90:1065-
bronchoscopy. Often hemoptysis occurs from tears of
1089, 2010.
the pharyngeal mucosa and resolves without further Gardner GM, Courey MS, Ossoff RH: Operative evaluation
intervention. of airway obstruction. Otolaryngol Clin North Am 28:737-
750, 1995.
Suggested Readings
Andrews BT, Graham SM, Ross AF, Barnhart WH, Ferguson
JS, McLennan G: Technique, utility, and safety of awake
SECTION B Airway Operations
CHAPTER
Tracheotomy
6 Author James I. Cohen
Comments by Bruce J. Davidson, William M. Lydiatt, and Eben L. Rosenthal
STEP 1. With the patient’s neck in the natural or neutral strap muscles, defatting the neck, or using a longer tube
position or slightly flexed, mark a horizontal line at the may be needed to fit the tube appropriately.
level of the cricoid cartilage (Figure 6-1A and B) about 2
to 3 cm in length. I prefer a vertical incision of 1.5 cm staring just below
If the skin incision is marked with the patient’s head the cricoid cartilage. The vertical incision keeps the
extended, then it will end up being too low and will line of retraction pointed laterally, facilitating exposure.
force the tip (and cuff) of the tracheotomy tube into the Because the cosmetic deformity is primarily related
back wall of the trachea (Figure 6-2). The thicker the to the round scar formed by the tracheotomy, this is
soft tissues in front of the trachea, the higher the inci- one place where the rule of tension lines can be
sion must be relative to the cricoid to accommodate the violated. WMLydiatt
curvature of the tube (Figure 6-3).
I typically use a vertical incision. Although the
An issue that must be considered in this regard is the horizontal incision follows natural skin creases, the
level of the patient’s cricoid in the neck. This can fact that a tracheotomy tube remains in the wound
limit the level that the incision can be placed after the procedure reduces any cosmetic advantage
superiorly. BJDavidson to a horizontal incision. A vertical incision along the
midline reduces the amount of dissection required and
reduces the risk of bleeding and subsequent need for
Extended-length tracheotomy tubes are made by
ligation of the anterior jugular veins. BJDavidson
certain vendors and may be helpful in obese patients;
alternatively, endotracheal tubes can be adapted for
the use in severely obese patients. ELRosenthal
STEP 2. Position the patient with a horizontal shoulder
roll under the scapulae, and neck fully extended.
The absence of an inner cannula and faceplate, For patients with a particularly stocky build, a vertical
however, makes the use of an endotracheal tube shoulder roll can achieve the same degree of extension
problematic and this should only be considered in but also allow the mass of the shoulders to fall more
an emergency situation, when longer tubes are not posteriorly and improve access to the surgical field.
available or when the longer operative time for a Using heavy adhesive tape to retract the shoulders and
defatting tracheotomy is not considered a reasonable chest or breast soft tissues can be helpful in the obese
option. JICohen individual.
In situations in which the cricoid is too low to be

STEP 3. Infiltrate the skin and subcutaneous tissues with
palpable or its level is so close to the clavicular heads
lidocaine (Xylocaine)/epinephrine solution.
or sternum that the faceplate would impinge on these
structures, it should be marked instead a sufficient In the case of tracheotomy under local anesthesia, the
distance above these structures to accommodate the deeper soft tissues should be infiltrated as well, but in
faceplate comfortably. Maneuvers such as sectioning the general one should avoid infiltration of the trachea itself
49
Incision
A
Correct location of
tracheotomy tube
in normal neck
FIGURE 6-1. A, Preferred location of the incision for tracheotomy in an individual of normal
size. B, Lateral view demonstrates that incision placement allows for the normal curvature of
the tracheotomy tube and directs the tube into the center of the tracheal lumen.
CHAPTER 6 Tracheotomy 51
Correct location of
tracheotomy tube
in normal neck
Tracheotomy incision too low
FIGURE 6-2. An incision that is placed too low will cause the tip of the tube to impinge on the
posterior tracheal wall because of the inferior pressure on the skin edges by the tracheotomy
faceplate.
until its face is exposed because it may reduce the point will extend the functional length of the incision
patient’s perception of his or her ability to breath and and facilitate subsequent dissection.
significantly increase his or her anxiety. Drape the
patient with a folded towel wrapped under the chin and I dissect along the midline from skin to the median
a towel clipped at the top of the head so as to keep the raphe. BJDavidson
face exposed—this will facilitate subsequent tube untap-
ing and retraction if the patient is intubated and prevent
panic if the patient is under local anesthesia by allowing I prefer to do this dissection bluntly using a curved
continued eye contact. mosquito hemostat, which allows for continued
placement of the children’s retractors. These retractors
are slightly thinned and lower profile than army-navy
In patients with stridor undergoing urgent tracheotomy
retractors. The strap muscles can then be dissected
under local anesthesia, I prefer to prep and drape
and retracted laterally. One should avoid dissecting
the patient prior to injection of anesthesia so that
laterally beyond the trachea to avoid entering planes
proprioceptive sensation from accessory respiratory
opened in the neck dissection. Similarly, one should
muscles remains intact until the tracheotomy
avoid excessive dissection along the anterior trachea
procedure is ready to commence. BJDavidson
to limit the creation of a false passage when the
tracheostomy tube is changed or replaced in the
postoperative period. WMLydiatt
STEP 4. Incise the skin and subcutaneous tissues down
to the level of the sternohyoid muscles, retracting the
overlying soft tissues superiorly and inferiorly with sharp
STEP 5. After incising the middle layer of the deep cervi-
hooks and dissecting them off the strap muscles to
cal fascia in the midline vertically, use a curved clamp
expose the median raphe over a 2- to 3-cm distance
to undermine the strap muscles sufficiently on either
(Figure 6-4).
side of the midline so as to allow the insertion of army-
Even though the incision is relatively short, adequate navy retractors for lateral retraction to expose the
undermining of the fat and subcutaneous tissues at this thyroid isthmus.
Correct location of
tracheotomy tube
in a thick neck
Correct location of
tracheotomy tube
in normal neck
FIGURE 6-3. In an obese individual the normal curvature of the tracheotomy tube and
increased distance between the skin and trachea create the need for a higher incision if the
tube is still to rest in the middle of the tracheal lumen.
Median raphe
FIGURE 6-4. Exposure of the median raphe

of the sternohyoid muscles.
Fat pad
Sternohyoid m.
Sternothyroid m.
Thyroid gland
FIGURE 6-5. The strap muscles are retracted

Trachea laterally by sequential undermining and then
retraction.
This can be done sequentially in layers, first on one side STEP 6. Expose the pretracheal fat pad immediately
and then the other, creating a pocket for the insertion below the isthmus where the investing middle layer of
of the end of the army-navy retractor. Use the short ends the deep cervical fascia is thinnest. Dissect through this
of the retractors and make sure the direction of retrac- fat pad vertically in the midline so as to expose the ante-
tion is lateral and not outward because this will artifi- rior face of the trachea (see Figure 6-6).
cially deepen the wound and make subsequent dissection
more difficult (Figures 6-5 and 6-6). I routinely divide the isthmus with electrocautery. This
is particularly helpful in patients with a short neck,
obese patients, and patients with poor cervical
I agree that the shortest retractor that will expose the
extension. ELRosenthal
field should be used. I use the rake end of a Senn
retractor until I get to the median raphe, then the
retractor end of this instrument. I find that except in Create a pocket sufficiently wide on both sides so as to
obese patients, even the short end of an army-navy allow the ends of the army-navy retractors to be inserted.
retractor takes up too much space and blocks access The inserted ends are then retracted laterally to expose
to the field. The retraction of the subcutaneous tissues the face of the trachea and, equally important, are
and strap muscles should be lateral and downward rotated superiorly, which facilitates retraction of the
(toward the operating room [OR] table) to keep the trachea superiorly into the wound by applying force to
wound as shallow as possible. As long as dissection the thyroid isthmus. Draining veins can usually be
stays along the midline, the trachea will typically rise retracted laterally. Going below the thyroid isthmus
up between the two retractors as the overlying fascia ensures that the tracheotomy is not placed too supe
is divided. BJDavidson riorly and does to some degree “pad” the anterior
tracheal wall from the pressure the tracheotomy tube
places on it, thereby reducing the possibility of an
The army-navy retractors can sometimes be awkward “anterior trap door deformity” that can result in
and bulky within a small wound. They can also push tracheal narrowing after decannulation.
the trachea deeper into the wound and make
dissection difficult. As an alternative, Senn retractors
can be used for exposure particularly if a vertical STEP 7. If the patient is under local anesthesia, then at
incision is used. ELRosenthal this point with the anterior face of the trachea exposed,
infiltrate the tracheal lumen with lidocaine (Xylocaine). If
FIGURE 6-6. Exposure of the anterior trachea is facilitated by retracting the thyroid lobes
superiorly and then entering through the small fat pad that sits below its isthmus.
needed for exposure and to secure the exposure, the

cricoid hook can be placed into the trachea at the supe- I agree with the approach below the thyroid isthmus.
rior edge of the exposure and the pulled superiorly and Occasionally the anatomy favors an approach superior
outward to make the wound as shallow and wide as to the isthmus and in this situation, bleeding from the
possible (Figure 6-7). region of the pyramidal lobe of the thyroid may be
encountered. I find that division of the thyroid isthmus
If the patient is intubated, make sure the cuff is tempo- is rarely required. I prefer a cricoid hook in the anterior
rarily deflated prior to infiltration or cricoid hook place- tracheal wall in most cases. I then retract caudally
ment to avoid rupturing the cuff and the subsequent and laterally to maximize exposure of the
urgency in tracheotomy tube placement that this will trachea. BJDavidson
create. A cricoid hook is not needed at this point if the
tracheal face is easily exposed and stabilized by the
army-navy retractors.
STEP 8. With the cuff deflated, incise the trachea hori-
I typically do not inject the trachea of patients under zontally between two tracheal rings over the anterior
general anesthesia, only in those under local 90 to 120 degrees of its face. Spread the incision in
anesthesia. Epinephrine should not be injected into the a vertical direction using a clamp or tracheal spreader
trachea, so in tracheotomy under local, the surgeon to create sufficient room for tracheotomy tube
should ensure at the outset of the case that the OR insertion.
table has prepared a syringe of plain lidocaine for
injection at this point in the procedure. BJDavidson If not previously placed, a hook is now placed in
the superior lip of the incision to pull the opening
wider and up into the wound, which will facilitate tube
When the trachea is exposed, the size of the insertion. Placing a heavy suture around the tracheal
tracheotomy tube can be estimated. Have the ring at the lower edge of the incision and tying it as
tracheotomy tube on the Mayo stand with the balloon a loop for retraction can facilitate tube insertion
previously tested and now deflated. A small amount of by widening the tracheal opening and providing
lubricant may aid passage through the tracheal countertraction at the time of tube insertion (Figure 6-8)
incision. WMLydiatt or if decannulation occurs in the early postoperative
period.
FIGURE 6-7. Placement of the cricoid hook stabilizes the trachea and allows it to be retracted
into the operative field, creating a wound.
FIGURE 6-8. Placement of an inferior retraction suture to facilitate replacement of the

tracheotomy tube if it becomes displaced in the early postoperative period.
FIGURE 6-9. Proper securing of the tube with adequate “tension” on the tracheotomy ties is
facilitated by tying them over two fingers with the neck in flexion.
If a retaining suture is not felt to be required, a second After the endotracheal tube is withdrawn it is
hook inferiorly can allow the tracheotomy to be important to aggressively suction the airway through
retracted to allow tube insertion. I try to avoid tracheal the tracheotomy site prior to placement of the
spreaders. These take up a significant amount of tracheotomy tube. ELRosenthal
space and therefore require the tracheal incision to be
larger than necessary. Also tracheal spreaders can
lacerate the balloon of the tracheotomy tube when the
Make sure the tracheotomy tube is perpendicular with
tube is inserted with a spreader in place. BJDavidson
the anterior wall of the trachea. Because the trachea is
at a 10- to 20-degree angle as it descends into the
A horizontal incision also minimizes the sharp edges chest, this will mean the tube should be pointed
from severed tracheal rings that can inadvertently slightly cephalad. Once the tube can be felt to pass
pierce the balloon. Avoid fracturing the rings above through the tracheal incision, it can be rotated and
and below the incision from overly zealous directed down the trachea. WMLydiatt
spreading. WMLydiatt
I will often not place a stabilization suture, but rather Keep the endotracheal tube in the trachea until the posi-
divide the third tracheal ring in the midline to allow tion and function of the tracheotomy tube are con-
room for the tracheotomy tube. ELRosenthal firmed. This way, if trouble with insertion is encountered,
the tube can be reinserted for ventilation.
STEP 9. With the trachea open, pull back or have the

anesthesiologist pull back the endotracheal tube so STEP 10. Secure the tracheotomy faceplate with ties
the tip is just above the tracheal opening and insert tightened with the patient’s neck flexed so as to allow
the tracheotomy tube. only two fingers within the loop (Figure 6-9).
Sutures give a false sense of security, particularly in

thicker necks, in which enough redundancy in these soft common themes in everyone’s comments. In this
tissues exists to allow tube displacement even when they context all of the other variations listed should be
are intact. In addition, they interfere with tracheotomy seen as helpful hints that will allow a flexibility in
site care. approach should the need arise. JICohen
I use sutures and tracheotomy ties in most

tracheotomies. For patients undergoing free flap Suggested Readings
reconstruction, tracheotomy ties can compromise
Carron JD, Derkay CS, Strope GL, Nosonchuk JE, Darrow
venous outflow, so I prefer sutures alone. DH: Pediatric tracheotomies: changing indications and out-
In patients with obese necks and in whom there is comes. Laryngoscope 110:1099-1104, 2000.
more than the usual concern about decannulation, Goldenberg D, Golz A, Netzer A, Joachims HZ: Tracheotomy:
sutures may be placed around the adjacent tracheal changing indications and a review of 1,130 cases. J Otolar-
rings and tied to the faceplate of the tracheotomy yngol 31:211-219, 2002.
tube. BJDavidson Massick DD, Yao S, Powell DM, Griesen D, Hobgood T, Allen
JN, et al: Bedside tracheostomy in the intensive care unit: a
prospective randomized trial comparing open surgical tra-
EDITORIAL COMMENT: Few operations have as cheostomy with endoscopically guided percutaneous dila-
tional tracheotomy. Laryngoscope 111:494-500, 2001.
much of both dogma and variation in surgical
McWhorter AJ: Tracheotomy: timing and techniques. Curr
technique as tracheotomy. As can be seen by the
Opin Otolaryngol Head Neck Surg 11:473-479, 2003.
diversity of commentary, most surgeons have Oliver ER, Gist A, Gillespie MB: Percutaneous versus surgical
developed a set of individual tips or pearls that tracheotomy: an updated meta-analysis. Laryngoscope
help them deal with myriad variations in tracheal 117:1570-1575, 2007.
and neck anatomy that this operation forces them Pratt LW, Ferlito A, Rinaldo A: Tracheotomy: historical
to confront. The key to success is adherence to review. Laryngoscope 118:1728-1758, 2008.
the few basic principles of proper positioning, Ruggiero FP, Carr MM: Infant tracheotomy: results of a
midline dissection, and adequate exposure—the survey regarding technique. Arch Otolaryngol Head Neck
Surg 134:263-267, 2008.
CHAPTER
Laryngotracheal Reconstruction for
7 Subglottic and Proximal Tracheal Stenosis
Author Henry A. Milczuk
Comments by Roger C. Nuss, James Sidman, and James D. Smith
Second, laryngopharyngeal reflux, if present, must

Preoperative Considerations be controlled medically or surgically. Eosinophilic
This section demonstrates the principal surgical maneu- esophagitis can also affect LTR outcomes and should be
vers for successful laryngotracheal reconstruction (LTR) aggressively treated prior to airway surgery. If the larynx
with costal cartilage grafts. This procedure is often per- is inflamed (e.g., uncontrolled gastroesophageal reflux
formed on patients who already have a tracheostomy. [GER]), then surgery should be delayed until the mucosa
If the patient’s airway is stable and controlled, then LTR has settled.
should be considered only after all other medical condi-
tions are stable. Three other important considerations Many laryngologists advocate for treatment both
must be made prior to undertaking LTR. preoperatively and postoperatively with proton pump
First, endoscopic examination, microdirectlaryngos- inhibitors (PPIs) to minimize the effects of any
copy and bronchoscopy must be performed in order to laryngopharyngeal reflux on surgical outcome. RCNuss
accurately diagnose the site(s) of obstruction or any
other synchronous lesions. True vocal cord (TVC)
We treat all patients with antireflux medication while
mobility must be known (this can be established in clinic
intubated postoperatively, but do not perform any
by fiberoptic laryngoscopy), and palpation of the crico-
studies to determine the presence of gastroesophageal
arytenoid joint helps to define the integrity of the pos-
reflux disease (GERD). This has not affected our
terior glottis.
outcomes for LTR surgery. JSidman
Preoperative fiberoptic laryngoscopy, with video
recording for careful playback review, is imperative prior Based on the endoscopic findings, analysis of the
to the operative procedure. Assessment of vocal fold defect permits the surgeon to determine what must be
and arytenoid mobility will help determine the type repaired. This chapter demonstrates an anterior and
of procedure, especially if a posterior graft is posterior costal cartilage graft for LTR, but it should
necessary. RCNuss be understood that not all cases require this type of
reconstruction.
I agree with Dr. Nuss on the importance of preoperative The third consideration is whether the LTR is per-
fiberoptic laryngoscopy. JDSmith formed as a single-stage reconstruction or a two-stage
reconstruction. Generally stenting of the airway is
During endoscopy, sites of stenosis need to be care- needed after LTR in order to stabilize the cartilage
fully evaluated: anterior and posterior subglottis, proxi- grafts. In single-stage LTR an endotracheal tube is used
mal trachea, suprastomal granuloma or collapse (if for stenting. This implies that the patient will need to
tracheostomy is present), and tracheomalacia are all be hospitalized in the intensive care unit (ICU) for a
possible in a patient with acquired laryngotracheal ste- period of time while the grafts heal. Depending on
nosis. The length of stenosis can be determined either the patient this may require sedation and assisted
by endoscopy or, when the stenosis is too narrow to ventilation, or if he or she is cooperative and will not
allow any telescope to pass through, computed tomog- manipulate the endotracheal tube, the patient may be
raphy (CT) can be performed. ambulatory. Posterior grafts generally take more time to
heal than anterior grafts only, and this needs to be con-
Endoscopic measurements of the length of stenosis can
sidered by the surgeon and discussed with the patient
be facilitated by marking directly on the telescope as
or parents prior to surgery.
one passes the distal point of obstruction and
The alternative is to perform a two-stage LTR, in
withdraws to the proximal point of stenosis. RCNuss
which a tracheotomy site is maintained. In this situation
58
CHAPTER 7 Laryngotracheal Reconstruction for Subglottic and Proximal Tracheal Stenosis 59
the patient who has had a tracheostomy prior to LTR tube will be used postoperatively (if single-stage LTR)
will not require prolonged hospitalization. Different should be made with the attending anesthesiologist prior
options for stenting the reconstructed laryngotracheal to surgery. If a tracheostomy is present, then a flexible,
complex include Albouker stents, Cotton-Lorenz stents, cuffed tube is sewn to the chest wall opposite the rib
Montgomery stents, or Montgomery T-tube. graft harvest site. This can be an armoured tube or
trimmed oral RAE tube.
The anesthesiologist and surgeon will need to
Another stent to be considered is the Healy-
communicate during the procedure when the airway is
Montgomery stent (HMS), that combines a stenting
open. From time to time the ventilating tube may be
T-tube with a tracheotomy tube that has an inner
removed to gain better surgical access. Prior to this the
cannula for easier cleaning. RCNuss
anesthesiologist may want to provide Fio2 of 1.0 to
optimize the patient’s oxygen saturation. Mechanical
In a two-stage LTR a T-tube can provide a tracheal ventilation should cease while the tube is out of the
airway and laryngeal stent in one piece. The other stents trachea.
must be secured with sutures above the tracheostomy
site. The stents are removed endoscopically after the
It is critical that ventilation be halted during the use of
surgeon has determined that the grafted area has healed.
electrocautery, or airway fire may ensue. Again, good
Typically the tracheostomy is maintained for a short
communication between the anesthesia team and
time after stent removal to ensure that restenosis
surgical team is an absolute must. JSidman
does not occur. Then the tracheostomy tube is removed
using the head-and-neck surgeon’s usual protocol for
decannulation. When an endotracheal tube is being taken out of the
airway and replaced throughout the procedure, one
We do not perform two-stage LTR for any patients, must be aware of O2 concentration around and below
even grade 3 or 4 stenosis. We leave anterior graft the surgical drapes. Use of a bipolar electrocautery
patients intubated for 3 to 5 days, and anterior and may help to reduce the risk of operating room (OR)
posterior graft patients for 7 days. Extubation is done in fires in this setting. RCNuss
the ICU without laryngoscopy. The first postoperative
laryngoscopy is 4 to 6 weeks later. JSidman
Finally, when a single-stage LTR is planned, a deci-
sion needs to be made about what type of endotracheal
Different donor sites for cartilage used to reconstruct tube, oral or nasal, should be placed before the anterior
the larynx have been proposed. Auricular and thyroid graft and who should place the tube. Again a complete
cartilage has been discussed, and some authors have discussion with the anesthesiologist prior to surgery will
used hyoid bone for laryngotracheal grafts. However, aid in a smooth execution of the LTR.
costal cartilage offers relatively large amounts of hyaline A soft enteral feeding tube is placed near the end of
cartilage and perichondrium, which allows greater ver- the procedure.
satility during reconstruction. Concern for donor site
morbidity has led to the search for alternate sources of
cartilage, but careful surgical harvest will avoid compli- The feeding tube should be placed before grafts are
cations at the donor site. This chapter provides details placed, to be absolutely sure it is not in the airway.
for successful harvest of costal cartilage. We place a weighted feeding tube at the beginning,
Because of the various possible ways one can perform before prep is done. JSidman
an LTR (single- or two-stage, different graft sites), this
chapter describes a two-stage anterior and posterior
LTR. If another type of LTR is appropriate given the Elements to successful LTR include endoscopy, rib
type of laryngotracheal stenosis, then steps described graft harvest, careful placement of graft(s), secure
can be eliminated. For example, if a single-stage LTR is airway, and postoperative ICU care.
planned, then nasotracheal intubation is substituted for
the steps describing stent placement. Similarly, if only
an anterior graft is needed, then the surgeon ignores the
Endoscopy (Figures 7-1 and 7-2)
steps for posterior grafting.
STEP 1. Both awake flexible fiberoptic laryngoscopy
(FFL) and microdirectlaryngoscopy and bronchoscopy
Anesthetic Considerations (MDLB) must be performed by the surgeon before LTR.
Decisions about the type of tube to be used for ventila- Awake FFL is performed in clinic prior to surgery with
tion during the procedure and what type of endotracheal the patient sitting upright in an examination chair.
A B
Anterior
stenosis
ENDOSCOPIC VIEW
FIGURE 7-1. A, Endoscopist’s view of an anterior

subglottic stenosis. B, Sagittal view illustrating the
length and usual three-dimensional nature of stenosis.
A B
Posterior
stenosis
ENDOSCOPIC VIEW
FIGURE 7-2. A, Endoscopist’s view of a more

circumferential subglottic stenosis. B, Sagittal view.
anesthesia, especially with children. The principal

This is also a good opportunity to record and rate a
advantage to spontaneous ventilation is that the surgeon
child’s voice quality using a standardized tool such as
sees a dynamic airway during respiration. Also there are
the Consensus Auditory-Perceptual Evaluation of
no tubes or jets to distort the view of the airway.
Voice (CAPE-V) scale. RCNuss
The spontaneous ventilation technique does indeed

Topical anesthesia and a vasoconstrictor are applied
provide an excellent opportunity to examine the
to the nose prior to inserting the fiberoptic laryngo-
dynamic pediatric airway without endotracheal tubes
scope. Pass the scope through the middle meatus, then
to distort the surgeon’s view. This requires close
turn inferiorly past the palate to just above the epiglot-
communication between surgeon and anesthesiologist
tis. The patient is asked to phonate “E” for several
to adjust drips of medications to achieve the desired
seconds. The oropharynx, hypopharynx, and supraglot-
plane of anesthetic. RCNuss
tic larynx are also seen easily during FFL.
Inspection of the nasal passages before application of The findings from both endoscopic procedures can
topical anesthetic agent helps determine which side is be recorded if imaging equipment is available.
more patent, allowing for easier passage of the scope. Two examples of what may be found during MDLB
The middle meatus as well as the inferior meatus are are found in Figures 7-1 and 7-2. Figure 7-1A depicts
acceptable pathways for the fiberoptic scope, best the endoscopist’s view of an anterior subglottic stenosis.
decided by the anatomy of the child’s nasal passage. Figure 7-1B is a sagittal view illustrating the length and
The preoperative FFL should be recorded to allow for usual three-dimensional nature of stenosis. Such an iso-
careful review of the examination. The following lated lesion would be amenable to LTR with anterior
points should be ascertained: (1) do both vocal graft only.
folds/arytenoids move equally and symmetrically with
respect to range and speed, (2) are vocal fold edges We would perform anterior and posterior grafts on this
smooth and straight, (3) is there any evidence of because it appears to be a grade 3 stenosis, despite
scarring of the vocal fold, or presence of anterior the bulk of the stenosis being anterior. We feel that
glottic web, or any supraglottic scarring? Use of the failure rate is too high in grade 3 or 4 stenosis to
stroboscopy may help determine whether vocal fold justify anterior graft alone. JSidman
mucosal wave is symmetric. RCNuss
Figure 7-2A shows a more circumferential subglottic

STEP 2. For MDLB the patient is placed in a supine posi-
stenosis, and Figure 7-2B demonstrates its length. This
tion on the operating table. Once the patient is anesthe-
lesion, with its anterior and posterior scar, will need
tized, a suspension laryngoscope is inserted transorally.
anterior and posterior grafts in order to expand the
The tongue of the laryngoscope is positioned within the
airway and eliminate stenosis.
vallecula and the suspension arm attached. The operat-
In order to evaluate the trachea, the patient is taken
ing microscope, set at a focal length of 400 mm, is then
out of suspension and the laryngoscope removed. If the
used to visualize the larynx. Microlaryngeal instruments
stenosis permits atraumatic insertion, a rigid, ventilating
are used to inspect, palpate, and retract the laryngeal
bronchoscope is used. However, as is often the case, the
tissues. While in suspension, rigid telescopes of different
subglottic airway is too small for safe passage of a bron-
sizes and optical angles are used to gain further visual-
choscope. In these cases options include passing the
ization of the pathology. The telescopes are passed into
bronchoscope through the tracheostomy site (if it is
the subglottis and proximal trachea where definitive
present), using a flexible bronchoscope with a laryngeal
analysis of the stenosis is now done. Care is taken not to
mask for ventilation, or using CT. By whatever means,
abrade the mucosa or cause further injury to the larynx.
the surgeon needs to know the status of the trachea distal
Depending on the patient and the extent of laryngeal to the stenosis. Tracheomalacia or other potential sites
stenosis, pathology in the subglottis may or may not be of distal airway obstruction may result in failure to
seen during FFL. Thus to complement the awake exami- decannulate and are a relative contraindication to LTR.
nation as well as provide greater detail of the larynx and
trachea, MDLB is scheduled. A telescope by itself, either 4 mm or 2.7 mm, allows
If a tracheostomy is present, the anesthesiologist can for inspection of the subglottic and tracheal airway in
have unencumbered access to the airway distal to the all but the most severe degrees of stenosis. Balloon
main areas of stenosis. However, if tracheostomy is not dilatation of the stenosis may offer the surgeon a
present, the surgeon and anesthesiologist must discuss temporary way to further inspect the degree and
the combined airway plan prior to induction. Many length of stenosis. RCNuss
centers prefer spontaneous ventilation techniques for
As with any reconstructive surgery, proper analysis subglottic stenosis starts in relation to the vocal cords,
of the deformities, selection of reconstructive materials, especially if there is limited cord mobility. Palpation
and the condition of the surrounding tissues will deter- with a blunt probe will assess of the texture of the cica-
mine which techniques will most likely correct the trix; is it firm and mature or soft and edematous?
problem. Laryngotracheal reconstruction requires that Reconstructive surgery has a greater chance of success
extralaryngeal sources of obstruction be corrected first. if the larynx is not inflamed.
For example, children with large tonsils or adenoids If there is high-grade or complete (Myer-Cotton
may benefit from adenotonsillectomy before LTR. grade 4) subglottic stenosis, assessing the distal airway
can be challenging. These patients invariably have a
This is an excellent point that cannot be tracheostomy, which allows the bronchoscope to visual-
overstated. RCNuss ize from the stoma distally. Compliant patients may
allow this to be done in clinic, but if there are any con-
cerns with airway control, then bronchoscopy must be
The principal method to evaluate the larynx and done in the OR. One site that may not be seen well by
trachea prior to LTR is endoscopy. Awake flexible fiber- endoscopy is the airway proximal to the stoma. Espe-
optic laryngoscopy provides the surgeon information cially in children, or if there is suprastomal collapse or
about the nasal and pharyngeal airway. It is important granuloma, neither flexible or rigid endoscopes may
to assess motion of the vocal folds and their status. adequately visualize this important area. Knowledge of
the proximal trachea will determine the length of ante-
If the patient already has a tracheostomy, it can be
rior graft. A CT of the neck and chest may demonstrate
very difficult to diagnose supraglottic pathology such
lesions not well seen by endoscopy.
as laryngomalacia. This is because many patients with
tracheostomy do not use their upper airway, and so
Positioning (Figure 7-3)
the arytenoids appear swollen and obstructed. This
usually self-resolves after LTR surgery and the upper STEP 3. The patient is placed in a supine position with
airway is being used. JSidman a shoulder roll to optimize neck extension. The neck and
right anterior chest are prepped and draped sterile. If
the patient has a tracheostomy, a flexible, cuffed tube is
If vocal cord pathology is evident, this should be
sewn to the chest wall opposite the planned costal car-
addressed before LTR. For example, most surgeons will
tilage donor site. This tube can be an Armour tube or cut
start PPI medications to minimize the inflammatory
oral RAE tube. A portion of the tracheal ventilation tube
effects of laryngopharyngeal reflux. In some patients a
is kept within the sterile field. The anesthesia circuit can
swallowing assessment may be indicated. A modified
be placed under the sterile drapes; this allows access
barium swallow with the aid of a speech and language
by the anesthesiologist during the procedure, if needed.
pathologist, or functional endoscopic examination of
The bed is not turned. The surgeon and assistant are on
swallowing (FEES), can be performed prior to surgery.
opposite sides of the table.
Evidence of aspiration on preoperative examination The head should be stabilized with a scroll or donut to
may be either an absolute or relative contraindication prevent turning during surgery and loss of evaluation
to airway reconstructive surgery. RCNuss of the neck midline. JSidman
MDLB must be performed prior to LTR. The optical

STEP 4. Next injections of 1% lidocaine with 1 : 100,000
resolution of the endoscopes and microscope, in addi-
epinephrine are performed subcutaneously at the inci-
tion to the ability to palpate the tissues, provides essen-
sion sites and deeper in the midline along the laryngo-
tial information to the surgeon. During MDLB careful
tracheal complex that is to be exposed during the
analysis of the sites of scarring, degree of stenosis, length
procedure. A single dose of intravenous (IV) steroids and
of subglottic and tracheal involvement, problems at the
antibiotics is given preoperatively.
tracheostomy site, and any distal lesions will lead the
surgeon to decide how best to reconstruct the airway in Keeping the head of the patient toward the anesthesia
order to decannulate the patient. A vallecular laryngo- station allows the anesthesiologist easy access for adjust-
scope, as opposed to an anterior commissure laryngo- ing the ventilating tubes intraoperatively.
scope, provides a more complete view of the larynx.
Microlaryngeal instruments allow palpation and move- Anesthesia can also be at the foot of the table,
ment of the cricoarytenoid joints. Also the posterior allowing the surgeon easier access to the field for
glottis and interarytenoid space are evaluated for intraoperative endoscopy. JDSmith
webbing. It is important to determine where the
Apron flap incision
Incision within
inframammary
fold
FIGURE 7-3. Positioning and incisions.
The anesthesiologist can also observe the surgical

We use perioperative combination of clindamycin and
field, which aids in the combined airway management.
ceftazidime. We have found this prevents migrating
A local anesthetic may limit the use of narcotics
atelectasis during the intubated postoperative period
during surgery if emergence is planned after surgery.
of single-stage LTR surgery. JSidman
Injecting epinephrine will help limit blood loss when the
surgical field has a scar as is often the case in LTR cases
(previous tracheotomy or neck surgery). Antibiotics are
directed against skin and upper airway flora. Cefazolin Costal Cartilage Graft Harvest
is a good choice in many cases, or clindamycin can be (see Figure 7-3)
used especially if there is a history or high incidence of
methicillin-resistant Staphylococcus aureus (MRSA). STEP 5. Incision with scalpel is made over the fourth or
Dexamethasone is the preferred steroid for its strong fifth rib from the sternum laterally in the inframammary
antiinflammatory effects with minimal aldosterone-like fold. The subcutaneous fat and pectoralis muscles are
activity. divided with electrocautery to optimize hemostasis.
Care is taken while removing the last muscle fibers from
the anterior perichondrium of the rib. The anterior peri-
The choice of perioperative antibiotics is somewhat chondrium must be preserved. Scissors work well in
arbitrary, though good Staphylococcus (staph) removing the remaining muscle tissue adhering to the
coverage for skin flora makes sense. A preoperative perichondrium.
Gram stain and culture of tracheal secretions
help guide more directed antibiotic therapy in The decision as to which rib should be harvested will
the postoperative period. For patients with depend on the length of the cartilaginous component
preexisting tracheostomy, there is frequent of the rib, as well as its width and flatness. A wide, flat
colonization with Pseudomonas as well as costal cartilage is preferable to a narrow and more
Staphylococcus. RCNuss twisted or curved rib. RCNuss
Perichondrium
incision 1
Perichondrium
incision 2
FIGURE 7-4. Incisions on rib.
trates the cartilage because the plane beneath the pos-

It is critical not to damage the perichondrium with
terior perichondrium must be found in the next step.
the cautery or sharp instruments because this
creates a surface on which granulomas form
Elevating Posterior Perichondrium
postoperatively. JSidman
(Figure 7-5)
Camouflage of the incisions will be greatly appreci-

STEP 7. Using a Cottle or Freer elevator the posterior
ated by any patient. In women the inframammary fold
perichondrium is left down and the cartilaginous portion
offers a natural site for incisions (e.g., used during mam-
of the rib is separated from it.
moplasty). Monopolar cautery at 15 to 20 watts typi-
cally achieves dissection and hemostasis without too
much thermal tissue injury. The anterior perichondrium The Doyen (“pigtail”) elevator can be used to separate
becomes the fibrous scaffold on which the respiratory the posterior perichondrium from the rib and help
mucosa grow. Bare cartilage does not support epithelial avoid a pleural tear. JSidman
growth (and it was the exposed cartilage that likely led
to airway stenosis initially), thus great care must be used
at all stages of handling the costal cartilage graft to I use a rib periosteal elevator with a sharp edge to
preserve this perichondrium. start the elevation. JDSmith
Incisions on Rib (Figure 7-4) Separate the posterior perichondrium from the entire
length of costal cartilage that is planned for harvest.
Place a malleable retractor or other instrument between
STEP 6. The scalpel is used to incise the perichondrium
the posterior perichondrium and the cartilage.
along the superior and inferior edges of the rib. Bleeding
may occur from the inferior incision because the vascu-
lar pedicle to the rib runs along the inferior edge. This
STEP 8. A scalpel is then used to divide the cartilage
can be avoided by staying anterior with the scalpel.
starting at one of the bone-cartilage junctions. Once the
There is typically an anterior ridge along the inferior cartilage is cut, a skin hook can be placed into cartilage
rib. Just posterior to this ridge is the vascular pedicle to help expose the posterior surface of cartilage.
that should be avoided. Avoid an incision that pene- Use the Cottle elevator to complete the separation of
Posterior
perichondrium
FIGURE 7-5. Elevating the posterior perichondrium.
cartilage and perichondrium if needed. Protect the length of the rib. Placing an instrument beneath the
pleura by using the malleable instrument when the planned incision to release the rib protects against injury
second incision is made to separate bone and cartilage to the pleura. Further assurance is gained by testing for
and release the graft. Wrap the graft in a moist sponge an air leak during a Valsalva maneuver.
and put in a secure place on the back table.
A tear in the pleura is easily identified with this
maneuver. If present, a suction catheter is placed
STEP 9. Next fill the chest wound with sterile saline. Ask
through the tear and a figure-of-eight suture is placed
the anesthesiologist to perform a Valsalva maneuver to
while suctioning. Alternatively, a chest tube can be
check for injury to the pleura. If no air bubbles are seen,
placed but is rarely necessary. JSidman
it is safe to close the wound.
I prefer to do the costal cartilage harvest first. The

STEP 10. Close the chest wound in layers. Absorbable chest wound is closed prior to opening the airway and
Vicryl sutures are used to reapproximate the muscle and contaminating the field. By doing this there is no need
pectoralis major fascia. Place a Penrose drain beneath for regowning or using separate instrument trays (the
the muscle. Skin and subcutaneous tissue may be closed surgeon goes from “clean to dirty”). This strategy
in one or two layers based on surgeon preference. Cover requires protection of the chest wound with an occlusive
the wound with an occlusive dressing, then use sterile dressing and additional drapes. If the entire length of
drapes to cover the chest. cartilaginous rib is harvested there usually is sufficient
graft material for nearly any LTR.
Violation of the posterior perichondrium can lead to
injury to the parietal pleura and subsequent pneumo-
thorax. This must be considered at all times during this Knowing the length of the stenosis prior to costal
part of the dissection. The rib has a triangular shape in cartilage harvest, as well as plans for anterior only
cross-section, and the perichondrium is often more versus anterior and posterior grafts, allows for the
adherent closer to the sternum. Thus it may be easier to collection of an appropriate length of donor costal
start laterally and use both anterior and posterior peri- cartilage. Preservation of the posterior perichondrium
chondrial incisions to find this plane. Once the subperi- allows for regrowth of the patient’s rib over
chondrial plane is established a “pigtail” elevator can time. RCNuss
sometimes be used to complete the dissection along the
Laryngotracheal incision
Incision closed
with Penrose drain
FIGURE 7-6. Neck incisions.
Neck Incisions (Figure 7-6) A standard subplatysmal apron flap provides reliable
healing, presentation of the relevant neck anatomy, and
reasonable camouflage of the incisions. The ellipse of
STEP 11. If tracheostomy is present, an apron flap
soft tissue around the tracheostoma can be used as a
including an elliptic incision around the stoma is created.
handle to minimize trauma to the trachea and mucosa.
The lateral limbs of this incision are at the anterior
It can also aid with maintaining the ventilating tube in
border of the sternocleidomastoid muscle. The superior
position. The strap muscles should not be dissected off
extent is to the hyoid bone.
of the hyoid unless necessary for visualization. It is
important that they close over the airway and the ante-
We simply make a fusiform incision around the rior graft because they may promote survival of the graft
tracheotomy, about 3 cm long. The subplatysmal through inosculation.
dissection is carried superiorly to the palpated hyoid For clarity, the thyroid gland is not shown in these
bone. JSidman illustrations. However, the surgeon should be prepared
to split the thyroid gland in the midline if the isthmus
lies over a part of the anterior trachea that requires
If no tracheostomy and a single-stage reconstruction reconstruction. Care should be taken to preserve the
are planned, a shorter apron flap from the level of anterior perichondrium of the trachea. This situation is
the cricoid to the hyoid can be fashioned. Raise more commonly found in children than adults.
subplatysmal flaps to hyoid using electrocautery
dissection.
Anterior Airway Incision (Figure 7-7)
STEP 12. Next, split the strap muscles in the midline and STEP 13. A fresh scalpel is used to make a midline inci-
retract them laterally. Handheld retractors (e.g., army- sion through the cricothyroid membrane and cricoid
navy retractor) or sutures tied to the strap muscles can cartilage. Its inferior extent is dictated by the length of
be used. stenosis.
Level of anterior
commissure
Anterior
laryngotracheal
split
FIGURE 7-7. Anterior airway incision; laryngofissure.
This is a very important step in the operation. The This may be a point at which endoscopic evaluation
previously done laryngoscopy helps determine how of the glottis and subglottis by an assistant can
high the anterior tracheal incision needs to go and prove invaluable. The concern is to create the incision
depends on the exact location of the subglottic high enough to completely traverse the stenotic
stenosis. Only a No. 15 blade should be used here segment and to avoid trauma to the vocal folds and
and not a No. 11, to avoid accidental damage to anterior commissure. If necessary, as in the presence
the posterior tracheal wall. We have the assistant of an anterior glottic web, the incision can be
surgeon place a McCabe dissector in the airway endoscopically guided exactly through the anterior
through the stoma and in the midline. The surgeon commissure. RCNuss
then slowly cuts from inferior to superior. First the
tracheal rings above the stoma are cut, then the This incision should be precisely in the midline and
cricoid cartilage exactly in between the easily cleanly through cartilage. A fresh scalpel blade will help.
identified cricothyroid muscle insertions. Lastly, If there is dense fibrosis laterally along the cricoid, this
the inferior portion of the thyroid cartilage is cut, may be removed sharply. However, the mucosa overlying
no higher than the vocal cords. Laryngofissure is this area must be preserved. Gently elevate the mucosa,
not indicated in this operation and destabilizes the then use a scalpel to excise the fibrosis beneath it while
larynx. JSidman maintaining the integrity of the lateral lamina of the
cricoid. The idea is to re-create the “signet ring” lumen
of the natural subglottic airway. A ridge within the
If there is suprastomal granuloma or collapse (based subglottic airway could result in excessive transluminal
on endoscopic evaluation), the incision is carried to the pressure from the airway stent with resulting failure of
stoma. If necessary, elevate stomal soft tissue from the proper healing. The subglottic lumen may be signifi-
tracheal wall preserving the tracheal perichondrium. cantly narrowed in the transverse dimension. If the
The incision is also carried superiorly to just below the cricoid is divided laterally, the “four-quadrant” LTR will
anterior commissure. require additional time to heal and extubation may be
Incision
extended
FIGURE 7-8. Securing the TVCs.
delayed. Again, careful analysis of the airway stenosis superior extent of the posterior subglottis and cricoid
by endoscopy will determine the reconstructive needs. lamina. However, most children do not require complete
separation of the thyroid cartilage, as shown in Figure
We do not perform the four-quadrant LTR and have 7-7. The child’s posterior lamina of the cricoid can be
found that large anterior and posterior grafts solve the accessed without dividing the anterior commissure.
problem in all except grade 4 stenosis. For these we Complete laryngofissure destabilizes the larynx and, if
often perform cricotracheal resection. JSidman not precisely performed, jeopardizes the true vocal
cords and voice results. (If only an anterior graft is
If a single-stage LTR is planned (no tracheostomy at needed, incision through the anterior commissure is not
the end of the procedure), the cuff of stomal soft tissue needed.)
can be removed at this point. The distal ventilation tube
will now require monitoring because it is likely to fall The laryngofissure should be done only if there is
out during the next stages of the open laryngeal surgery. an anterior glottic web or if the superior part of the
The ventilation tube is replaced prior to placement of posterior cricoid (or interarytenoid space) cannot be
the anterior graft in a single-stage LTR. If a two-stage reached without splitting the anterior commissure.
LTR is planned, then preserving the stoma aids postop- The incision of the anterior commissure must be
erative care. The patient will not have a fresh stoma precisely in the midline and extend from the inferior
once the LTR is completed. edge of the thyroid cartilage to the thyroid notch.
Secure the anterior commissure using 6-0 Prolene on the
anterior true vocal cords, to be used later to sew to
Laryngofissure (see Figure 7-7) and Inset
contralateral thyroid cartilage (see Figure 7-8). Prior
of Suture to Secure the TVCs (Figure 7-8)
to completing the incision through the thyroid notch,
mark the sites of the anterior commissure on each
STEP 14. In adult patients who require a posterior graft, thyroid lamina with methylene blue or other indelible
a laryngofissure may be necessary to expose the marker.
Posterior
cricoid split
Elevating
posterior
pocket
FIGURE 7-9. Posterior cricoid split.
STEP 15. Once the anterior larynx is split to create the The laryngofissure must be precisely in the midline
needed exposure, 3-0 Prolene sutures placed lateral to in order to preserve true vocal cords. Some centers
the thyroid cartilage incision are used to retract the two perform this incision while the assistant does direct
sides laterally. Additional 1% lidocaine with 1 : 100,000 laryngoscopy. This allows endoscopic guidance of the
epinephrine is injected into the posterior subglottis in laryngofissure. This maneuver is awkward, however.
the midline. Once the anterior commissure is divided, its location
is marked on the thyroid laminae so the two points can
This injection is an extremely helpful maneuver and
be realigned precisely during repair. Also the anterior
will significantly help reduce oozing and improve the
true vocal cords are secured with fine monofilament
surgeon’s exposure. RCNuss
suture or they will retract and correct reconstruction of
the anterior commissure will be impossible; do not cut
needles from the suture. A bulldog clamp or other
Wait several minutes for vasoconstriction. If there is atraumatic clamp can be used to tag these sutures. Once
no contraindication, additional 0.5% oxymetazoline or the posterior lamina of the subglottis is fully exposed,
dilute (1 : 100,000) epinephrine may be applied to the local vasoconstriction helps visualize the next critical
mucosa on a cottonoid pledget. At this point the venti- incision.
lating tracheal tube can easily become dislodged from
the airway. It is incumbent on the surgeon to remain
vigilant throughout the remainder of the procedure and
reinsert the tube if needed.
An equally common event may be pushing the Posterior Cricoid Split (Figure 7-9)
endotracheal tube too distally, causing hypoventilation
of one lung. This must also be addressed
promptly. RCNuss STEP 16. Another fresh scalpel is used to make a midline
incision through the posterior subglottis.
We inject the posterior cricoid mucosa with local Creating a pocket of “just the right size” will indeed
anesthesia with epinephrine 1 : 100,000. The posterior help with the placement of the posterior graft. Too
cricoid limits are easily palpated with an instrument, large a pocket may allow the graft to slide laterally,
and the novice is always surprised at how much and too small a pocket will not allow the flanges to fit
taller it is than the anterior cricoid. Hence the term in correctly. RCNuss
“signet ring” (which has no meaning to many
surgeons!). JSidman
Placing a Posterior Graft (Figure 7-10)
This incision splits the cartilaginous lamina from

the interarytenoid space superiorly to the posterior tra- STEP 18. Multiple scalpel blades will be needed for
cheal wall inferiorly. Care is taken not to create multiple cutting and carving cartilage. A Teflon block is helpful
incisions in the cartilage. The depth of this incision as a cutting board for the cartilage graft. An angled
is to the posterior perichondrium of the cricoid. The elevator, such as a Rosen knife from a middle ear tray,
posterior cricoarytenoid muscles are not divided. It is may also be useful. An elliptic or pentagonal cartilage
extremely important that the retrocricoid mucosa is graft is carved from the rib graft. The perichondrium
kept intact. faces the lumen of the larynx. A narrow point should
extend superiorly toward the interarytenoid space.
This is important to avoid violating the We carve the graft slightly trapezoidal, with
esophagus. JSidman dimensions usually about 4 by 3 by 7 mm long. The
shelf on each side is 1 to 2 mm and is snap fit under
the posterior cricoid lamina without any previous
STEP 17. Elevate the outer (posterior) perichondrium undermining. This graft is quite solid and no sutures
from posterior lamina to create a pocket. A Cottle eleva- are placed. We abandoned the sutures technique
tor or a Rosen knife (otologic instrument) works well. about 10 years ago, and it has markedly reduced
This subperichondrial pocket should extend the length the problem of postoperative granuloma
of the cricoid lamina and extend a few millimeters later- formation. JSidman
ally from the midline.
A posterior ledge about 3 mm surrounds the graft.

We do not perform this step. We feel that elevating
This ledge will insert into the subperichondrial pocket
posterolaterally creates a space into which the
just created. Skin hooks applied to the cricoid cartilage
posterior graft sinks toward the esophagus, and
and rotating it help expose the pocket. The graft should
so the surface of the graft will not be flush with
“snap” into place. Use a monofilament absorbable
the cut cricoid edges. We allow the insertion of
suture on a noncutting needle to place at least four
the graft to perform the little undermining
horizontal mattress sutures in order to secure the
necessary. JSidman
graft.
If a single-stage procedure is planned, once the pos-
The posterior lamina of the cricoid is typically thicker terior graft is secure, pass a cuffed endotracheal tube
than the anterior portions. Stay within a single incision into the trachea (see Anesthetic Considerations). The
in order to aid in cartilage healing. Once the posterior surgeon directs the tube across the posterior graft and
perichondrium is identified, the incision ceases. Division into the distal trachea. The initial tracheal ventilating
of the retrocricoid mucosa can lead to contamination of tube is removed and ventilation proceeds via the newly
the LTR wound with saliva, chondritis, and failure of placed tube.
the surgery. The width of the graft will depend on the degree of
Do not divide the interarytenoid muscles unless there posterior stenosis and the mobility of the tissues. The
is a web. If there is a web, it can be repaired with a flap thickness of the graft should approximate the thickness
of perichondrium from the posterior cartilage graft of the posterior lamina. The thickness of the posterior
interposed between the incised web (not illustrated). lamina and the graft can be measured with calipers. The
Elevating the posterior perichondrium is a difficult perichondrium provides the scaffold for respiratory
part of the procedure and its proper execution will mucosa to grow. It is important to minimize any gaps
greatly influence reconstruction and healing. The angles between the graft and the subglottic mucosa. In a
for dissection are impaired by the contralateral larynx. severely scarred larynx, achieving enough mobility to
A pocket that can secure the flanges of the posterior insert and secure the graft without sutures may be dif-
graft will minimize or eliminate intraluminal sutures on ficult. A monofilament, double-armed suture (e.g., PDS,
the graft site. Monocryl, Maxon) is less traumatic to the tissues.
Posterior
graft
FIGURE 7-10. Placing the posterior graft.
is placed on the lateral edge on one side of the skin

Burying the sutures so that there is no exposed suture incision. Suture is passed through the strap muscles,
material intraluminally, helps prevent the development lateral cricoid, stent, and around the contralateral
of granulation tissue or suture granulomas in the sternocleidomastoid muscle and back in a mattress
postoperative period. RCNuss fashion.
Monofilament suture passes more easily through

Likewise, skin hooks reduce trauma to cartilage these tissues when it comes time to remove the stent.
compared with forceps. The endotracheal tube should Tying the knot over a Teflon button on the surface of
be at least a half-size smaller than one would normally the skin minimizes trauma to the skin, and it becomes
use, or smaller still if cuff pressure can be limited. simple to find the suture to cut at the time of stent
A small tube that is still adequate for low-pressure removal.
ventilation during the postoperative period minimizes Several types of stents have been described for LTR
the transmural pressure against the reconstructed sub- (complete discussion is beyond the scope of this chapter).
glottis. Good capillary perfusion optimizes wound What is important is the size of the stent, or a stent that
healing. can be fashioned to fit the laryngotracheal defect that
needs support. Also most stents are made from milled
(smooth) Teflon or Silastic, which limits the reactivity
Stent Placement for Two-Stage LTR
of the airway to this foreign body. In young children
(Figure 7-11)
manufactured stent choices are limited; most are made
for school-age children and larger patients.
STEP 19. If a two-stage repair is planned, the surgeon If a single-stage procedure is planned, at this point
places the stent over the posterior graft instead of the the endotracheal tube is passed by the anesthesiologist.
endotracheal tube. The stent is secured by passing a 2-0 Often it is a nasotracheal tube because this offers some
nylon suture on a large cutting needle. A Teflon button security against accidental extubation.
Stent secured
with suture
Stent placed
FIGURE 7-11. Stent placement for two-stage laryngotracheal reconstruction (LTR).
that perichondrium faces the airway lumen. An elliptic

We also prefer nasotracheal intubation. The or hexagonal shape is used to repair the defect in the
anesthetist intubates by standard technique as the anterior airway. The ledge that extends laterally from the
surgeon guides the tube after it is in the subglottis. Be graft should be at least 5 mm. Monofilament sutures
careful not to use a nasal RAE tube because this has with noncutting needles are used. The sutures do not
two curves that are very difficult to suction in the violate mucosa or perichondrium and are placed through
pediatric ICU (PICU) postoperatively. A straight nasal the graft so that that perichondrium aligns with the
tube suffices here. JSidman mucosa. All sutures are placed first to allow parachuting
the graft into place.
I like to present a tonsil clamp or other long-handled
clamp through the larynx. This provides the anesthesi- The key to this suture is placing the needle into the
ologist with a target. I like to grasp the tip of the endo- “crotch” between the shelf and the perichondrium
tracheal tube and deliver it through the operative field edge, forcing the perichondrium and the tracheal edge
to the distal trachea. At this point the trimmed RAE together. We also do not tie the sutures until they are
tube is removed and ventilation continued via the endo- all placed. We attempt to achieve an airtight closure
tracheal tube. to about 20 cm H2O pressure delivered by the
anesthesiologist in the saline-filled wound. JSidman
Anterior Graft “Parachuting” into Place

The shape of the graft allows the surrounding airway
(Figure 7-12)
tissues to more easily close around the recipient site.
This limits the amount of air leak through the repair.
STEP 20. Once the airway is secured (or stent in place), The ledge around the anterior graft prevents displace-
the anterior repair with cartilage graft is performed over ment into the airway lumen. It can also provide a surface
the tube. The remaining costal cartilage is carved to on which the suture knot can be tightened atraumati-
create the anterior graft. Again the graft is oriented so cally. More accurate suture placement is achieved by
Anterior Anterior
commissure commissure
suture suture
Anterior graft
FIGURE 7-12. Anterior graft “parachuting” into place.
passing all sutures first, then positioning the graft (para- If two-stage LTR was performed, insert sterile tra-
chuting) within the anterior defect. cheostomy tube after laryngofissure repair.
A 5-mm ledge is indeed very generous. It is also As noted, we do not perform laryngofissure as part of
possible to fashion an anterior graft that is completely a standard LTR. JSidman
fusiform in shape, or has a square caudal portion
(similar to a “square-backed canoe”) if one is
incorporating and closing the tracheostomy stoma in In general, it is wise to avoid a complete laryngofissure
the repair. RCNuss with division of the anterior commissure unless this is
absolutely necessary, such as for repair of a glottic
Laryngofissure Repair (Figure 7-13) web. RCNuss
STEP 21. Repair of laryngofissure and anterior commis- STEP 22. Reapproximate the strap muscles over the
sure requires precise realignment. Using the methylene laryngotracheal complex. Vicryl or other absorbable
blue marks as a guide, pass the 6-0 Prolene through the suture is used. A Penrose drain is placed beneath the
contralateral thyroid lamina. Do this on each side, then inferior edge of strap muscles, and strap muscles are
carefully bring tension on the sutures as you align the loosely closed. The apron flap is now returned to posi-
marks on the thyroid lamina. Tie down each Prolene tion and layered closure performed. Absorbable suture
separately while maintaining tension on the other. Then is used to close the platysma and subcutaneous tissues.
monofilament suture can be used to repair the thyroid Skin closure can be done with suture or staples.
lamina on both sides of the commissure.
Because of the precision needed to correctly reconstruct
I use PDS to avoid the possibility of later “spitting” of the anterior commissure and true vocal cords after
the sutures through the laryngeal mucosa. JDSmith laryngofissure, some centers will do this with endo-
scopic guidance assisting the surgeon. The endoscopic
Laryngofissure
repair sutures
Horizontal suture
of anterior
commissure
FIGURE 7-13. Laryngofissure repair.
manipulation of the larynx can impede the closure of discussed with the ICU team. Avoiding paralysis of the
the larynx, however. Careful initial markings (see Figures patient will avoid challenges in fluid management,
7-11 and 7-12) obviate the need for endoscopic though this may not be possible with young children
assistance. who, when agitated, unintentionally extubate them-
An airtight seal is rarely possible after the anterior selves. Enteral feeding is begun within the first 24 hours
graft is placed; therefore, to prevent pneumomediasti- and continued until extubation. The drain placed in the
num, the Penrose drain is used. Meticulous technique chest donor site is left in place for 24 to 48 hours or
and good hemostasis will limit the amount of serosan- until the drainage has ceased. The neck drain is kept
guineous drainage. Skin and flap closure can be done by until there are no signs of air leak.
the surgeon’s preference.
It is also reasonable to leave the neck drain in place

We do strive for and achieve airtight closure up to a until the patient is extubated. RCNuss
pressure of at least 30 cm H2O. Fill the repair site with
saline, deflate the endotracheal tube cuff, ask the
anesthesiologist to perform a Valsalva maneuver,
We do not routinely place a chest donor site drain. We
and look for air bubbles. A few additional sutures will
do, however, always place a drain under the strap
help seal the leak and may save problems in the
muscles, even when we achieve an airtight
postoperative period by minimizing the chance of
closure. JSidman
pneumomediastinum. RCNuss
Once drains are removed, dressings are no longer

Postoperative Management needed on the wounds. Application of ointment to keep
The patient is transferred directly from the OR to the the incision moist is all that is needed; if used, nonab-
ICU or other unit where nursing and respiratory care is sorbable sutures or staples are removed per the sur-
skilled in airway and ventilator management. A chest geon’s routine. Antibiotics are used while drains are in
radiograph is obtained to ensure that a pneumothorax place, then discontinued once they are removed. Anti-
does not exist. Initial focus is on respiratory status. If reflux medications are begun (or resumed) immediately
the patient is to become ambulatory, either with a tra- after surgery and continued for at least 2 months. If the
cheostomy or nasotracheal tube, then weaning from the patient has a nasotracheal tube the nasal ala must be
ventilator is discussed with the attending intensivist. If watched for signs of pressure ischemia. Adjusting the
the patient will not be ambulatory during the postopera- position of the tube and using taping techniques can
tive period while grafts are healing, a sedation plan is prevent alar rim necrosis.
extubating the patient. Failure at extubation after LTR

This is an excellent point. This has to be reinforced to
has many causes including edema, restenosis, graft
all medical providers and to the parents. Educating
failure, and respiratory failure. Steroids given within 8
everyone about this preventable problem is time well
hours prior to extubation may help prevent postextuba-
spent. RCNuss
tion stridor.
The decision to return the patient to the OR for

As noted, we do not perform extubation in the OR, but
microdirectlaryngoscopy and timing for extubation are
wait about 6 weeks for the first laryngoscopy. We use
based on the extent of reconstruction, number of grafts
3- to 5-day intubation for anterior-only grafts, and
used, and overall patient status. Knowing that the
7 days for anterior and posterior grafts. JSidman
airway edema has subsided is also an important consid-
eration. Airway edema can be determined by what pres-
sure an air leak can be generated around the endotracheal The patient should be monitored carefully for at
tube. Using a manometer and an Ambu bag, the endo- least 24 hours after extubation. Pulse oximetry and
tracheal tube cuff is deflated, and the air pressure is cardiac monitoring will help detect impending respira-
measured once air is heard escaping from the patient’s tory compromise. Especially if the patient was kept
mouth. Successful extubation is most likely if the pres- sedated or paralyzed while intubated he or she will be
sure is less than 20 cm H2O. The patient should not be weak and require physical therapy in order to resume
paralyzed during this maneuver. activities of daily living once extubated.
In general it takes 4 to 7 days for an anterior graft–
only LTR to heal. Ten to 14 days are often needed to Tapering of benzodiazepines or narcotics may be
allow the posterior graft to heal. The posterior graft is necessary if these were used for sedation after the
more difficult to position and is subject to more defor- initial surgery. RCNuss
mational pressures (swallowing, tube movement, etc.).
A speech and language pathologist can also perform

“Healing” is hard to define in this setting. The strength
a swallowing evaluation to ensure that the patient is not
of the repair may not develop for several weeks. Thus
aspirating and that it is safe for the patient to eat.
the integrity and positioning of the graft are completely
Ideally, when discharged the patient has resumed a
dependent on the shape and fit of the graft as well as
regular diet and normal activities.
the sutures for at least the first few weeks. The length
of time to keep a patient intubated after a single-stage
LTR is somewhat arbitrary, based on tradition and It is common for children to be uncoordinated and
good results on past experience. One may also disoriented following 5 to 7 days of intubation and
consider extubation much sooner, once perioperative sedation. We don’t start oral feeding until they are
edema has subsided. A sooner extubation helps avoid oriented, and do not routinely perform swallow
postoperative complications related to prolonged studies. JSidman
periods of sedation or bedrest. One may also argue
that healing occurs sooner with the stent or
endotracheal tube out. RCNuss Of note, patients who have undergone an LTR with
both anterior and posterior grafts may have a higher
risk of aspiration of thin liquids, especially if there is
In an awake, single-stage LTR patient who has an noted to be vocal fold immobility prior to the
air leak at less than 20 cm, extubation may be performed surgery. RCNuss
at the bedside. In most cases, though, it is advised to
return the patient to the OR prior to extubation. MDLB
allows the surgeon to assess the larynx and trachea for In two-stage LTR the patient does not require the
the status of the grafts and for granulomas or other same degree of vigilance postoperatively, especially if
lesions that could complicate extubation. The grafts the stomal soft tissue is preserved as a “mature stoma.”
should show evidence of epithelialization when the These two-stage LTR patients should be able to resume
white perichondrium starts turning pink. Often granu- their preoperative tracheostomy care routine within a
lomas are excised, either sharply or with laser. If there couple of days after surgery. Enteral feeding is advised
are no major obstructing lesions, the patient is carefully to minimize the risk of aspiration and limit laryngeal
reintubated by the surgeon using a slightly smaller oral movement.
endotracheal tube, especially if the patient has had pro- Stent removal is planned at least 3 weeks after
longed sedation. This approach allows the patient to be surgery. The length of time the stent remains is place is
properly weaned from the sedating medications and determined by the condition of the laryngotracheal
neuromuscular status more fully restored prior to finally complex at the time of LTR. If the recipient cartilage
framework and mucosa were in good condition with

limited fibrosis, early stent removal is planned. However, and nursing care available. If patients are not
more severely damaged (or missing) framework or cared for on a regular basis by very experienced
larger areas of mucosal injury mean that the stent will ICU nurses, ICU personnel, and physicians, it may
be needed to support healing for a longer time. be safer to do a two-stage procedure from the
Stent removal is performed during microdirectlaryn- standpoint of postoperative airway control.
goscopy. The surgeon can grasp the stent with micro- Although it requires more time and procedures,
laryngeal forceps and remove it once the suture is cut the final results from correction of the stenosis
and pulled through. This maneuver should be done with should be the same with both procedures.
minimal trauma to the larynx. Once the stent is out, the Therefore, the ultimate decision should be based
surgical site can be inspected and granulation tissue on what is safest for the patient’s postoperative
removed, if needed. I prefer to decannulate the patient airway care in your hands and setting. JDSmith
weeks later once it is clear that laryngeal function has
returned and there are no signs of restenosis.
Suggested Readings
EDITORIAL COMMENT: The technique described
Goldenberg D, Esclamado R, Flint PW, Cummings CW: Surgi-
in this chapter is an excellent summary of both cal management of upper airway stenosis. In Cummings
a one- and two-stage LTR. Although one CW, Flint PW, Harker LA, Haughey BH, Richardson MA,
commentator does only one-stage LTRs, the Robbins KT, et al, editors: Cummings otolaryngology
beginner or occasional operator should head & neck surgery, ed 4, Philadelphia, 2005, Mosby,
understand the two-stage procedure and consider pp 2103-2127.
it in the more severe or complicated stenosis Postic WP, Cotton RT, Handler SD: Surgical pediatric otolar-
repairs. The choice also is influenced by the ICU yngology, New York, 1997, Thieme Medical Publishers,
pp 384-403.
CHAPTER
Cricotracheal Resection
8 for Subglottic Stenosis
Author Peter E. Andersen
Commentary by James I. Cohen, Robin T. Cotton, and Paul W. Flint
Perform suspension laryngoscopy or tracheoscopy to STEP 2. The skin incision is very similar to that used for
inspect the nature of stenosis. On conclusion, intubate thyroid surgery. Elevate the subplatysmal skin flaps up to
with a small endotracheal tube (ETT) with the cuff the hyoid bone and down to the sternal notch (Figure 8-3).
positioned below the area of stenosis (Figure 8-1).
If a laryngeal release is planned, I will do it at this point
Especially in children, an alternative to a cuffed ETT is because the exposure is easiest. JICohen
to use the appropriate ETT sized to the area of stenosis.
In cases of severe stenosis, balloon dilatation may be The setup can be reversed depending on the surgeon’s
used to increase the airway diameter to place a larger preference. RTCotton
ETT before proceeding with surgical correction. This
may provide a temporary but safer airway during the
surgical procedure. RTCotton STEP 3. Divide the strap muscles in the midline from
hyoid bone to sternal notch (Figure 8-4).
Using a zero-degree rigid telescope to visualize the
stenosis allows for accurate measurement of length to I elevate the strap muscles off the thyroid and
be resected. By marking the telescope with a blue pretracheal tissues fully because I think this helps with
marker at the hub of the laryngoscope as the telescope overall mobilization of the laryngotracheal complex so
passes the level of the vocal folds, and the proximal that subsequent reanastomosis is tension free. JICohen
and distal limits of the stenosis, length of the stenosis
and proximity to the vocal folds is determined. PWFlint
STEP 4. Divide the thyroid isthmus and reflect the thyroid
lobes laterally off of the trachea and cricoid cartilage.
I use jet ventilation during the laryngoscopy and Divide the pretracheal fatty tissue and reflect this later-
tracheoscopy. ally and off the trachea. You should now have the area
of stenosis exposed with at least three rings of normal
In children, inhalation anesthesia with an apneic trachea visible below the area of stenosis (Figure 8-5).
technique is the preferred method during
microdirectlaryngoscopy and bronchoscopy (MDLB). I make every effort to dissect at least the anterior
Surgical planning is often made at a prior MDLB before 180 degrees of the trachea and cricoid free because
proceeding to a definite reconstructive procedure. this significantly improves mobilization. To protect the
A Maloney esophageal bougie is placed to help define nerve, this often means a subperichondrial dissection in
the esophagus during the tracheal dissection later in the region of Berry’s ligament. JICohen
the procedure to prevent accidental entry into the
esophagus. RTCotton As long as you hug the trachea during this maneuver
you will not injure the recurrent laryngeal nerve. The
closer you get to the cricoid, the more careful you have
STEP 1. The patient is in the supine position with a hori- to become. It is not necessary to visually identify the
zontally placed shoulder roll. The ETT should be brought nerve during this maneuver.
over the head as shown. Make sure to have ready access
to the ETT pilot balloon and the tape securing the ETT
in place. The operating room (OR) setup is as shown STEP 5. Begin your releasing maneuvers by bluntly dis-
(Figure 8-2). secting the fatty tissue off of the anterior wall of the
77
FIGURE 8-3. Location of incision.
FIGURE 8-1. Position the balloon of the endotracheal tube

distal to the level of the stenosis.
Superior retraction on the larynx facilitates extending
this dissection as inferiorly as possible. When complete
Anesthesia there should be no scar bands tethering the trachea
machine
from the level of the cricoids to the carina with a single
Anesthesiologist plane of dissection. JICohen
Assistant 1
Care should be taken with this maneuver to identify
the innominate artery and prevent accidental injury.
Preservation of the lateral attachments is crucial for
vascular supply to the trachea. RTCotton
If a suprahyoid release is needed for closure, perform it

now by dividing the suprahyoid muscles from the hyoid
bone from lesser cornu to lesser cornu. Divide the hyoid
bone just lateral to the lesser cornua with a saw or bone
Assistant 2
cutter.
Alternatively, you may leave this decision until after the

resection. A high stenosis at the level of the cricoid
Scrub nurse First surgeon may be closed without this maneuver. Extension of the
Mayo instrument stenosis into the cervical trachea and/or resection of a
table
tracheotomy site increases the likelihood that a
FIGURE 8-2. Operating room layout. suprahyoid release will be required. PWFlint
trachea with your finger. Continue this blunt dissection I find it helpful to use a right-angle clamp to dissect
into the mediastinum as far as possible (preferably to underneath the hyoid at the area it is to be divided
the carina). Sweep laterally along the trachea on both and elevate it forward. This facilitates its
sides to free up approximately 270 degrees of the division. JICohen
trachea from the surrounding tissues (Figure 8-6).
CHAPTER 8 Cricotracheal Resection for Subglottic Stenosis 79
FIGURE 8-4. Vertical division of strap muscles in the midline.
FIGURE 8-5. Elevation of strap muscles off of the thyroid gland, larynx, and trachea. Dotted
line indicates location of division of the thyroid isthmus.
FIGURE 8-6. A, Reflection of thyroid lobes off of the trachea and cricoid cartilage up to
the ligament of Berry and blunt dissection of trachea within the mediastinum using finger
(inset). B, Skeletonization of central portion of hyoid and division of hyoid at lesser cornu to
release tension during closure (this maneuver is not required in all cases).
FIGURE 8-7. Entry into the trachea.
It may be preferable to perform the suprahyoid release A vertical incision through the stenotic segment
when assessing the anastomotic closure. The tension allows the surgeon to adapt the operation to a
on the anastomosis and the mobility of the trachea will laryngotracheoplasty with cartilage augmentation if the
often dictate whether a suprahyoid release is needed. stenotic segment is found to be longer intraoperatively
Releasing the musculature from the superior than what was appreciated on endoscopy.
attachments of the hyoid is often all that is Endoscopically assisted division is often helpful
needed. RTCotton in revision cases, in which a second surgeon
performs the endoscopy during the laryngotracheal
fissure. RTCotton
STEP 6. Enter the trachea through the area of stenosis
and using scalpel or scissors gradually remove the ste-
notic anterior and lateral trachea up to the cricoid car-
tilage and inferiorly until you have reached healthy Visualization of the airway is facilitated by placing skin
trachea (Figure 8-7). hooks in the anterior wall for lateral displacement. If
the area of stenosis is not readily apparent, direct
I prefer to enter in a vertical manner at the midline of laryngoscopy may be performed and the airway
what appears to be the tightest area of the stenosis. visualized with a telescope as a needle is passed into
I then extend this superiorly and inferiorly until I come the trachea from the surgical field, providing precise
to what appears to be a more normal airway. At this external landmarks. PWFlint
point I “T” it laterally. I find this allows me to be most
precise in terms of preserving as much of the normal
airway as possible. JICohen STEP 7. Intubate the patient through the operative field
(Figure 8-8).
I enter the trachea vertically through a less than 1-cm I find that sewing a red rubber catheter to the oral
tracheotomy and then gradually remove trachea until I endotracheal tube prior to withdrawing it greatly facili-
have reached healthy tissue. Take care not to puncture tates the oral endotracheal reintubation at the latter
the balloon of the ETT during this maneuver. stages of the operation.
Red rubber
catheter
FIGURE 8-8. A and B, Removal of oral endotracheal tube from the operative field and
replacement with endotracheal tube into distal trachea. Catheter sewn to tip of removed
endotracheal tube facilitates reinsertion (inset).
A second sterile ETT then can be placed through the After the midline incision to divide and assess the
fissure and used to ventilate the patient and the oral stenosis, the lateral aspects of the stenotic segment
placed tube can be removed. Cuffed anode tubes or a are then skeletonized hugging the tracheal cartilage.
cut oral ray are preferable. The tube can be secured The cricothyroid muscle is peeled off the cricoid from
by sutures to the neck or chest skin. We do not place medial to lateral. Care must be taken around the
a red rubber catheter through cricoid to provide better cricothyroid joint to not inadvertently injure the
visualization and assessment of the resection; 2-0 recurrent laryngeal nerves. A horizontal incision is
Prolene lateral retention stitches are placed around a made in the posterior wall of the cricoid and the
single trachea ring in the distal tracheal segment and mucosa is dissected off the cricoid inferiorly to the
clamped. These ensure that the tracheal stump is end of the cricoid. The posterior tracheal wall is then
secured once the trachea has been dissected away from the esophageal party wall using
transected. RTCotton the bougie to help identify the esophagus. Blunt
dissection is then used to free up the posterior
trachea. Preservation of the lateral attachments
ensures vascular supply to the trachea and prevents
This maneuver is a time saver at the end of the case.
injury to the recurrent laryngeal nerves. The stenotic
Alternatively, the ETT may be passed over a
tracheal segment can then be removed. A posterior
nasogastric (NG) tube fed retrograde through the
tongue is left to help cover the denuded posterior
tracheotomy. This technique reduces the number of
cricoid. RTCotton
objects within the operative field. PWFlint
STEP 9. Dissect the trachea off of the esophagus for no

STEP 8. Divide the posterior tracheal wall and resect the
more than five rings (Figure 8-10). The five-ring limit is to
posterior wall up to the cricoid cartilage (Figure 8-9).
decrease the risk of ischemia of the tracheal stump.
Although some redundancy of the posterior wall is well

This maneuver may be delayed until just prior to
tolerated and smoothes out with time, I agree that it
closure and after assessing the amount of tension
should be resected even with the level of anterior
necessary to approximate the trachea to the cricoid.
tracheal resection. However, I prefer to divide it
A suprahyoid release should be considered at this
horizontally at the midpoint of the area of stenosis and
time as well. Limiting posterior dissection minimizes
trim it only after fully mobilizing the airway off the
the risk of ischemia and subsequent dehiscence or
underlying esophagus. I find there is often some
restenosis. PWFlint
distortion of the back wall until this is performed and a
more accurate assessment of the level to trim it can
be done. JICohen
More dissection can be used, especially in children, to
gain appropriate mobility of the trachea. Once the
During this maneuver it is tempting to leave the
tracheal dissection is complete, the esophageal
posterior wall intact if it is not diseased. However, I find
bougie can be removed. RTCotton
this to be counterproductive because during the closure
this tissue will bunch up posteriorly as the tracheal
anastomosis is performed.
STEP 10. Elevate the cricothyroid muscles off of the
If there is substantial scarring in the posterior
anterior and lateral aspects of the cricoid (Figure 8-11).
subglottis and the posterior tracheal wall is in good
shape, consider leaving some of the posterior wall The attachments of the cricothyroid muscle anteriorly
attached to the tracheal stump. This can be advanced are divided using the bipolar cautery. More laterally
into the posterior subglottis during closure to cover dissection in a subperichondrial plane with a periosteal
exposed cricoid cartilage. If not needed it can be elevator.
discarded later.
The goal is to join this plane inferiorly to the previous
If identification of the tracheoesophageal groove and plane of dissection of the thyroid off the trachea so
common party wall is not easily accomplished that the upper segment of the airway is fully exposed
because of scar, you may choose to divide the and mobilized as much as possible. JICohen
anterior and posterior walls at the proximal end of the
stenosis to facilitate separation of the trachea from
the esophagus. PWFlint STEP 11. Remove the anterior arch of the cricoid carti-
lage (Figure 8-12).
ETT
Catheter
Head
Head Head
FIGURE 8-9. A, Separation of posterior tracheal wall from esophagus. B, Division posterior
tracheal wall and dissection of distal trachea off of esophagus.
This can be done quickly with a pair of heavy scissors. STEP 12. Elevate the mucosa off of the inner aspect of
In addition, resect the soft tissue of the cricothyroid the remaining lateral cricoid bilaterally and then resect
membrane up to the inferior aspect of the cricoid the exposed cricoid cartilage using a Lempert rongeur
cartilage. (Figure 8-13).
The cricoid can be assessed. The anterior and lateral The goal here is to remove as much of the lateral cricoid
arch can be removed using a Beaver blade. This cartilage as possible without disrupting the cricoaryte-
excision often is beveled to prevent injuring the noid joints. If the posterior subglottis is scarred, you can
recurrent nerves. If the posterior cricoid plate is either resect the involved mucosa and advance the pos-
scarred and thick, a diamond drill bit can be used to terior tracheal flap (described in Step 10) into the defect
thin the posterior cricoid plate. RTCotton or elevate just the mucosa off of the underlying fibrous
tissue and perform a submucosal fibrosectomy.
Carina
FIGURE 8-10. Circumferential mobilization of distal trachea (about five rings can be
circumferentially mobilized without risk of avascular necrosis).
Bipolar
cautery
Head
Cricothyroid m.
FIGURE 8-11. Reflection of the cricothyroid muscles off anterior and lateral aspect of cricoid
cartilage.
Anterior arch
of cricoid cartilage
FIGURE 8-12. Removal of the anterior arch of the cricoid cartilage.
Elevate lateral
cricoid mucosa Lempert
rongeur
Thyroid
cartilage
FIGURE 8-13. Reflection of the mucosa off the interior aspect of the lateral arches of the
cricoid cartilage. Nibble back the lateral cricoid cartilage to just anterior to the cricoarytenoid
joint (inset).
Feet
Head
FIGURE 8-14. Closure of the posterior wall to

the trachea to the posterior cricoid lamina and
mucosa.
Preservation of the lateral aspect of the cricoids In this step the shoulder roll should be removed and the
cartilage facilitates closure and improves the strength neck flexed slightly. If tension is too great and there is
of the closure. A modification of the technique concern about tearing of the mucosal layer, consider
described here entails pulling the tracheal rings inside tagging the posterior wall sutures, and place and tie the
the cricoid remnant in a telescoping manner and lateral sutures from the cricoid to tracheal ring first, thus
suturing the proximal tracheal ring to the cricoid reducing tension on the mucosal layer (see Steps 15 and
juxtaposed in a side-by-side manner. PWFlint 16). This method requires placement of the ETT prior to
securing the lateral and anterior sutures. PWFlint
STEP 13. Close the posterior tracheal wall with inter-

rupted sutures of 3-0 Maxon (Figure 8-14). Two 2-0 PDS retention lateral mattress sutures are then
placed through the thyroid cartilage and exiting the
I find that five sutures are usually needed. Place all the posterior lateral aspect of the cricoid. The suture is
sutures before tying. Make sure that the knots are on then placed submucosally on the tracheal stump to
the outside of the trachea. loop around a cartilage ring and then back through
cricoid and out thyroid cartilage. These sutures help to
relieve tension on the anastomosis and provide stability
during the closure. The anastomosis can be made as
Depending on the amount of tension and exposure, described previously, or per our preference, which has
I will sometimes lay in all the sutures (anterior and been to use a double-armed 4-0 PDS suture to perform
posterior) before tying them because I can place them a running closure. Once the initial posterior sutures
more accurately. To do this I begin in the midline have been placed, the running anastomosis is
posteriorly and tag each suture, placing the sutures in tightened using a nerve hook to ensure a tight closure.
order on an arm-navy style retractor—one on each The patient can then be intubated orally or transnasally
side of the field. After they are all placed, I reverse the if the plan is to leave the patient intubated. After
retractor and take them off to tie them in reverse order securing the running closure, the lateral retention
beginning posteriorly. JICohen sutures can be secured and tied down. RTCotton
FIGURE 8-15. Reintubation of the patient orotracheally.
FIGURE 8-16. Closure of the lateral and

anterior aspects of the anastomosis.
STEP 14. Reintubate the patient orotracheally (Figure STEP 15. Close the lateral and anterior portions of
8-15). the anastomosis using interrupted 3-0 Maxon sutures
(Figure 8-16).
Make sure the cuff of the ETT is not too far into the
trachea because as you close the anterior and lateral Place all the sutures prior to tying them. The lateral
parts of the anastomosis it is easy for the tube to wind sutures are placed from the trachea to the remaining
up in the right mainstem bronchus. lateral cricoid cartilage. The anterior sutures are placed
from the trachea to the anterior aspect of the thyroid

cartilage. You may need to drill holes for the sutures in
the thyroid cartilage.
Taking the patient out of neck extension at this point

can facilitate reanastomosis. JICohen
Coat the anastomosis with fibrin glue.
I have not found this to be necessary. JICohen
A leak test is often performed prior to placing the

fibrin sealant to assess for potential anastomotic leak.
Sterile saline is placed in the wound and the
anesthetist tests the anastomosis to 30 mm Hg
pressure. Any leaks are addressed with interrupted
sutures, and the anastomosis is tested until no
more leaks are noted. Fibrin sealant is then
placed. RTCotton
STEP 16. Close the wound over a 12 -inch Penrose drain.

Close the strap muscles in the midline and the skin
according to the surgeon’s preference (Figure 8-17). FIGURE 8-17. Wound closure.
Alternatively, you may use a closed suction drain to

monitor for air leak. I find this useful in more difficult
closures in which intubation postoperatively is I do not use a neck brace to maintain flexion, but if I
considered. PWFlint have concerns I keep the patient on a couple of
pillows to maintain flexion when he or she is supine
and counsel him or her to avoid significant extension.
If I am significantly concerned about the airway I will A standard cervical collar can be useful in this
leave the most anterior anastomotic suture long and regard. JICohen
bring it out through the wound should emergent
tracheotomy be necessary. JICohen
The Grillo stitch does seem unnecessary today, given

The strap musculature is then reapproximated. that other options including neck brace are available
The Penrose drain is placed on top of the strap when an extended resection is performed and neck
musculature. The straps provide important vascular flexion needs to be maintained. PWFlint
supply to the reconstruction and the Penrose left
between the trachea and the muscle can interfere with
this process. The distal retention sutures are then Children often will need to be transnasally intubated
looped around the hyoid bone using a free large Keith for 7 to 10 days. Additionally, cases in which the
needle. These allow for additional detensioning of the resection is close to the vocal folds are much more
anastomosis. RTCotton prone to glottic edema and often need intubation until
this subsides. We typically leave patients in a C-collar
or place chin-to-chest sutures for 10 to 14 days.
I routinely extubate these patients in the OR and do Stitches should be placed through the periosteum of
not send them to the intensive care unit (ICU) postop- the mandible and through the periosteum of the
eratively. The airway is much larger after the operation clavicular head. There was a brief period when we did
than it was before and therefore whatever airway swell- not use either of these methods and had a significant
ing occurs is not problematic. I do not suture the chin increase in dehiscence rates. RTCotton
to the sternum, nor do I use a neck brace.
Suggested Readings
EDITORIAL COMMENT: Otolaryngologists have
been relative latecomers to the performance Grillo H, Mathisen D, Ashiku S, Wright C, Wain J: Successful
of this operation rather than expansion treatment of idiopathic laryngotracheal stenosis by resec-
laryngoplasties or tracheoplasties. However, its tion and primary anastomosis. Ann Otol Rhinol Laryngol
advantages, in terms of being a reliable one-stage 112:798-800, 2003.
Grillo H, Mathisen D, Wain J: Laryngotracheal resection and
procedure without the need for tracheotomy, have
reconstruction for subglottic stenosis. Ann Thorac Surg
allowed it to quickly assume a prominent role in
53:54-63, 1992.
the management of upper airway stenosis. Sandu K, Monnier P: Cricotracheal resection. Otolaryngol
Although conceptually a straightforward Clin North Am 41:981-998, 2008.
operation, the details as outlined by the author
and commentators that focus on the creation of a
tension-free anastomosis and protection (without
identification) of the recurrent laryngeal nerves are
critical to its performance and are accomplished
similarly in adults and children. JICohen
CHAPTER
Surgery for Unilateral Vocal Fold Paralysis
Commentary by Mark S. Courey, C. Gaelyn Garrett, C. Blake Simpson
Preoperative Considerations For unknown reasons it is estimated that up to 30% of

Treatment of unilateral vocal fold motion impairment patients with unilateral vocal fold immobility due to
depends on the symptoms and position of the vocal fold. neurologic injury have adequate voice and swallow
Though most patients with a truly paralyzed vocal fold function and do not desire intervention for
and glottic insufficiency complain of occasional cough- management of their injury. In this case, adequate
ing when swallowing liquids, swallowing difficulties are voice does not mean “normal voice.” Rather it means
generally very mild in isolated cases of vocal fold motion acceptable voice for the patient. MSCourey
impairment.
Electromyographic studies of vocal fold activity during Another symptom associated with glottal insufficiency
swallowing demonstrate that thyroarytenoid muscle that is frequently overlooked is a sensation of
contraction occurs during the later stages of the shortness of breath when talking and occasionally
swallow. Therefore, if glottic closure is not complete, with mild aerobic exercise such as climbing stairs.
aspiration of retrained pharyngeal contents can occur This air escape usually improves after
after the swallow. This is clinically significant if injury medialization. CGGarrett
to the motor pharyngeal and sensory branches of
cranial nerve (CN) X occur in conjunction with injury to
the motor branches of the recurrent laryngeal nerve. In Vocal fold motion occurs in both the horizontal and
such cases, patients may not have normal pharyngeal vertical planes. This is due to the angled position of
function to allow stripping of the contents during the the cricoarytenoid joint and the action of the intrinsic
swallow or normal pharyngeal sensation to trigger a laryngeal muscles, which direct the vocal process of
second swallow of retained food products. MSCourey the arytenoids downward during adduction. Therefore
the immobile vocal process is usually at a higher level
Vocal quality is generally of greater concern. Rarely, than the mobile vocal process during adduction for
the immobile or weak vocal fold rests in a median phonation. As such, failure of vocal fold closure can
position, allowing satisfactory to excellent voicing occur from horizontal insufficiency as well as vertical
(Figure 9-1). Unfortunately, the majority of patients insufficiency or height mismatch because the upper
assume a paramedian to lateral (sometimes called the and lower lip regions of the vocal fold are not well
cadaveric) position of the weak vocal fold with variable approximated if the vocal processes of the arytenoids
degrees of glottic insufficiency. With a paramedian posi- do not meet in the vertical plane. This vertical
tion and good compensation from the opposite side, dimension of motion is difficult to evaluate because
some patients experience only vocal fatigue and a vague we typically use a monocular, two-dimensional
globus sensation from the added work necessary to endoscopy system during indirect laryngoscopy for
close the glottic gap and attain adequate voice. Raising laryngeal evaluation. MSCourey
vocal intensity (e.g., yelling) and lowering pitch often
expose the true limitations in voice as the glottic insuf-
ficiency increases. However, with a paramedian to Medialization procedures aim to restore glottic
lateral position of the vocal fold and inadequate com- competence by placing the immobile or weak vocal
pensation from the opposite vocal fold, patients will fold in or near the midline with adequate support to
experience a breathy aphonia that is terribly effortful to prevent displacement with subglottal air pressure during
use and precludes adequate phonation in most cases. voicing.
Patients with poorly compensated glottic insufficiency The vocal folds can be accessed in the lower half of
are candidates for medialization. the thyroid cartilage (Figure 9-2). The upper edge of the
91
The vocal fold often lies at a level below the midway

point between the lower border and the inferior point
of the notch. MSCourey
Paramedian
position
The angle of the vocal fold may be approximated
LEFT
from this spot as a line parallel to the true inferior
RIGHT
border of the thyroid cartilage. It is important to iden-
tify the tubercle of the thyroid cartilage and find the
inferior border posterior to this landmark to accurately
identify this line. Everything inferior to this line inside
the thyroid lamina represents the paraglottic space,
inclusive of the thyroarytenoid muscle complex, vocal
ligament, lamina propria, and mucosa of the vocal fold
Lateral
(see Figure 9-2).
(cadaveric) The best results can allow completely normal voicing
Median position
(normal adduction)
position with little or no compensation on the part of the oppo-
site vocal fold. To achieve this, the immobile or weak
FIGURE 9-1. Vocal fold position in unilateral paralysis. vocal fold needs to be able to vibrate at the same fre-
quency, phase, and amplitude as the normal vocal fold
without an anterior glottic gap. Excessive medialization
and midvocal fold tension can perturb vocal quality just
as much as inadequate medialization or midfold support.
Although stroboscopy is tremendously helpful in assess-
Superior edge
of vocal fold ing results (particularly failures), it is impractical in
most situations during the procedure, and the surgeon
Thyroid “tunes” the voice with his or her ear. This is why most
notch definitive medialization procedures are performed under
Arytenoid
light conscious sedation and local anesthetic.
Montgomery’s
tubercle
True inferior Although significant improvement in the speaking

border of voice is expected, patients need to be advised that
thyroid cartilage improvement in the singing voice may be variable
because of the persistent inability to dynamically
Thyroid change the tension and length of the paralyzed vocal
tubercle fold. CGGarrett
Vocal fold augmentation to correct glottic insuffi-

ciency occurs through two basic means: percutaneous
injection and open external medialization.
FIGURE 9-2. Surface anatomy of the laryngeal cartilages. Percutaneous or transoral injection of “filler” mate-
rials allows temporary improvement in glottic closure,
voice, and swallowing in a brief outpatient or office-
based procedure. Teflon paste is the only permanent
vocal fold typically runs from Montgomery’s tubercle at injectable material available, but has been associated
the anterior commissure to the vocal process. Unfortu- with chronic inflammatory responses and granulomas
nately, Montgomery’s tubercle lies on the inner thyroid in some patients. Although no safe permanent injectable
lamina, but the location of the anterior commissure can material exists, the duration of effect between available
be estimated from the surface of the thyroid cartilage injectables varies from 4 weeks to as many as 2 years.
by identifying a point midway between the lower border This often allows adequate time for return of function
of the thyroid cartilage and the inferior-most point of in cases of neuropraxia. Most weakness is considered
the thyroid notch. There is often a small blood vessel in permanent 1 year following injury or noted absence of
the cartilage here running to Broyles’ ligament. function.
CHAPTER 9 Surgery for Unilateral Vocal Fold Paralysis 93
Teflon paste has been abandoned for use in

Transoral Injection Laryngoplasty
medialization procedures by most surgeons because
of the significant incidence of inflammatory response STEP 1. The oropharynx and larynx are anesthetized
and the more reliable outcomes by other temporary locally with 2% to 4% lidocaine applied topically.
and permanent means. Also, the use of temporary
injection augmentation does not seem to affect the
recovery of a neuropraxic injury. Even partial recovery Anesthesia can be achieved by dripping topical
of innervation during this time can result in improved anesthetics directly onto the larynx and pharynx,
vocal fold tone and possible avoidance of further swabbing the larynx and pharynx with cotton soaked
treatment. CGGarrett in topical anesthetics and held with a McGill forceps
or through inhalation of nebulized agents. MSCourey
Permanent medialization is typically performed

when the deficit is determined to be permanent and
The glottis may be exposed with a mirror while the
stable. These procedures typically incorporate some
patient holds his or her tongue.
form of implant. These implants vary in composition
from polytetrafluoroethylene (PTFE [Gore-Tex]) tape,
solid polymerized silicone (Silastic), adjustable metal
A more facile way to perform this is to have an
shim, and preformed calcium hydroxylapatite. All have
assistant use a flexible endoscope for guidance. This
the same goal of re-creating glottal competence through
allows the surgeon to use both hands for the injection;
stable medial displacement of the vocal fold.
the nondominant hand holding the tongue and the
dominant hand holding the injection device. The
surgeon is then able to stabilize the shaft of the
Medialization procedures do not directly address the
needle on the index finger of the hand grasping the
vertical dimension of vocal fold motion and glottic
tongue. CBSimpson
closure. Cadaveric studies demonstrate that the
arytenoid cartilage does rotate during filling of the
paraglottic space. This rotation is an accidental
byproduct from filling the paraglottic space and STEP 2. Entry into the paraglottic space is performed
cannot reliably be controlled. Arytenoid adduction with a curved needle or cannula. Entry is best about
from sutures placed through the muscular process of 2 mm anterior to the vocal process, about 3 mm lateral
the arytenoids allows controlled repositioning of the to the edge of the vocal fold and about 4 mm deep into
arytenoids such that the vertical height of the vocal the tissue (Figure 9-3).
process can be adjusted. MSCourey
Temporary injection laryngoplasty allows safe, fast, and
minimally invasive correction of glottic insufficiency. It
is often used in the acute setting and does not alter the
Additional procedures, including arytenoid adduc-
likelihood of return to normal function with resolution
tion, reinnervation, and muscle flaps, can be used instead
of neuropraxia.
of or in addition to an implant for medialization. These
There are two primary means to access the paraglot-
procedures are not discussed in this chapter.
tic space for injection of the weak vocal fold: transoral
and percutaneous transthyroid or thyrohyoid space.
In selecting the medialization technique, the surgeon Sometimes, the addition of a superior laryngeal nerve
needs to consider the three-dimensional structure and block can aid in regional anesthesia.
dynamic function of the cricoarytenoid joint. Simple Improvement in cough and valving for swallowing
medialization with some materials does not always are reliable and often critical in patients at risk for
position the vocal fold at the same level as the mobile aspiration following cervical or thoracic surgery.
vocal fold nor does it always provide the needed bulk Although the vocal quality can be excellent follow-
in the vertical dimension. Alternative implant materials ing injection laryngoplasty, the voice results are proba-
or the other adjunctive procedures mentioned bly less reliable than formal medialization thyroplasty
previously should be considered in these cases. with an implant and will fade with time. The efficacy
Medialization outcomes with a fixed cricoarytenoid of injection depends on location of the injection and
joint as opposed to a passively mobile but paralyzed amount injected. This places the material into the para-
vocal fold are generally poorer, and proper patient glottic space near the vocal ligament posteriorly, where
counseling preoperatively will help set appropriate most of the medialization needs to occur. Careful injec-
expectations. CGGarrett tion, often with a Bruning or similar syringe, allows
gentle fusiform filling of the paraglottic space from
Vocal
process
30%
over-
injection
FIGURE 9-3. A, Transoral vocal fold injection. B, Needle

placement for vocal fold injection. B
posterior to anterior. The amount of material injected recovery. Injectable materials that disappear rapidly
varies based on the size of the patient, precise location (months) should be “overinjected” by as much as 30%
of injection, adequacy of filling, and type of injectable, beyond what appears appropriate or provides a good
but it is typically about 0.4 to 0.6 mL. vocal quality to allow for displacement or clearance of
The choice of injection material is up to the surgeon the material with time, whereas those that last for a year
and depends on the expected duration of vocal fold or more should be injected to good vocal quality. After
overinjection with short-acting material, the patient’s

STEP 3. The paraglottic space is accessed percutane-
voice will be very tight and pressed, but the patient can
ously directly through the thyroid cartilage with a 23- to
be reassured that this will improve over 5 to 14 days
25-gauge needle, depending on the viscosity of the
depending on the degree of injection. No voice restric-
injected material (Figure 9-4).
tion is necessary.
Gentle “coring” rotation of the needle allows passage
through even the densest of thyroid laminas. Once
Although overinjection is usually required for these through inner table of the thyroid lamina, careful
temporary injectables, the percentage of overinjection advance of the needle into the paraglottic space after
can vary among the type used. Anecdotally, the use of breaching the inner thyroid perichondrium will demon-
reconstituted collagen-based materials requires more strate “tenting” of the vocal ligament in the posterior
overinjection as a result of the loss of saline within the third of the vocal fold.
first several days postinjection. Less overinjection Accidental entries into the ventricle, subglottis,
(about 10%) may be required for the ready-to-use and false vocal fold are common and provide the
injectables such as calcium hydroxylapatite surgeon with a means to assess position and allow for
paste. CGGarrett replacement of the needle into the correct location. If
possible, the surgeon should avoid mucosal violation
because the small amount of bleeding will obscure the
This technique requires excellent topical anesthesia view from the laryngoscope and cause the patient to
and operative experience or skillfulness on the part of cough.
the surgeon. The technique can be difficult to learn
and requires practice for best results. The technique is
considered difficult even by surgeons who have This technique, the “point touch technique,” is
practiced their techniques. The procedure requires so somewhat easier to master than the transoral injection
much skill that when Teflon was first developed, it was technique. Because ideally the needle does not enter
proposed that the injection be limited to a number of the airway or pass the oropharynx, coughing and
surgeons with demonstrated abilities. MSCourey gagging are reduced. The surgeon can spend time
repositioning the needle. However, passing the needle
through the thyroid cartilage stimulates sensory nerve
fibers and is perceived as painful by most patients.
Generally an additional 0.1 to 0.2 mL of material is
Therefore, the technique is not recommended for
injected after the vocal fold is straight, giving it a
patients with low pain tolerance or even those with
convex, rounded contour. CBSimpson
laryngeal hypersensitivity who are difficult to examine
with indirect techniques. MSCourey
Percutaneous Transthyroid
Injection Laryngoplasty Injection location within the larynx is key to optimal
result. The most common complication is to inject too
STEP 1. The patient’s nose is treated with aerosolized superficially within the superficial layer of the lamina
topical anesthetic and decongestant. The surgeon then propria (SLP). Regardless of material used, the
palpates the larynx to identify the thyroid notch, crico- injection should be lateral into the vocalis muscle or
thyroid space, and posterior border of the thyroid carti- paraglottic space. Entry into the SLP can result in a
lage. The skin overlying the lower half of the thyroid stiff vocal fold or even an inflammatory response that
cartilage is anesthetized with 1% to 2% lidocaine. can take several weeks to resolve. CGGarrett
Selection of the point of entry is the most difficult part

of this procedure and is roughly based on the midpoint
STEP 4. When the needle is properly positioned in the
of thyroid cartilage in the anteroposterior dimension
paraglottic space, the surgeon injects the laryngoplasty
and midpoint of the lower half of the thyroid
material.
cartilage.
The needle should be withdrawn a few millimeters into
the paraglottic space and the vocal fold filled to the
STEP 2. An assistant exposes the glottis with a flexible desired degree.
laryngoscope and projects the image on a video screen If the lateral percutaneous approach fails to allow
for the surgeon to see. adequate placement of injectable, a transthyrohyoid
approach may be considered. Local anesthesia of the
Often, entry in the contralateral naris will allow the best vocal fold mucosa and airway is typically required for
view of the weak vocal fold. this approach (see Amin, 2006).
View Through Scope
FIGURE 9-4. Percutaneous transthyrohyoid injection of the vocal fold.
In patients who cannot tolerate unsedated transoral

or percutaneous injection laryngoplasty, the procedure accomplished under direct laryngoscopy and any
may be performed under brief general anesthetic by material injected too superficially can be easily
direct laryngoscopy by using a long needle or cannula removed. The patient is allowed to talk immediately
through a laryngoscope transorally. The procedure may after surgery to mold the material within the vocal fold.
be performed with a small endotracheal tube in place At least two recent studies comparing awake versus
or with mask ventilation under apneic conditions. The operating room injection revealed equivalent voice
injection point and degree of fill are identical as for outcomes but slightly higher complication rates with
transoral unsedated injection. A microscope or tele- the in-office approach (see references). The
scope and suspension bar may facilitate placement of approach used should be the one best suited for
injection. It is, however, impossible to assess adequacy the clinical situation and the experience of the
of injection by vocal quality for longer-acting injectables surgeon. CGGarrett
with this technique.
Type I Medialization Thyroplasty

Certainly, office-based procedures are attractive for
obvious reasons including the avoidance of general STEP 1. The patient is positioned in the “beach chair”
anesthesia, for example. For my patients, I offer both position for comfort. The back is up at about 30 degrees
in-office and general anesthesia approaches. In my with the knees and hips comfortably flexed to keep the
practice the transoral approach in the operating room patient from sliding off the table.
is the preferred method because of patient choice and
procedure outcome. A more precise injection can be This procedure is best performed under local anesthesia
with mild sedation to allow intraoperative assessment
Hyoid bone
Thyroid notch
Incision placed
in skin crease
FIGURE 9-5. Incision placement for medialization thyroplasty.
and “tuning” of the voice. Adequate preoperative assess-

My approach to the level of patient sedation has been
ment of vocal fold position, including degree of atrophy,
modified over time. A careful discussion with the
height discrepancy relative to the normal vocal fold, and
anesthesia team before surgery avoids any
integrity of the lamina propria is best achieved with
misunderstanding as to the level of alertness required
videostroboscopy. The procedure described here is much
to achieve optimal outcome. My practice is to avoid
as described by Netterville and produces reliable results.
any sedation (including anxiolytics) until just prior to
injection of the local anesthesia (a 1 : 1 mixture of 1%
lidocaine with 1 : 100,000 epinephrine and 0.5%
bupivacaine with 1 : 200,000 epinephrine). The
STEP 2. The neck is gently extended and carefully pal-
contralateral naris is anesthetized with a cottonoid
pated for surface landmarks. The cricoid, cricothyroid
pledget saturated with a mixture of tetracaine and
space, thyroid notch and lateral border of the thyroid
oxymetazoline. The patient is given intravenous
cartilage are identified.
propofol just prior to injection and placement of the
transnasal laryngoscope, then allowed to awaken fully
and remain unsedated for the remainder of the
STEP 3. An incision is marked out just above the inferior procedure. Communication with the patient during
border of the thyroid cartilage from the midline to the surgery is vital. Intravenous anxiolytics can be avoided
lateral border of the thyroid cartilage in or parallel to a in all cases with this approach. If needed, intravenous
skin crease. This is anesthetized with a mixture of 1% fentanyl is used for patient comfort during the
lidocaine and 0.25% bupivacaine containing 1 : 200,000 procedure. This approach is extremely well tolerated
epinephrine (Figure 9-5). by patients and allows them to cooperate fully during
the procedure. CGGarrett
In women—who have a very subtle thyroid notch—it is
advisable to identify the hyoid bone and thyrohyoid
space to confirm location of the entire thyroid lamina. The choice of medication(s) for sedation is important.
Wide injection and addition of a small amount of Generally, a dexmedetomidine (Precedex) drip is
sodium bicarbonate allow a field block and limit patient preferred, which allows adequate sedation without
discomfort. Additional local anesthetic may be needed disinhibition. The patient is generally able to respond
throughout the procedure. to commands quite readily when the medication
Sedation is best kept at a minimum because patients is stopped. Propofol (Diprivan) should be
who are deeply sedated may become disoriented and avoided. CBSimpson
suffer airway embarrassment if prone to sleep apnea.
troubleshooting if the vocal quality is not as good as

IV pole
expected.
The patient can be prepped and draped using a clear
plastic drape over the laryngoscope to allow manipula-
tion during the procedure.
Tape
loop STEP 5. Skin incision is made and subplatysmal flaps
View Through Scope
are raised to just above the hyoid bone superiorly and
below the cricoid inferiorly.
Careful undermining medially and laterally at the edges

of the incision facilitates maximal exposure through a
small incision.
STEP 6. The sternohyoid and sternothyroid muscles are

separated in the midline from the hyoid bone to the
lower border of the cricoid cartilage.
The surgeon should avoid cutting the sternothyroid and

thyrohyoid muscles because these are extralaryngeal
muscles that may be useful for compensation even fol-
lowing medialization thyroplasty to facilitate voicing.
STEP 7. The spine of the thyroid cartilage is identified

and the perichondrium is incised sharply.
Flexible
laryngoscope
STEP 8. The perichondrium is carefully elevated on the
ipsilateral side over the thyroid lamina using a combina-
tion of Freer and Cottle elevators (Figure 9-7A).
Extension of the perichondrium cuts should be made

laterally across the inferior and superior borders of the
thyroid cartilage to develop a flap and provide access to
the entire thyroid lamina.
Vocal folds A single hook in the thyroid notch stabilizes
the thyroid cartilage and facilitate dissection and
visualization.
Dense muscular attachments will be encountered at
the tubercle of the thyroid cartilage from the cricothy-
roid muscle. These should not be completely detached
to allow elevation of pitch following the procedure, but
the surgeon must elevate beyond these attachments to
identify the true inferior border of the thyroid cartilage
FIGURE 9-6. Flexible videolaryngoscopy during medialization (see Figure 9-2). The vocal folds are parallel to this true
thyroplasty. inferior border, and the surgeon can use this line to
ascertain the trajectory of the vocal folds and better
STEP 4. Visualization of the vocal folds can be attained orient the implant.
during the procedure by suspending a flexible laryn
goscope attached to a camera and video monitor The cricothyroid muscular attachments need to be
(Figure 9-6). detached enough to allow room for the inferior flanges
of the implant. Failure to detach these fibers may lead
The nose may be topically treated with 4% cocaine
to difficulty inserting the implant and possibly superior
solution on a cotton-tipped applicator to allow ade-
rotation of the implant. CBSimpson
quate vasoconstriction and analgesia for flexible lar
yngoscopy.
Visualization of the larynx during the procedure aids Modest elevation of the contralateral perichondrium
the surgeon in medialization at the appropriate height allows better visualization of the spine of the thyroid
and helps prevent medialization of undesired structures, cartilage and facilitates closure of the perichondrium at
such as the false vocal folds. It can also aid in the conclusion of the procedure.
Hook in
thyroid notch This is a posteriorly based flap. One should use
caution in making the initial incision over the thyroid
ala to avoid penetration through noncalcified cartilage
that can be seen in some patients (especially young
patients). CBSimpson
Right side of
thyroid cartilage
exposed
STEP 9. The midline of the spine of the thyroid cartilage
is identified. A mark is placed 5 mm laterally from this
spot in a woman and 7 mm laterally in a man. This marks
Perichondrium with the anterior border of the thyroid cartilage window. A
sternohyoid and thyrohyoid
muscles retracted rectangular window is then fashioned posterior to this
spot as determined by the implant type used for the
A
procedure (see Figure 9-7B).
Location If carving from a silicone block or using a Netterville
of window
thyroplasty implant (Medtronic Xomed, Jacksonville,
Fla.), the window will be 6 by 13 mm. The window
should be oriented parallel to the true inferior border
5 - 7 mm
from midline of the thyroid cartilage.
Regardless of implant type, the window must be at
3 mm from
inferior border least 3 mm from the inferior border of the thyroid car-
tilage near its anterior border to prevent fracture of the
cartilage at this site. Other implant systems are similar,
but may use windows of different sizes. If using Gore-
Tex tape, the window is typically smaller to prevent
lateral displacement of the tape through the window.
Once marked, a window in the thyroid cartilage may
be excavated using a 3-mm cutting burr, Beaver 69
blade, Kerrison rongeurs, and/or mastoid curettes.
Very careful attention must be paid to maintain the
inferior strut of cartilage and keep the window sharply
defined to a rectangular 6 by 13 mm, or as determined
Partial by the system used. Oversized or fractured windows do
excavation
with drill not allow stable placement of the implant and may not
allow optimal position of the implant for voice
restoration.
B
FIGURE 9-7. A, Exposure of thyroid cartilage. B, Placement

and creation of the window.
My approach is similar to that described, using the
Medtronic Netterville Silastic implant. I am now using
a smaller window, though, usually measuring 5 by 9 to
10 mm. CGGarrett
In order to obtain adequate exposure, the outer

perichondrium of the thyroid lamina is elevated
posterior to the attachments of the pharyngeal
constrictor muscles. These muscles are elevated along It is critical to maintain the anterior to posterior
with the outer perichondrium. If simultaneous support and dimension of the ipsilateral thyroid lamina.
arytenoid adduction is planned, the outer If the inferior strut is interrupted or the cricothyroid
perichondrium and associated muscles can be joint fractured, pull of the ipsilateral intrinsic laryngeal
elevated all the way to the posterior border of the muscles results in shortening of the injured side of the
thyroid lamina. This allows exposure of the posterior larynx. The patient will not be able to maintain
and piriform sinus mucosa in a relatively bloodless symmetric laryngeal tension and closure will be
plane. MSCourey permanently impaired. MSCourey
STEP 10. The inner perichondrium is carefully incised

with a Beaver blade and removed to provide access to This vessel is commonly identified running in
the paraglottic space just lateral to the thyroarytenoid proximity to the adductor branches of the recurrent
muscle fascia, nerve bundle, and vasculature. laryngeal nerve. Care should be taken to avoid injuring
the vessel because cautery will likely damage the
nerve and disrupt the innervation responsible for vocal
fold tone. MSCourey
Original descriptions of the procedure by Isshiki
stressed the importance of keeping the inner
perichondrium intact. It was thought that this provided
a barrier to infection. The concept was derived from STEP 11. Elevate the paraglottic space using right-angle
early 20th century reports of the procedure in which and “hockey stick” elevators to free the muscle from the
the inner perichondrium was violated and infection inner thyroid perichondrium (Figure 9-8A).
developed. This was before the availability of Elevation should always take place posteriorly and infe-
antibiotics. If one attempts to medialize the vocal fold riorly first. Elevation should proceed to the arytenoid
with an intact inner perichondrium, then the entire and allow medialization of the vocal process. This is at
inner perichondrium must be elevated from the inside least 5 mm posteriorly in most patients and may be
of the thyroid lamina to achieve adequate visualized on the flexible laryngoscope; 5 mm of inferior
medialization. If the inner perichondrium is incised or elevation should be completed and the surgeon will
removed, the paraglottic space is entered. The fascia see the paraglottic space displace medially through the
of the thyroarytenoid muscle serves as a barrier and window with inspiration. Very careful superior and
creates a relatively bloodless plane or potential space anterior elevation should also be performed, staying
in which dissection can be undertaken and an implant closely approximated to the thyroid cartilage. The upper
placed. The surgeon needs to exercise caution not to border of the window is often immediately adjacent to
violate the ventricular mucosa. This mucosa is closest the ventricle and it is easy to enter the laryngeal lumen
to the thyroid cartilage at the anterior and superior at this site. Very careful attention should be paid not to
portions of the window. If the overhead lights in the violate the mucosa because this may allow extrusion of
room are dimmed, the light from the flexible the implant into the airway after placement. Usually
laryngoscope will be visualized transilluminating only 3 mm of superior elevation and 1 to 2 mm of
through the mucosa. If the ventricular mucosa is anterior elevation is necessary.
violated, the breach must be closed primarily, then Elevation is complete when the surgeon can depress
oversewn with a fascia patch and the wound irrigated. the paraglottic space 8 to 9 mm from the inner border
Careful attention to this detail can allow the surgeon of the thyroid cartilage without difficulty.
to continue with the procedure without significant The site should be tested for mucosal violation by
increased risk of implant extrusion. Infection and filling the window with saline and having the patient
implant extrusion from type 1 thyroplasty is most likely cough. Airflow through the window indicates a leak. If
secondary to unrecognized perforation of the confirmed, the procedure should be aborted to allow
ventricular mucosa. MSCourey time for healing.
This step may not be necessary. When the Kerrison Anterior elevation through the window has the greatest
forceps are used to remove the cartilage from the chance of resulting in mucosal perforation. For this
window, the inner perichondrium tends to be removed reason I avoid anterior elevation and usually have
with each bite of the instrument. Once the window about 5 to 7 mm of medial displacement of the
has been completely removed, the remaining paraglottic contents. CGGarrett
perichondrium at the perimeter of the excision can
often be visualized as a slightly frayed, white
fibrous tissue adherent to the inner aspect of the
cartilage. CBSimpson This is especially true anteriorly, where the ventricular
mucosa often approximates the cartilage. In general,
the undermining within the paraglottic space occurs
inferior, posterior and superior to the window.
There is a small, vertically oriented blood vessel To avoid perforating airway mucosa no anterior
immediately deep to the inner thyroid perichondrium in elevation should be performed, as mentioned
the anterior third of the window. Judicious bipolar earlier. CBSimpson
cautery will be necessary if bleeding is encountered.
Area of elevation
within paraglottic
Elevator space
Vocal fold
pushed to
midline
FIGURE 9-8. A, Elevation of the

paraglottic space. B, Measuring
B medial displacement of the vocal fold.
STEP 12. Determine the location of the window relative focal fold may result in vibration of this tissue and a
to the vocal fold by depressing within the window and rough vocal quality despite an optimally medialized true
viewing the vocal fold on the monitor. vocal fold.
Typically, the window is high relative to the optimal

medialization point and the lower border of the window
medializes the vocal fold without medializing the false STEP 13. Depression on the paraglottic space near the
vocal fold, but the position of the vocal fold relative to posterior aspect of the window with a measuring rod
the window varies based on the size of the larynx and medializes the vocal fold and vocal process, closing the
support of the arytenoid. Medialization of the false glottic gap (see Figure 9-8B).
Convex
(more support)
Posterior
displacement Concave
(less support)
Thyroid cartilage
Vocal
ligaments
Convex Concave
Arytenoid
cartilage
B C Cricoid
cartilage
FIGURE 9-9. A to C, Creation of the thyroplasty implant.
STEP 14. While elevating within the paraglottic space,

test the voice with sustained vowel phonation, counting, Compensatory laryngeal hyperfunction can create
yelling, and even singing. When completed, the surgeon difficulty in determining adequate vocal fold position
prepares the implant material. Parameters for working intraoperatively. Therefore the best surgical results can
with carved Silastic are demonstrated in Figure 9-9. be achieved if the patient is instructed on how to
eliminate this hyperfunction preoperatively. One of the
Because these procedures are considered permanent, the goals of preoperative voice therapy with this group of
surgeon should make every effort to attain optimal patients is to “unload” the larynx so that patients
vocal quality with repositioning. produce adduction of the mobile vocal fold without
overexaggeration of the extrinsic and intrinsic
laryngeal muscles. Often this requires that the patient
accept a breathy or nearly aphonic voice. MSCourey
Typically, in the male larynx optimal medialization is at
the posterior inferior aspect of the window. However,
in the female larynx, it is not infrequent that the
optimal area for medialization is at the midpoint of the
window or even at the anterior aspect. CBSimpson
Most patients do not have significant muscle tension,

and in general correct medialization results in a good
Often, the patient acquires compensatory laryngeal vocal quality on the operating room table. However,
and extralaryngeal hyperfunction that is not desired the technique of reducing supraglottic muscle tension
once the vocal fold in repositioned. A basic understand- for those patients with a “tight” vocal quality as
ing of voice therapy and experience can help the surgeon described is a good method for managing these
tremendously in assessing voice and adequate medial- patients. CBSimpson
ization during thyroplasty.
Too much medialization results in a tight, pressed

foreign body sensation. In revision surgery, an
quality that is hard for the patient to use. Too little
excessively large posterior plastic implant or Gore-Tex
depression results in a breathy, weak vocal quality that
ribbon packed up against the arytenoids is frequently
does not project well. Generally, optimal medialization
encountered. Simple removal of this posterior implant
results in a voice that is slightly tight.
material often results in vocal improvement and relief
of foreign body sensation. MSCourey
At the time of insertion of the final implant, it is usually

preferable for the patient to have a slightly strained
vocal quality. Minimal lateral traction on the implant Remember when sizing the implant, that even a small
should result in resolution of the vocal strain. If slight anterior flange can result in unintended anterior
vocal strain is not present at the end of the case, then medialization and a pressed or strained voice. I
as edema resolves over the first month postoperatively generally carve my implants without an anterior flange,
the patient can be undermedialized. MSCourey with the remaining three sides securing the implant in
place. CGGarrett
Often, compensation on the part of the patient

STEP 15. Once positioned, any excess material project-
results in a tight vocal quality with minimal medial
ing from the face of the thyroid cartilage should be
displacement of the vocal fold (e.g., 5 mm). Relaxation
trimmed and the wound irrigated. The perichondrium
of the voice with forward-focused resonance using and strap muscles should be reapproximated using
humming and improved breath support may eliminate absorbable suture.
some of this tightness and relaxed voicing will allow
further medialization of the vocal fold. A small drain is advisable to note air leaks.
Diplophonia is common during medialization and
may signify a differential tone between the two vocal
folds. This can indicate too much or too little midfold
support. Gently rocking the elevator anteriorly and pos- A drain is not necessary in most cases. Meticulous
teriorly can allow fine tuning of the vocal quality to attention to hemostasis often obviates the need for
determine if more or less displacement of the vocal fold drain placement. CBSimpson
anteriorly is necessary. The surgeon can address this
when preparing the implant and provide more or less
support in the midfold by the shape of the implant.
STEP 16. The wound is closed in the platysma and skin
Once the surgeon determines through voice testing
layers per surgeon preference.
the adequate location of medialization, maximal depth
of medialization, and necessary midfold support, an Following the procedure the patient may resume normal
implant is prepared to these specifications. These can be voicing and oral intake. The voice is often somewhat
carved by hand from silicone, packed in to optimal tight, but this typically resolves as the patient adapts to
voice using Gore-Tex, or obtained preformed. Whatever the new position of the vocal fold and the edema
approach is used, the implant must be secure in the subsides.
window so that it cannot be displaced. This generally
means a tight fit to the window proper and a flange of
about 3 mm superiorly, inferiorly, and posteriorly to The voice is typically rough or raspy within a few
secure it in place. A 1-mm flange anteriorly does help hours after the procedure, and may take to 8 weeks
provide stability. If silicone is used, it is gently placed to completely normalize as the edema subsides
posteriorly in the window first, with the flanges care- and more functional phonatory patterns
fully folded, and gently tucked in anteriorly with forceps emerge. CBSimpson
and a Freer elevator. The flanges should open com-
pletely on the inside of the paraglottic space and the
implant should fit very securely.
Follow-up with videostroboscopy in 3 weeks typi-
cally provides adequate time for resolution of edema
Care must be taken not to place too much pressure and healing to note vocal fold position, mucosal wave-
on the vocal process or the body of the arytenoid. form, and vocal quality. In rare cases—particularly
Excessive force can displace the arytenoid into an those with long-standing glottic incompetence—voice
undesirable position, resulting in dysphonia and a therapy may be indicated to eliminate residual laryngeal
hyperfunction.
Suggested Readings
EDITORIAL COMMENT: Although conceptually
straightforward, surgical medialization of the Amin MR: Thyrohyoid approach for vocal fold augmentation.
paralyzed vocal cord requires careful attention to Ann Otol Rhinol Laryngol 115:699-702, 2006.
detail so that implant placement, whether by King JM, Simpson C: Modern injection augmentation for
injection or external approach, ends up being glottic insufficiency. Curr Opin Otolaryngol Head Neck
Surg 15:153-158, 2007.
exactly where it is desired. The author and
Mathison CC, Villari CR, Klein AM, Johns MM 3rd: Com-
commentators outline their particular preferences
parison of outcomes and complications between awake and
to accomplish this, which, as can be seen, cover a asleep injection laryngoplasty: a case-control study. Laryn-
wide spectrum. The variations in their technique, goscope 119:1417-1423, 2009.
all of which produce good results in their hands, Netterville J, Stone RE, Luken ES, Civantos FJ, Ossoff RH:
speak to the relative imprecision of the overall Silastic medialization and arytenoids adduction: the Vander-
technique of medialization regardless of approach bilt experience. A review of 116 phonosurgical procedures.
relative to the complexity of the function of the Ann Otol Rhinol Laryngol 102:413-424, 1993.
larynx in voice production; and the ability of Simpson CB, Rosen CA: Operative techniques in laryngology,
the body to adapt to an improved but not Heidelberg, 2008, Springer, pp 215-220, 241-251.
perfect vocal cord position in the majority of Sulica L, Rosen CA, Postma GN, Simpson B, Amin M, Courey
M, et al: Current practice in injection augmentation of the
circumstances. JICohen
vocal folds: indications, treatment principles, techniques,
and complications. Laryngoscope 120:319-325, 2010.
CHAPTER
Excision of Saccular Cysts
10 and Laryngoceles
Commentary by Paul W. Flint, Henry T. Hoffman, and Albert L. Merati
Preoperative Considerations vocal fold (marsupialization). This may be performed

Laryngoceles are rare benign cysts of the supraglottis. using a CO2 laser, as described in this section;
Most are internal and may begin as congenital saccular however, I prefer using a microdebrider with a 4-mm
cysts. These form from collections of serous mucus in Tricut blade for more rapid resection of the false vocal
the anterior ventricle. They may grow up into the false fold. Hemostasis is obtained using a laryngeal suction
vocal fold and become remarkably large. Many are not cautery device. PWFlint
appreciated until they begin to obstruct the airway,
but some contact the true vocal fold and contribute to
voice change. Not all saccular cysts or laryngoceles need be
External laryngoceles begin within the larynx and addressed surgically. Observation with fiberoptic video
grow from the false vocal fold out of the larynx through transnasal laryngoscopy after initial computed
the thyrohyoid space and may present as an anterior tomography (CT) imaging may suffice in most cases.
neck mass before they elicit any other symptoms. Concern about the etiology warrants attention to
In very rare cases—typically in wind instrument possible obstruction to saccular drainage by
players—reducible air-filled cysts may form. These cancer. HTHoffman
rarely require operative management.
I rarely need to do open approaches even for

Most are indeed fluid filled, but some truly are combined sacs. Almost all are handled endoscopically
just air-filled sacs like those seen in howler with the CO2 laser. ALMerati
monkeys. ALMerati
Management of the airway is critical because these

Removal of internal laryngoceles and saccular cysts lesions are not fixed. Recumbency can cause an appar-
can be performed endoscopically. External laryngoceles ent increase in size of the lesion and distort the laryngeal
and combined internal and external laryngoceles are anatomy. The surgeon should be prepared for a difficult
often managed through an open approach. In both intubation and to manage the airway with the assistance
approaches the patient is supine. All procedures, both of the anesthesia staff. I typically use intravenous (IV)
open and endoscopic, typically begin with upper airway steroids and a single perioperative dose of antibiotics
endoscopy to evaluate the lesion completely. directed at skin flora.
The surgical approach to removal of an internal Endoscopic Management

laryngoscope should be dictated based on the of Internal Laryngocele
pathology identified. The saccular cyst is typically fluid
filled and does not communicate with the airway,
whereas the laryngocele is more likely to contain air STEP 1. Perform direct suspension microlaryngoscopy.
and communicate with the airway via the laryngeal
ventricle. Marsupialization of a saccular cyst is likely to I prefer a Lindholm or similar supraglottic laryngoscope
result in recurrence, and complete excision is for this—exposure is critical. I inspect the lesion
recommended as described here. An air-filled thoroughly with 0- and 30-degree telescopes and try
laryngocele, on the other hand, may be managed to determine the origin of the lesion, if possible, and
endoscopically with removal of the medial wall or false the fullest extent of the lesion within the paraglottic
space.
105
Vocal Blunt
fold probe
Laryngocele
Incision False
opened vocal
with laser cord Laryngocele
FIGURE 10-1. Incision of the false vocal fold mucosa over FIGURE 10-2. Blunt dissection within the submucosa of the
the cyst. false vocal fold to expose the cyst.
The endoscopic approach is facilitated using a

addition, a small ( 1 8 × 1 8 inch) cottonoid pledget may
Lindholm laryngoscope, which provides full
be used on a small alligator forceps to facilitate blunt
visualization of the false fold and the aryepiglottic
dissection. Even very large laryngoceles involving the
fold. PWFlint
entire aryepiglottic fold may be dissected in this fashion.
Great care should be taken not to injure the superior
vocal fold mucosa because this may result in scarring
STEP 2. Begin with a mucosal incision in the false vocal and permanent dysphonia. Closure of the false vocal
fold (Figure 10-1). fold mucosa is not necessary. Redundant false vocal fold
or aryepiglottic fold mucosa may be trimmed at the
I start over the middle of the lesion between the aryepi- conclusion of the procedure.
glottic fold and the free edge of the false vocal fold. The
incision may be made with either a CO2 laser or sickle
knife. Great care should be taken to avoid rupture of The saccular cyst may be removed using a similar
the cyst at this point to facilitate dissection and prevent approach and instrumentation. Removal may be
partial excision. Marsupialization of the lesion is an facilitated by excision of the false fold and preserving
accepted technique, but can allow reformation of the cystic component to be removed entirely. Once
the cyst. the false fold is removed, exposure anteriorly may be
facilitated using a Dedo-style laryngoscope placed
I routinely marsupialize even the largest sacs, even in above the glottis to better access the anterior portion
combined laryngoceles. Although it is true that the of the cyst. PWFlint
surgeon should strive for complete removal of the
portion in the ventricular fold, peeling the sac lining off
the thyroid cartilage or out of the paraglottic space is
likely not necessary and can be a negative; wide Vestibular fold resection with the CO2 laser in the
marsupialization accomplishes surgical goals with operating room is a very straightforward way of
fewer risks. ALMerati handling these lesions; the false vocal fold, particularly
when there has been previous infection such as in
mucopyocele, can be bloody and difficult to dissect.
STEP 3. Dissect the lesion from posterior to anterior In most cases, surgical dissection can be
(Figure 10-2). accomplished with the CO2 laser with a standard
laryngoscope directed at the false vocal fold. As the
Attempt to identify the “stalk” or initiating pore of the excision proceeds, the laryngoscope can be advanced
lesion anteriorly. into the field for maximum exposure at any given
Dissection is easiest with blunt instruments. Various time. ALMerati
endoscopic blunt microprobes are available for this. In
CHAPTER 10 Excision of Saccular Cysts and Laryngoceles 107
Resection of external or combined internal and external

Hyoid laryngoceles usually requires an external approach
bone
because access through the thyrohyoid membrane is
Sternohyoid Incision line extremely difficult endoscopically. Adequate exposure is
muscle
critical in this dissection, but the incision can be hidden
to some extent in a skin crease. The cyst may be difficult
Submandibular to appreciate in the supine position because it may
gland reduce into the oropharynx and larynx.
Omohyoid
muscle
Thyrohyoid Posterior belly of Complete excision of an external or combined internal/

muscle digastric muscle external laryngocele is best accomplished with an
open external approach to minimize the likelihood of
Laryngocele recurrence. The isolated external laryngocele and the
more common combined internal/external laryngocele
FIGURE 10-3. Placement of the incision for open removal of may be air filled or fluid filled. The fluid-filled lesions
an external or combined laryngocele. are more likely to present as a laryngopyocele with
acute airway obstruction necessitating urgent surgical
intervention. PWFlint
I use the CO2 laser supplemented by the Freche
monopolar microcautery for the endoscopic resection
of internal saccular cysts. The Freche microcautery on
low settings can be used not only for hemostastis but The key to the open procedure is the safe handling of
also as a cutting tool. Use of the CO2 laser may permit the superior laryngeal nerve bundle at the lateral
greater accuracy in a more refined resection than aspect of the thyrohyoid membrane. It is large and
the Freche in permitting definition of the capsule of easily identifiable. Injury to this will lead to alteration
the cyst. Hemostasis may also be obtained by in swallowing and should not occur in elective,
electrocautery using a small suction to transfer the noninfected laryngocele surgery. ALMerati
energy (low setting) from a handheld conventional
Bovie unit with care to avoid touching adjacent
structures and instruments with the suction. STEP 4. Elevate subplatysmal flaps to the upper border
The cyst is removed in its entirety along with the of the cricoid and 1 cm above the hyoid bone.
majority of the false vocal cord. An adequate
specimen for histopathologic assessment is submitted
to evaluate for possible cancer obstructing the duct STEP 5. Identify and separate the strap muscles
orifice. If the cyst extends sufficiently far into the neck (Figure 10-4).
to preclude full resection endoscopically, an external
With large lesions that extend laterally, the omohyoid
approach is used. HTHoffman
muscle should be separated from the underlying strap
muscles and divided over the thyroid cartilage. The ster-
Open Approach to nohyoid and thyrohyoid muscles are identified. The thy-
rohyoid muscle should be elevated from the superior
External Laryngocele border of the thyroid cartilage and divided. In some cases,
the sternohyoid muscle needs to be divided, but often a
STEP 1. Perform suspension microlaryngoscopy to eval- portion of the muscle can be preserved medially.
uate the lesion fully. Remove the laryngoscope when When more exposure is necessary, the strap muscles
completed. should be divided in such a fashion that they may be
reapproximated at the conclusion of the procedure.
Horizontal mattress sutures may be placed in each side
STEP 2. With the patient supine, extend the shoulders and tagged for reapproximation at the conclusion of the
by extending the head of the bed or using a shoulder procedure. Some laryngoceles may track medially and
roll. Turn the head away from the side of the lesion. even cross the midline to the opposite side of the neck.
The surgeon may need to modify the approach to
achieve adequate exposure without violating the cyst.
STEP 3. Make a transverse incision over the superior Dissection deep to the thyrohyoid muscle should be
border of the thyroid cartilage from about 1 cm across done with care because the laryngocele lies immediately
the midline to 1 cm beyond the lateral border of the beneath the thyrohyoid membrane (which is often
thyroid cartilage (Figure 10-3). extremely thin or dehiscent over the cyst) and may
Hyoid
Omohyoid bone
muscle Divided strap
Thyrohyoid muscles
muscle
Submandibular
gland
Thyroid
cartilage Exposure of
laryngocele
Superior
laryngeal Exposed thyroid Laryngocele
nerve cartilage retracted
FIGURE 10-4. Dissection of strap muscles over an external FIGURE 10-5. Exposure of the upper half of the thyroid
or combined laryngocele. cartilage deep to the laryngocele.
overhang the superior ala of the thyroid cartilage. Eleva-

I use a similar approach as described here. Because
tion of the anterior thyroid cartilage perichondrium
the external component likely emanates through the
may be performed to protect the cyst wall and prevent
neurovascular space, care must be taken not to injure
premature rupture.
the SLN. PWFlint
STEP 6. Identify the cyst and gently dissect superiorly

STEP 8. Remove the upper third of the thyroid cartilage
over the inferior border of the thyroid cartilage.
transversely with a sagittal saw or scalpel (Figure 10-6).
The thyroid cartilage may safely be resected 5 mm from

the midline medially to the posterior border without
Early in the external approach to a laryngocele or
affecting the structure or function of the larynx. The
saccular cyst, I work to identify and preserve
surgeon should be very careful not to resect or destabi-
structures. These structures are the superior laryngeal
lize the anterior commissure at Broyle’s ligament. This
nerve (SLN), the digastric muscle, the hyoid bone, the
attaches in the midline near the midvertical height of the
upper border of the thyroid cartilage, the hypoglossal
thyroid cartilage. The inner thyroid cartilage should be
nerve, and the thyrohyoid membrane with special
maintained to protect the sac during resection of the
attention to the entry point of the SLN. Preservation of
thyroid ala.
the superior laryngeal nerve is a goal we have
achieved consistently. HTHoffman
STEP 7. Expose the superior border of the thyroid carti- In my experience, I have not had to remove thyroid
lage and dissect the cyst into the preepiglottic space cartilage or reflect perichondrium to perform the
(Figure 10-5). external resection. I routinely perform concurrent
endoscopic laser resection when an external approach
The thyroid perichondrium should be incised at the is needed to ensure full removal to prevent recurrence
upper border of the thyroid cartilage and dissected infe- (see Ettema et al, 2003). Retraction to separate the
riorly to the inferior border. Dissection in the preepiglot- hyoid bone from the thyroid cartilage has permitted
tic space must be done carefully to avoid violating the adequate exposure to remove the lesion in all of the
cyst. A Kittner dissector (aka “peanut”) is often very cases I have encountered. HTHoffman
helpful.
CHAPTER 10 Excision of Saccular Cysts and Laryngoceles 109
Tract extends
from laryngeal
ventricle
Inner thyroid
perichondrium Laryngocele
(to be removed) decompressed
FIGURE 10-6. Exposure of the paraglottic space after FIGURE 10-7. Removal of the laryngocele within the
removal of the upper portion of the thyroid cartilage. paraglottic space.
The strap muscles should be closed in the midline. The

The author describes a rectangular section removed
platysma is reapproximated in airtight fashion and the
from the super aspect of the thyroid lamina. I prefer
skin edges brought together.
removing the upper third of the thyroid lamina, with a
If the suction drain does not hold suction because of
semilunar type of incision through the cartilage,
air entry through the larynx, the neck may be wrapped
beginning at the inferior aspect of the notch and
with a gentle pressure dressing and a straight drain bag
moving posteriorly with preservation of the superior
applied instead of self-suction bulb. Alternatively, low
cornu. PWFlint
continuous wall suction can be used. Regardless of man-
agement, the goal of drainage is to evacuate air and
prevent the development of subcutaneous emphysema.
STEP 9. Gently dissect the cyst free from the inner
Air or hematoma in the postoperative period can cause
thyroid perichondrium (Figure 10-7).
airway embarrassment. Fortunately, expanding air
Dissection should proceed from posterior to anterior within the tissue is unlikely because the laryngeal
and superior to inferior as the laryngocele is carefully mucosal violation is supraglottic and under compara-
traced down to a cone near the anterior ventricle. The tively low pressure. A possible exception to this prin-
cyst will come immediately adjacent to the ventricular ciple is the air-filled laryngocele, which may be created
mucosa and may be transected and tied at this point or by supraglottic pressure, possibly from ventricular pho-
excised if separable from the ventricular mucosa. Pre- nation. The patient should avoid activities such as
serve the thyroid perichondrium for closure, if possible. voicing or wind instrument playing during the healing
Needle aspiration for partial decompression of the period following excision of an air-filled laryngocele.
laryngocele may be very helpful during dissection behind A tracheotomy tube is rarely necessary.
the thyroid ala.
Often a small entry is made into the ventricular
mucosa during removal of the laryngocele anteriorly.
This should be managed very conservatively with a If the airway is encountered, all attempts are made to
simple small absorbable suture. Closure of perichon- close the wound, and drainage is necessary. A
drium over this site may be considered. This opening is Penrose drain with pressure dressing may be
generally of no clinical significance during recovery preferred. PWFlint
because the ventricle is above the glottic pressure head
and little or no air escape is expected during cough or
Valsalva. The surgical mistake is to tether the superior
vocal fold mucosa and create a sulcus vocalis in aggres-
sive efforts to close this ventricular mucosa. I use a passive Penrose drain due to the
communication between the endolarynx (endoscopic
resection) and neck to avoid suctioning air. I have a
STEP 10. Close the wound by redraping the remaining low threshold for placing a tracheotomy, which is
thyroid perichondrium and reapproximating the strap usually removed within 7 to 14 days. HTHoffman
muscles over a suction drain.
Valsalva, although not great for the healing larynx, is EDITORIAL COMMENT: The author and
not a concern compared with “open glottis” high commentators nicely highlight the debate
pressure, such as with glass-blowing and horn surrounding the need for excision versus
playing. Most high subglottic pressure activities are marsupialization for internal laryngoceles in terms
due to a closed glottis. Laryngocele is a supraglottic of the risk of recurrence versus the greater
problem. ALMerati difficulty of complete excision. Certainly
improvements in technology have increased the
chances of a complete excision. There seems,
however, to be consensus regarding the external
approach for the larger lesions with extraglottic
extension although a lack of uniformity in terms of
Postoperative Considerations the need for thyroid cartilage excision to facilitate
The patient may resume oral intake quickly. Dysphagia adequate exposure. JICohen
is common in the postoperative period, but usually mild
and similar to that noted following thyroidectomy.
Supraglottic swallowing strategies may be helpful in Suggested Readings
allowing rapid return to oral feeding and may be taught
by a speech-language pathologist during recovery. Dursun G, Ozgursoy OB, Beton S, Batikhan H: Current diag-
nosis and treatment of laryngocele in adults. Otolaryngol
Changes in voice are typically temporary and related
Head Neck Surg 136:211-215, 2007.
to mild laryngeal edema. When properly performed, the
Ettema SL, Carothers DG, Hoffman HT: Laryngocele resec-
mucosal waveform should not be altered because the tion by combined external and endoscopic laser approach.
glottic plane is not entered and the intrinsic muscles of Ann Otol Rhinol Laryngol 112:361-364, 2003.
voicing are not altered. Extralaryngeal muscle incorpo- Thabet MH, Kotob H: Lateral saccular cysts of the larynx.
ration is common following surgery and may be Aetiology, diagnosis and management. J Laryngol Otol
managed with voice therapy. 115:293-297, 2001.
SECTION C Neck
CHAPTER
Drainage of Deep Space Neck Infections
Commentary by William M. Lydiatt, Henry A. Milczuk, and Joseph Valentino
More limited abscesses of the masseteric, parotid,

Preoperative Considerations and submandibular or thyroid spaces as well as more
Imaging, usually computed tomography (CT) with con- superficial infections of lower neck can be approached
trast, is essential in deciding whether a patient who directly through the overlying skin or mucosa and are
presents with signs and symptoms suggesting deep space not the subject of this chapter. Infections of the sublin-
infection requires surgical drainage and, if so, how it gual space are dealt with separately at the end of this
should be approached. chapter.
Distinguishing between cellulitis and abscess can be The carotid sheath is the key to successfully approach-
difficult on clinical grounds alone, and sometimes even ing each of these spaces. The fascia that surrounds each
with imaging the subtle changes associated with early space sends attachments to the carotid sheath, which
abscess formation as compared with soft tissue edema can therefore be followed and/or traversed to provide
and swelling alone are hard to detect. If in doubt the an avenue for drainage (Figure 11-2).
clinical course and morbidity to the patient will deter- Airway considerations are essential in preoperative
mine the need for drainage versus intravenous (IV) anti- (and postoperative) management. Trismus and laryn-
biotics and observation. geal and pharyngeal edema may complicate airway
intubation.
Preoperative flexible fiberoptic endoscopy is manda-
Distinguishing abscess from phlegmon is often more
tory. The experience of the anesthesiologist, the ability
difficult in children. Surgical exploration of what
of the patient to lie flat, the amount of lower neck
appeared to be abscess might discover only
edema or swelling, and the anticipated need for postop-
phlegmon. Furthermore, in children even a clear
erative intubation and ventilation all factor into a deci-
abscess may resolve with antibiotic therapy.
sion about whether tracheotomy under local, fiberoptic
When choosing a nonsurgical management,
intubation, awake intubation, or a regular induction
clinical response must be carefully monitored and
sequence is most appropriate.
drainage implemented in a timely manner for
nonresponders. JValentino
In general, deep neck space infections create a
difficult airway by causing pharyngeal and supraglottic
On an anatomic basis, the many subdivisions of the edema. I prefer to also have an anterior commissure
deep spaces of the neck and their extensions and inter- scope available for direct intubation because this
connections can be quite confusing. From a surgical allows the surgeon to move aside the swollen tissues
standpoint they are more straightforward because to directly view the glottis and intubate through the
within the context of infection the majority of the scope. In Ludwig’s angina, direct visualization is more
anatomic compartments merge into three spaces, the difficult because of base of tongue edema. Fiberoptic
parapharyngeal space, the retropharyngeal space, and intubation works best with a plan for awake
the deeper lateral compartment (Figure 11-1). Imaging tracheotomy if the larynx cannot be readily visualized
can help determine which space(s) are likely to be by fiberoptic means. WMLydiatt
involved.
111
Parapharyngeal
space
Retropharyngeal
space
Deep lateral space
FIGURE 11-1. From a surgical perspective, the

anatomic compartments of the neck can be
grouped into three spaces: the parapharyngeal
space, the retropharyngeal space, (A) and the
deep lateral space (B). B
CHAPTER 11 Drainage of Deep Space Neck Infections 113
Fascia
Retropharyngeal space
FIGURE 11-2. The fascia that surrounds each space sends attachments to the carotid sheath,
which can therefore be followed and/or traversed to provide an avenue for drainage.
Operative Technique issue because the wound will likely be left open to drain.
However, this maneuver will cut down on the trouble-
some skin edge bleeding.
STEP 1. With the patient supine and the neck turned to
the contralateral side outline, a 4- to 5-cm horizontal
incision that straddles the anterior border of the sterno- The role of local anesthesia in preemptive analgesia
cleidomastoid (SCM) muscle. If the abscess is lower in and the potential prevention of paresthesias may also
the neck, the incision should be at the junction of the be important. WMLydiatt
middle and lower third of the muscle. If it is higher in the
neck, then the junction of the upper and middle thirds
of the muscle is more appropriate (approximately the STEP 3. Raise subplatysmal skin flaps superiorly and
level of the hyoid) (Figure 11-3). inferiorly so as to expose the anterior border of SCM
over a distance of 4 to 5 cm and incise the fascia along
An incision along the anterior border of the SCM can its anterior border over this distance (Figure 11-4A).
provide more exposure for any given length. However,
this is generally not a limiting factor with an appropri-
ately placed horizontal incision, and the likelihood is
I prefer not to raise subplatysmal flaps unless the
that the incision will not be closed primarily and there-
abscess is superficial as well. Directly accessing the
fore heal by secondary intention. The cosmetic conse-
involved space will decrease the amount of secondary
quences of this are more significant with an anterior
intention healing needed without substantially effecting
border incision.
exposure. WMLydiatt
Use a natural skin crease when possible to maximize

cosmetic outcome. WMLydiatt STEP 4. Dissect the SCM off the underlying soft tissues,
retracting it posteriorly to expose the lateral surface of
the internal jugular vein over a distance of 2 to 3 cm
STEP 2. Infiltrate the incision with 1% lidocaine (Xylo- (Figure 11-4B).
caine) with 1:100,000 epinephrine.
The vein does not need to be cleaned off completely, but
Erythema and edema will make precise hemostasis more it is used to define the plane and the direction of the
difficult with these operations and are less of a critical carotid sheath.
Incision for
abscess high
in neck
Incision for abscess

low in neck
FIGURE 11-3. An incision straddling the

anterior border of the sternocleidomastoid
muscle at a level appropriate to most of the
fluid collection is outlined.
Fascia
incision
Internal jugular vein
A B
FIGURE 11-4. The fascia along the anterior border of the sternocleidomastoid muscle is
outlined (A), and the muscle is mobilized posteriorly to expose the internal jugular vein (B).
Frequently these tissues are quite edematous and

friable, rendering them difficult to dissect out with
standard soft tissue techniques. I rarely would dissect
out any neural or vascular structures other than the Parapharyngeal space
SCM or possibly the digastric muscle. In many of
these cases gentle blunt dissection into the abscessed
space with a hemostat clamp is adequate. When
purulence is encountered, open the space to allow
finger dissection. Finger dissection of these planes
is typically not difficult because the pus has
accomplished most of the dissection. If possible I try
to collect a few milliliters of purulence and send this to
the microbiology lab for aerobic and anaerobic culture.
The use of swabs is less effective in identifying
organisms. JValentino
STEP 5. If the primary focus of infection is high in the

neck, bluntly dissect a tunnel superiorly (using an index
finger) along the lateral surface of the carotid sheath
until the tip of the styloid process is felt (Figure 11-5A).
Once this point has been reached, turn your finger later-
A
ally to palpate the medial surface of the mandible, medial
pterygoid muscle, and medial surface of the subman-
dibular gland, and then medially to palpate the anterior
surface of the spine (Figure 11-5B).
Retropharyngeal
space
This maneuver is very important in odontogenic-based
infections because these perimandibular spaces must
be opened into the neck wound for adequate
drainage. JValentino
This ensures that both compartments of the para-

pharnygeal space and upper retropharyngeal space have
been entered and adequately explored. A certain amount
of venous oozing will be created by the blunt dissection,
particularly in the inflamed tissue that is present but this
will quickly settle with pressure and irrigation.
STEP 6. If the focus of infection is lower in the neck

posterior to the carotid sheath, then the finger is run
B
posteriorly underneath the SCM and inferiorly along the
sheath down to the clavicle. FIGURE 11-5. A and B, Blunt dissection is used to ensure
that all possible extension of the parapharyngeal space is
reached.
STEP 7. If the focus of infection is lower in the neck in
the retropharyngeal space, the tougher fascia anterior
to the carotid sheath between it and the visceral com- If the pharynx should be inadvertently entered in the
partment must be incised before bluntly dissecting into retropharyngeal region, repair is not specifically required
the retropharyngeal space (Figure 11-6). It is explored (nor is it usually technically feasible). Rather, passive
superiorly and then inferiorly to below the clavicle to be drains are placed close to the opening and the wound
sure any loculations have been broken up (Figure 11-7). allowed to heal secondarily.
Incision
Common
carotid a.
Internal
jugular v.
FIGURE 11-6. The middle layer of the deep

cervical fascia is incised along the anterior
border of the internal jugular vein to facilitate
entry into the retropharyngeal space lower in the
neck.
Retropharyngeal
space
FIGURE 11-7. Blunt finger dissection is then used

to enter the space and explore it superiorly and
inferiorly for pus.
STEP 8. If imaging has suggested any individual pockets

that extend beyond the spaces already explored as men- Unless the patient is toxic or the airway is
tioned earlier, these can be individually targeted although compromised, I typically provide IV hydration and
usually they are contiguous with these spaces and will antibiotics for approximately 24 hours, and then
have been entered by the aforementioned maneuvers. reassess. That is, I will not always take a child to
surgery with a “parapharyngeal space abscess” as
read by a radiologist. Retrospective studies have
STEP 9. After irrigation, passive drains are placed into demonstrated a reasonably high false-positive rate
all of the spaces that have been entered surgically, (10% to 50%), and other series would suggest that
making sure that they extend all the way into the pockets many small “abscesses” in this region can be
entered. They are secured to the skin edge and the successfully managed medically.
wound is closed loosely around them, allowing sufficient I prefer CT with contrast to other imaging
space for drainage to occur. modalities for initial assessment. If follow-up
assessment is needed, ultrasound can help determine
In situations in which significant purulence and necrotic
if there is a discrete fluid collection (abscess) in the
tissue is encountered, initially packing the wound with
location defined by the CT scan. This strategy avoids
povidone-iodine (Betadine)–soaked gauze brought out
repeated radiation exposure.
through the incision may aid in mechanically debriding
In children the need for fiberoptic airway
the abscess cavity.
examination is optional. Bedside assessment of the
airway usually is sufficient to determine the degree of
A Pulsavac irrigation system with 3 L of saline works
airway compromise and make an airway plan with the
very well to further debride and irrigate. Antibiotic
anesthesiologist. A fiberoptic examination in a young
irrigant may also confer a minor advantage. WMLydiatt
child (most who present with deep neck infections are
younger than 5 years old) is difficult under the best of
Frankly, necrotic tissue, typically muscle and fascia, circumstances.
should be debrided back to healthy bleeding tissue. The anesthetic plan in children with a potential for
When encountered I will routinely take the patient airway embarrassment starts with mask induction
back to the operating room (OR) within 48 hours for a using an inhalation anesthetic (e.g., sevoflurane) to
second-look procedure to ensure further debridement maintain spontaneous ventilation. Once anesthesia is
is not necessary. JValentino achieved with this method, a fiberoptic examination or
intubation may be performed. HAMilczuk
Although suction drains can be used for isolated
well-circumscribed abscess cavities, the appeal of passive
drainage is the ability to then advance the drains out
more slowly, healing the cavity from the bottom while In children it is often possible to drain parapharyngeal
preventing reaccumulation. space abscesses through an intraoral approach. If the
abscess is medial to the carotid sheath, an intraoral
Patients who remain septic may have reaccumulated approach will provide access to the abscess cavity
purulence in loculated spaces. Simple reexploration with minimal dissection. This approach avoids a
of these spaces with finger dissection can be quite skin incision. Once the patient is intubated, a
useful. If purulence is encountered, thorough irrigation tonsillectomy mouth gag can be used to expose the
of the wound is important. If this is a recurring issue, pharynx. Thus my approach is simply a modification of
the use of irrigation systems with antibiotic solutions a tonsillectomy.
can be of value. JValentino Soft tissue swelling along the posterior or lateral
pharyngeal wall identifies the point where the vertical
Pediatric Considerations incision should be made. Blunt dissection through the
constrictor muscle will reach the abscess (which
These comments are more applicable to children, which frequently drains spontaneously or with minimal
can be managed using a somewhat different protocol. dissection). Once the abscess cavity has been fully
evacuated and irrigated, and I like to use a curette for
Particularly in children the parapharyngeal and this purpose, the procedure is completed. There is no
retropharyngeal spaces present a challenge in need for a drain. I do observe children for about
distinguishing abscess versus cellulitis by CT scan. 24 hours after surgery to ensure that their toxic state
Circumferential enhancement of a lesion in this space resolves, and they have resumed at least a liquid diet.
is not a guarantee that the lesion is an abscess. If the If the abscess extends lateral to the carotid sheath,
lesion is larger than 2 cm, or if the child is toxic, this an external approach is indicated. The steps I use are
clinical situation is more likely to be an abscess. similar to those described. HAMilczuk
Submental
incision
FIGURE 11-8. A submental incision is outlined.
Ludwig’s Angina
Operative Technique
Infection of the sublingual space with edema of the floor
STEP 1. Outline a submental incision approximately
of mouth and anterior tongue musculature usually
2 cm behind the mentum and about 2 cm in length.
require a separate surgical approach even if there has
Infiltrate with 1% lidocaine (Xylocaine) with epinephrine
been extension to the other adjacent deep spaces men-
(Figure 11-8).
tioned above.
Frank suppuration in this area is unusual and instead
a through-and-through phlegmon extending from the
floor of mouth mucosa all the way to the platysma is STEP 2. Incise the skin and subcutaneous tissues down
encountered. Despite this, patients with significant to the underlying fat.
infection in this region seem to respond better to surgi-
cal drainage.
STEP 3. With a finger placed intraorally in the floor of
mouth, direct a tonsil clamp through this incision supe-
A scant malodorous fluid is frequently riorly up through the floor of mouth mucosa, spreading
encountered. JValentino as you go so as to create a tunnel (Figure 11-9).
The complex anatomy of the sublingual glands, root STEP 4. Using the clamp bring a 12 - to 1-inch passive
of tongue musculature and platysma makes precise drain through the floor of mouth incision out into the
localization of a locus of infection difficult by an exter- neck, and either secure it to itself by bringing the intra-
nal approach alone and so through-and-through drain- oral end out through the mouth (forming a loop) or secure
age is preferred. it separately to the oral mucosa and skin (Figure 11-10).
Oral mucosa
Sublingual glands
FIGURE 11-9. A tunnel is created by blunt

dissection with a tonsil clamp from the
submental region through and through into
the floor of mouth.
Alternatively, one may incise the mylohyoid and bluntly

enter into the sublingual and submandibular spaces,
placing passive drains into each side without entering
the oral mucosa. Direct palpation of the floor of mouth
is essential to ensure all the phlegmon has been
entered (I rarely open the mucosa of the floor of
mouth). It is essential to look for dental causes of
these infections and if time permits have a
preoperative dental evaluation so appropriate
measures can be taken expeditiously. WMLydiatt
STEP 5. Repeat on the contralateral side.
EDITORIAL COMMENT: There is striking similarity

in all of the commentators’ anatomic approach to
the neck abscesses—the differences rest mostly
with type and placement of drains and the unique
aspects of pediatric abscesses. All authors
emphasize the importance of a specific plan for
airway management and that this is as critical to FIGURE 11-10. A drain is placed through this tunnel and
the overall success as the surgery itself. JICohen looped out of the mouth back to itself; this ensures it will be
retained in place and not come out inadvertently.
Suggested Readings Sichel JY, Attal P, Hocwald E, Eliashar R: Redefining parapha-

ryngeal space infections. Ann Otol Rhinol Laryngol
Brook I: Microbiology and management of infected neck 115:117-123, 2006.
cysts. J Oral Maxillofac Surg 63:392-395, 2005. Wang LF, Kuo WR, Tsai SM, Huang KJ: Characterizations of
Huang TT, Liu TC, Chen PR, Tseng FY, Yeh TH, Chen YS: life-threatening deep cervical space infections: a review of
Deep neck infection: analysis of 185 cases. Head Neck one hundred ninety-six cases. Am J Otolaryngol 24:111-
26:854-860, 2004. 117, 2003.
Marioni G, Rinaldi R, Staffieri C, Marchese-Ragona R, Saia Weber AL, Siciliano A: CT and MR imaging evaluation of
G, Stramare R, et al: Deep neck infection with dental origin: neck infections with clinical correlations Radiol Clin North
analysis of 85 consecutive cases (2000-2006). Acta Otolar- Am 38:941-968, 2000.
yngol 128:201-206, 2008.
Potter JK, Herford AS, Ellis E 3rd: Tracheotomy versus endo-
tracheal intubation for airway management in deep neck
space infections. J Oral Maxillofac Surg 60:349-354, 2002.
CHAPTER
Thyroglossal Duct Cyst Excision
12 (Sistrunk Procedure)
Author James I. Cohen
Commentary by Robert H. Maisel, Henry A. Milczuk, Joseph Valentino, and Mark K. Wax
whether there is a significant base of tongue or supra-

Preoperative Considerations hyoid component.
The presence of thyroid tissue in the thyroid bed should
be confirmed prior to excision. Ultrasound evaluation of the neck may provide
Although a lingual thyroid is a relatively rare condi- similar diagnostic information, distinguishing solid
tion, one wants to avoid creating surgical hypothyroid- from cystic qualities of the lesion as well as defining
ism by mistaking a lingual thyroid for a thyroglossal the presence of normal thyroid tissue in thyroid
duct cyst and excising it. In an adult, palpation of the bed. JValentino
normal thyroid in the thyroid bed alone will suffice. In
children this may be more difficult and ultrasound may
be needed. Preoperative fine-needle aspiration (FNA) biopsy
should be considered only if other features suggest the
Whether it is computed tomography (CT), ultrasound possibility of thyroid cancer.
(US), or a thyroid scan is up to the surgeon. MKWax
Such features would include a solid mass, or complex
lesion or cervical lymphadenopathy seen on imaging
I suggest that confirmation of thyroid tissue in the studies. JValentino
normal thyroid bed requires imaging in both adults
and children. This ensures that excision of the mass
between the thyroid cartilage and hyoid bone does not Operative Steps
leave the patient permanently hypothyroid. RHMaisel
STEP 1. Position the patient with the neck in extension.
An oral endotracheal tube and oral airway can help push
Also if the mass presents with acute infection, I like to
the tongue base anteriorly and increase the prominence
wait several weeks after antibiotic treatment before
of the hyoid (Figure 12-1A).
excision. This gives the cyst and surrounding tissue a
chance to “cool down” prior to excision. There will still
be fibrosis, but the extent and the vascularity (i.e.,
STEP 2. Outline a horizontal incision at or just below the
amount of bleeding) will be less after this “cooling off”
level of the hyoid that is approximately as long as the
period. HAMilczuk
body of the hyoid (see Figure 12-1B).
Preoperative imaging is not required if there is

STEP 3. Elevate skin flaps in the plane of the superficial
nothing unusual about the mass itself (i.e., it is midline,
layer of the deep cervical fascia superiorly above the
perihyoidal and moves with swallowing). However, if
level of the hyoid and inferiorly to below the level of
there are atypical features (off midline, recurrent after
the mass.
previous excision, previous infection with drainage),
then CT scan can be helpful in surgical planning. Due to the central dehiscence of the platysma, the proper
CT with contrast takes advantage of both the iodin- plane of dissection is often more easily identified and
ated nature and significant vascularity of thyroid tissue, initiated laterally by horizontal division of the medial
which can help delineate it from surrounding tissue. In edge of the platysma and subplatysmal dissection. Wide
addition it can assess the relationship between the mass undermining facilitates the subsequent dissection and
and the body of the hyoid, whether the disease is unifo- allows retraction of the incision to the important areas
cal or multifocal (more common if recurrent) and of dissection.
121
Cyst
Tongue
Hyoid bone
Tongue
Cyst
Hyoid bone
Incision
Cyst
Thyroid cartilage
FIGURE 12-1. A, The endotracheal tube (and an oral airway)

serves to help displace the tongue base and hyoid forward,
facilitating dissection. B, The incision is designed to provide
adequate surgical access both above and below the body of
the hyoid. B
CHAPTER 12 Thyroglossal Duct Cyst Excision (Sistrunk Procedure) 123
Hyoid bone
Hyoid bone fragment
Thyrohyoid m.
Sternohyoid m.
Thyroid Thyroid
cartilage Cyst cartilage
Cyst
FIGURE 12-2. The infrahyoid strap muscles are divided at FIGURE 12-3. The body of the hyoid bone is divided at
their insertion into the body of the hyoid. approximately the lesser cornu bilaterally.
If the mass has previously drained, it may be neces- Leaving a small cuff of muscle on the hyoid rather
sary to excise the drainage site in a horizontal elliptical than dissecting the muscles directly off it in a subperi-
fashion along with the mass. osteal plane avoids inadvertent transaction of the thy-
roglossal duct cyst tract or entry into the cyst.
In these cases the cyst may be subcutaneous or
superficial to the superficial layer of deep cervical
fascia. HAMilczuk STEP 5. Circumferentially dissect the hyoid just medial
to the junction of the greater and lesser cornu by passing
a right-angle clamp underneath it from inferior to supe-
STEP 4. Divide the infrahyoid strap muscles in the midline rior. Use a bone cutter or saw to divide it bilaterally,
and elevate them off the mass. Horizontally divide the thereby freeing up the body of the hyoid from its inferior
sternohyoid and thyrohyoid muscles just below their and lateral attachments (Figure 12-3).
attachments to the hyoid (as well as the medial aspect
of the omohyoid) as far lateral as the lesser cornu and I generally grasp the central hyoid bone with the
reflect them laterally and inferiorly (Figure 12-2). thyroid tenaculum or Allis clamp. This often is
necessary to rotate the midline tissue that will be
Removal of the central portion of the hyoid is a excised and allow soft tissue dissection. RHMaisel
required part of the procedure. Usually only a minimal
amount of the sternothyroid muscle needs to be
divided. The rest can be retracted. MKWax In children the hyoid bone can often be divided with a
heavy pair of scissors. HAMilczuk
Because the body of the hyoid will be removed anyway,

detachment of these muscles from it is needed and per- Although embryology dictates that the thyroglossal
forming it at this point greatly facilitates exposure. duct tract may pass deep to or through the center of the
Hyoid bone
Cyst
Tongue
Hyoid bone
Cyst
Tongue
FIGURE 12-4. A, The body of the hyoid limits access to the thyroglossal duct cyst and its
tract. B, Sectioning of the body of the hyoid laterally allows it to come forward, improving
surgical exposure.
Hyoid bone
Cyst
Tongue
FIGURE 12-5. Retraction on the body of the

hyoid brings the base of tongue and suprahyoid
component of the cyst and/or tract into the
operative field facilitating dissection.
body of the hyoid, this is not the principle reason for its mobilization of body of the hyoid allows it to be dis-
excision. Rather the center of the hyoid hinders access to placed forward, exposing any suprahyoid component
plane deep to the cyst and the thyroglossal duct cyst’s (see Figure 12-4B) as well as to be used as a “handle” to
pathway of descent (Figure 12-4A). This may make com- retract the tongue base musculature inferiorly, giving
plete removal of the upper portions of the cyst or the tract access to the entire tract up to the foramen cecum (Figure
impossible, thereby leading to recurrence. Adequate 12-5). It is then removed en bloc with the specimen.
Geniohyoid m.
Geniohyoid m.
Tongue m.
Hyoid bone Thyroglossal

fragment duct
Cyst
Cyst
FIGURE 12-6. The body of the hyoid is mobilized by division FIGURE 12-7. With continued traction on the body of the
of the suprahyoid musculature. hyoid, the tract is followed up to the foramen cecum.
STEP 7. Horizontally divide the soft tissues overlying the

Clinical experience as well as embryology has shown mylohyoid muscle from lesser cornu to lesser cornu.
that thyroglossal duct material can be located within Grasp the body of the hyoid with an Allis or similar clamp
the hyoid bone. The classic teaching of the modified and retract it anteriorly and inferiorly. Much as was done
Sistrunk operation suggests a need for removal of the inferior to the hyoid, horizontally divide the mylohyoid
hyoid bone. The precept that access to any remnant and geniohyoid muscles off the hyoid leaving a small
of the cyst or tract superior to the hyoid bone as it cuff of muscle attached so as to avoid in advertent
comes to the tongue base, requires a midline fragment transaction of a tract in close proximity to the hyoid
of hyoid bone between the lesser cornu to be periosteum (Figure 12-6).
removed. There is almost no circumstance in which
removal of the central compartment is not considered.
We have seen recurrent cysts in patients in whom the STEP 8. With the body of the hyoid retracted inferiorly
hyoid was not removed. RHMaisel as a “handle” and with it now completely freed up from
its surrounding attachments except the geniohyoid,
Dividing the hyoid just medial to the lesser cornu continue the dissection of the cyst/tract superiorly by
avoids a subsequent need to free it up from the digastric developing a plane of dissection around it all the way up
tendons. to the foramen cecum (Figure 12-7).
Too much traction will avulse the hyoid handle from

STEP 6. Begin dissection below and lateral to the body
the attached muscle and cyst tract. HAMilczuk
of the cyst, thereby pedicling it on its superior attach-
ments. If a tract runs inferiorly from the mass to the
pyramidal lobe of the thyroid, this should be divided after Placing a finger transoral to palpate the tongue base
ensuring it leads to normal thyroid tissue. and push the foramen cecum toward the operative field
Hyoid bone
Cyst
Tongue
FIGURE 12-8. Placing a finger in the mouth to

push the base of tongue forward can facilitate the
suprahyoid portion of the dissection.
can facilitate this dissection although usually retraction

The tract of the cyst within the tongue is often
on the body of the hyoid if properly mobilized will
indistinct, or there can be many small branches that
accomplish the same thing (Figure 12-8).
cannot be seen. Thus I like to take some of the
surrounding muscle, dissecting in a “cone” toward the
Using the finger on the foramen cecum reduces the foramen cecum. HAMilczuk
retraction forces on the hyoid. Care should be
taken to avoid avulsion of the hyoid from the tract
and tongue muscles. Loss of the handle makes STEP 10. Close the wound in layers reapproximating the
this important part of the dissection more mylohyoid and infrahyoid strap muscles if possible.
difficult. HAMilczuk Place a Penrose or small suction drain in the wound bed
because there is a high incidence of seroma as a result
of the mobile nature of the muscular layers involved.
STEP 9. Under direct vision gradually divide the genio-
hyoid muscles and continue the dissection of the tract
superiorly to the level of the foramen cecum (mucosa of Reapproximation of the strap muscles and suturing
the tongue base), where it is transected. If there is any these muscles across the midline are not difficult
question of the superior extent of the tract, entry into to accomplish. This provides better closure of the
the oral cavity at the foramen cecum should be done and dead space created by the excision of the hyoid
then repaired primarily. bone. JValentino
Frequently the tract is quite small and difficult to

identify at this point. Suture ligation just prior to EDITORIAL COMMENT: All commentators agree
dissecting into the oropharynx is adequate. If the tract on not just hyoid removal but also the importance
is a true sinus through the foramen cecum, primary of mobilization and traction on the central portion
repair is optimal. JValentino of the hyoid as a fundamental maneuver in gaining
access to any superior extensions of the
thyroglossal duct cyst to ensure complete cyst
A penetration of the oral mucosa required to remove a removal. Each has different “tricks” for dealing
thyroglossal duct tract that reaches the foramen with the dissection of these higher remnants
cecum can be closed either intraorally or within the tongue base, which speaks to the
transcervically. RHMaisel difficulty of this portion of the operation. JICohen
Suggested Readings Maddalozzo J, Venkatesan TK, Gupta P: Complications

associated with the Sistrunk. Laryngoscope 111:119-123,
Bennett KG, Organ CH Jr, Williams GR: Is the treatment for 2001.
thyroglossal duct cysts too extensive? Am J Surg 152:602- Pelausa ME, Forte V: Sistrunk revisited: a 10-year review of
605, 1986. revision thyroglossal duct surgery at Toronto’s Hospital for
Ellis PD, van Nostrand AW: The applied anatomy of thyro- Sick Children. J Otolaryngol 18:325-333, 1989.
glossal tract remnants. Laryngoscope 87:765-770, 1977. Sattar AK, McRae R, Mangray S, Hansen K, Luks FI: Core
Gupta P, Maddalozzo J: Preoperative sonography in presumed excision of the foramen cecum for recurrent thyroglossal
thyroglossal duct cysts. J Arch Otolaryngol Head Neck Surg duct cyst after Sistrunk operation. J Pediatr Surg 39:e3-e5,
127:200-202, 2001. 2004.
Hewitt K, Pysher T, Park A: Management of thyroglossal duct Sistrunk WE: The surgical treatment of cysts of the thyroglos-
cysts after failed Sistrunk procedure. Laryngoscope 117:75, sal duct tract. Ann Surg 71:121-122.2, 1920.
2007.
CHAPTER
Branchial Cleft Cyst Excision
Commentary by Markus Gapany, Henry A. Milczuk, and Mark K. Wax
Preoperative Considerations patients who fall into a high-risk category for these
The key to a success is complete excision of all remnants cancers (patients older than 40, smokers, patients with
of the branchial apparatus. Fundamental to this are an a history of head and neck cancer), a cystic mass in
understanding of the potential course of a tract if it the neck should be considered metastatic until proven
should exist and an incision(s) that allow complete otherwise. Such patients should always have an
access to it. anatomic imaging study (CT or magnetic resonance
Although the embryology of the branchial cleft imaging [MRI]), an FNA and operative endoscopy prior
apparatus is complex, from a surgical standpoint the to excision of the mass. In general, it is a good
important considerations are the hypoglossal nerve, the practice to always include an FNA into routine
nerve associated with each branchial arch (cranial nerve preoperative workup of cystic neck masses. MGapany
[CN] VII, IX, X) and the potential internal site of entry
of the tract because together these determine the opera- If a cyst is infected, one should wait as long as pos-
tive approach (Figure 13-1). sible to let the inflammation settle down before operat-
The tract is the deepest structure within any given ing. If incision and drainage (I+D) is necessary for this
branchial apparatus and runs deep to any other struc- to occur, it should be done at a site where an incision
tures within that arch. The tongue is a not a branchial for ultimate excision would be placed, and minimal dis-
arch derivative, and therefore all tracts that enter the section beyond the drainage of the abscess should be
pharynx must run over the top of the hypoglossal nerve done.
before entering the pharynx.
A cystic swelling under the sternocleidomastoid,
especially if recurrent, should raise suspicion for a bran- My preference is to avoid incision and drainage of
chial cleft cyst. However, cystic neck nodes containing infected branchial cleft cysts because it makes the
either thyroid carcinoma or squamous cell carcinoma operation for excision more technically challenging.
(usually from Waldeyer’s ring) can also exist in the same Instead, I prefer to needle-aspirate the infected
location. Computed tomography (CT) or fine-needle masses, remove as much pus as possible, and treat
aspiration (FNA) should be done preoperatively if the the process with appropriate antibiotics. MGapany
clinical context warrants this.
Technique (Second, Third,

Because the majority of these masses present in and Fourth Arch)
children and adolescents, I do not routinely perform
an FNA of the mass or a CT scan prior to STEP 1. Examination under anesthesia and endoscopy
surgery. MKWax to locate the internal tract opening in the tonsillar fossa/
pyriform sinus are worthwhile if the history suggests its
presence (second arch–recurrent tonsillar swelling or a
sense of foul-tasting drainage; third and fourth arch–
Cystic metastatic lymph nodes are frequently recurrent thyroiditis).
encountered in squamous cell cancers of tonsil and/or
tongue base. Sometimes these metastatic lymph
nodes become clinically and radiographically Although this is described, I have never found it
indistinguishable from branchial cleft cysts, that is, useful. A fistulogram or injection with methylene blue
they appear as thin-walled, fluid-filled structures. In provides better anatomic information. MKWax
128
CHAPTER 13 Branchial Cleft Cyst Excision 129
Glossopharyngeal n.
Stylohyoid m.
Posterior belly
of digastric m. II
Hypo-
glossal n.
External carotid a. Cyst
Sup. Incision
laryngeal n.
Internal
Hyoid carotid a.
bone
Cyst II
III
Thyroid
cartilage Cyst III
IV Sternocleidomastoid m.
Vagus n.
Common
carotid a.
FIGURE 13-2. The skin incision generally straddles the
Recurrent
anterior border of the SCM muscle at an appropriate level,
laryngeal n.
ellipsing, if necessary, the external opening of any tract.
STEP 3. Any external opening or scar associated with a

cystic neck swelling should be excised with a horizon-
FIGURE 13-1. The potential cervical course of the branchial
arch tracts. tally appropriately ellipse or incision extended as neces-
sary to follow it more deeply (see Figure 13-2). However,
this incision does not necessarily determine the location
If an internal opening is present, complete excision
of the main incision, which is instead over the main cyst
of the opening from an external approach and oversew-
itself. If necessary, a series of short horizontal incisions
ing of the pharyngeal defect are necessary.
along the course of the tract connected by subplatysmal
dissection are more cosmetically acceptable than a
STEP 2. Outline an incision that straddles the anterior single long incision or one oriented along the anterior
border of sternocleidomastoid (SCM) muscle (Figure border of the SCM.
13-2) and overlies the cystic swelling.
Cannulation with a lacrimal probe (see Figure 13-2) or
Because it is not a branchial arch derivative, the SCM injection of an external tract opening or the cyst with
comes to lie over the top of the branchial apparatus, methylene blue can be helpful in tract identification if
and therefore branchial cleft cysts and tracts are best done carefully without excess force or spillage, which
approached by horizontal incisions that allow access to leads to general tissue staining and general obscuring of
the SCM’s anterior border and dissection of the muscle surgical planes.
off the underlying soft tissues.
If either of these two maneuvers is not possible, the
It is very important to start the dissection along the tract is often associated with some muscle fibers that
anterior border of the SCM and follow its fascial plane are distinct from the SCM. Sometimes tracts will dilate
medially to and superiorly to the level of greater auricular beneath the skin allowing for cannulation. I much
nerve. Such wide exposure allows for an easy access to prefer using a lacrimal duct probe to define the
the branchial cleft cyst, decreasing the pressure on the tract. HAMilczuk
cystic mass during the dissection and minimizing the
risk of inadvertent rupture with spillage of the contents.
The dissection medially along the SCM facilitates the Occasionally preoperative radiology with barium
identification and preservation of the CN XI. MGapany facilitates preoperative planning. MKWax
Digastric m.
Hypoglossal n.
Accessory n.
Cyst
Cyst
Sternocleidomastoid m.
FIGURE 13-4. The hypoglossal nerve should be identified to

prevent injuring it inadvertently.
FIGURE 13-3. The tract is freed up and delivered into the

main operative field where the body of the cyst lies.
STEP 4. The external tract is freed up from the surround- unpredictable, and identification of a potential tract
ing soft tissues and delivered into the main incisional difficult, increasing the chances of
cavity around the cyst itself (Figure 13-3). The main cyst recurrence. MGapany
is gradually dissected free of the surrounding soft
tissues respecting its relationship to the surrounding
STEP 5. If a tract is identified it is gradually followed
nerves, which in the case of a second arch derivative
superiorly, identifying and preserving those structures
includes CN XI superiorly. This nerve should be identi-
that it will approximate. A second arch tract dives
fied if the cyst is large enough to approximate it. For
between the internal and external carotid arteries as it
second arch derivatives this dissection also usually
heads superiorly over CN XII and IX through the middle
involves retraction of the posterior belly of the stylohyoid
constrictor to the tonsillar fossa (see Figure 13-1). Often
or digastric muscles superiorly. As the deep surface of
the tract ends blindly as a fibrous tract, which should be
the cyst is freed up, CN XII must be identified in a retro-
amputated as high as possible ensuring there is still not
grade manner to avoid injuring it (Figure 13-4).
a lumen present. A third arch tract heads superiorly over
CN XII nerve before diving behind the internal carotid
I recommend starting the dissection of the branchial artery and penetrating the lateral thyrohyoid membrane
cleft cyst by first identifying its capsule. Dissection in below the superior laryngeal nerve to enter the upper
the capsular plain facilitates the process, helps with aspect of the pyriform sinus (see Figure 13-1).
the identification and preservation of adjacent neural
and vascular structures, and prevents inadvertent
rupture of the cyst. MGapany STEP 6. Although theoretically a fourth arch tract would
descend into the chest before reascending into the
neck, this is rarely, if ever, seen. However, more com-
In uninfected cases I usually perform a capsular
monly problems from fourth arch derivatives present as
dissection of these cysts. CN XII is often seen in the
recurrent infections around the thyroid from a residual
depths of the wound, but not specifically looked for or
stump of the internal connection of the tract to the low
identified. MKWax
pyriform sinus. Exposure and removal of these remnants
involve excision of the thyroid lobe, removal of a portion
Throughout the dissection, every effort should be made of the posterior aspect of the thyroid cartilage to expose
to avoid rupturing the branchial cleft cyst. If the cyst the pyriform sinus, and identification and protection of
ruptures, complete dissection of the sac becomes the recurrent laryngeal nerve (Figure 13-5). The entry
of the tract must be amputated and oversewn.
CHAPTER 13 Branchial Cleft Cyst Excision 131
IV
Thyroid
gland
Recurrent laryngeal n.
FIGURE 13-6. The external opening of a first arch derivative

can be variable in position.
FIGURE 13-5. Complete removal of the internal aspect of a

fourth arch tract may require excision of the ipsilateral thyroid
lobe and removal of a small portion of the thyroid ala.
First arch derivatives can also exit from the
When the branchial cysts are large, their dissection submandibular region. A persistent mass or sinus
can be associated with significant traction and drainage site in this area, sometimes mistaken for
pressure on the walls of the mass, thus increasing the lymphadenitis, should have imaging to rule out the
chance of inadvertent rupture. To prevent this, and to possibility of a first arch derivative. HAMilczuk
facilitate further dissection, I frequently resort to
controlled decompression of the cyst by aspirating one
Preoperative contrast MRI can be helpful in identifying
third to one half of the contents and then oversewing
the presence of intraparotid first arch branchial cleft
the puncture site to prevent leakage. I usually perform
remnant extension as well as help to determine the
controlled aspiration at the point where about half of
degree of involvement of the parotid gland with
the dissection has been completed. MGapany
the process, thus facilitating better planning of the
operation. MGapany
I routinely use a small suction drain through the
wound for 1 day. MKWax
The surgeon should always anticipate the possibility
of intraparotid first branchial cleft remnant extension,
and be prepared for possible facial nerve dissection.
STEP 7. First arch derivatives require excision and dis-
It is therefore wise to have the nerve integrity
section of any external fistula, which is then followed
monitoring system (NIMS) available in the operating
proximally (Figure 13-6). If they extend more deeply to
room and have the NIMS needle electrodes placed
approximate the parotid fascia, the operation should be
preoperatively. MGapany
converted to a parotidectomy with facial nerve identifi-
cation at the stylomastoid foramen proximally and ante-
grade dissection. This allows for protection of the nerve The relationship of the tract to the nerve is variable
as the dissection is carried deeper. extending superficial, deep to its branches or sometimes
between them as it heads to the external auditory canal
When I suspect a first arch fistula or cyst, I obtain a (Figure 13-7A). If there is significant scarring around
CT scan and fistulogram as my preoperative planning the ear canal, distal identification of the facial nerve
methodology. MKWax branches and retrograde dissection may be necessary
instead (Figure 13-7B).
External tract
opening
I
Facial n. Cervicofacial branch
of facial n.
Parotid
gland
A B
FIGURE 13-7. The tract of a first arch derivative may have an intimate relationship with the
facial nerve requiring antegrade (A) and/or retrograde (B) approaches for nerve identification
and protection.
Dissection of the inflamed and scarred tract off the other than with respect to identification of the
facial nerve branches can be very difficult and facial nerve when operating on first branchial cleft
nerve-wracking (for both surgeon and patient), and remnants. Similarly, all commentators advise
should be performed by expert parotid gland caution in the vigor of retraction during dissection
surgeons. MGapany to prevent rupture that can significantly complicate
identification of all parts of the cyst and complete
If the tract attaches to the canal (usually at the bony removal. JICohen
or cartilaginous junction), excision and oversewing of
the canal may be necessary. Preoperative examination Suggested Readings
of the ear canal or a history of drainage from the ear is
a clue to this. Acierno SP, Waldhausen JH: Congenital cervical cysts, sinuses
and fistulae. Otolaryngol Clin North Am 40:161-176, 2007.
Briggs RD, Pou AM, Schnadig VJ: Cystic metastasis versus
Occasionally the first arch derivative adjacent to the branchial cleft carcinoma: a diagnostic challenge. Laryngo-
external auditory canal duplicates it. In this case there scope 112:1010-1014, 2002.
will be a common wall. Careful dissection separates Garrel R, Jouzdani E, Gardiner Q, Makeieff M, Mondain M,
the two. Canal repair may require temporary Hagen P, et al: Fourth branchial pouch sinus: from diagnosis
stenting. HAMilczuk to treatment. Otolaryngol Head Neck Surg 134:157-163,
2006.
Kadhim AL, Sheahan P, Colreavy MP, Timon CV: Pearls and
pitfalls in the management of branchial cyst. J Laryngol
EDITORIAL COMMENT: The main areas of
Otol 118:946-950, 2004.
disagreement among the commentators have
Kenealy JF, Torsiglieri AJ Jr, Tom LW: Branchial cleft anoma-
to do with the extent of workup needed lies: a five-year retrospective review. Trans Pa Acad Oph-
preoperatively to either rule out other pathology thalmol Otolaryngol 142:1022-1025, 1990.
masquerading as a cystic neck mass or determine Mukherji SK, Fatterpekar G, Castillo M, Stone JA, Chung CJ:
the course of the cyst tract. There is some Imaging of congenital anomalies of the branchial apparatus.
discussion as to whether capsular dissection Neuroimaging Clin N Am 10:75-93, 2000.
alone or identification of specific structures is Schroeder JW Jr, Mohyuddin N, Maddalozzo J: Branchial
needed during removal without uniform agreement anomalies in the pediatric population. Otolaryngol Head
Neck Surg 137:289-289, 2007.
SECTION D Pharyngeal Operations
CHAPTER
Operations on the Cervical Esophagus
14 and Cervical Spine
Commentary Peter E. Andersen, William R. Carroll, and Bruce J. Davidson
General Considerations Most surgeons approach the cervical esophagus from

Operations that access the cervical esophagus and cervi the left side. Many neurosurgeons, however, strongly
cal spine share many common principles in terms of prefer to approach the cervical spine from the right.
achieving exposure and avoiding complications, the The head-and-neck surgeon responsible for the
foremost of which is injury to the laryngeal nerves. approach should be comfortable with the position of
Many of these operations are part of a multidisciplinary the recurrent nerve on both sides. WRCarroll
undertaking, working, for example, with general surgery
or thoracic surgery for patients undergoing esophagec
tomy or neurosurgery for cervical spine decompression General Technique of Exposure
or fusion. It is important that the teams communicate
beforehand about ideal patient positioning (the degree of
STEP 1. Position the patient in neck extension with the
neck extension invariably ends up being a compromise
head turned to the right.
between what is ideal for either team) and the timing of
the cervical exposure portion of the operation. If possible position a shoulder roll vertically between
In general, the left side of the neck should be chosen the shoulder blades not only to promote neck extension
for exposure, especially if low exposure is needed. The but also to allow the shoulders to fall back, providing
reason for this relates to the position of the left recurrent better access to the operative field, particularly with a
laryngeal nerve, which is longer and more vertical in heavyset body habitus.
position than its counterpart on the right because of its
course around the aortic arch rather than the subclavian
artery. This decreases the chance of: STEP 2. Outline a horizontal incision centered over
n Direct injury, because it stays in the tracheoesopha the anterior border of the sternocleidomastoid (SCM)
geal groove for the majority of its course in the muscle running almost to the midline. It should be
operative field rather than traversing the space located at approximately the level of the cricoid cartilage
between the laryngotracheal complex and carotid (Figure 14-1).
sheath.
n Stretch injury, because its length distributes any supe Although a more vertical incision along the anterior
rior traction forces over a longer segment of nerve. border of the SCM of equivalent length offers more
exposure than a horizontal incision, the cosmesis of the
If the head and neck surgeon is left handed the latter is preferable. When exposure is anticipated to be
placement of the surgical instrumentation may be difficult, a more vertical incision may be considered.
more convenient if the approach is done from the right
side. This does make dealing with the recurrent I agree that a horizontal incision gives better cosmesis
laryngeal nerve more difficult but not excessively so. and provides adequate access for any procedure.
This is a situation in which preoperative discussion However, many of our surgical colleagues are more
between the surgical teams is essential for a good familiar with the vertical incision. Again, preoperative
result. PEAndersen discussion is critical. PEAndersen
133
Hyoid bone
Cervical
vertebra
Thyroid
cartilage
Trachea
Esophagus
Anterior border of
sternocleidomastoid m.
FIGURE 14-1. The incision is centered over the anterior border of the sternocleidomastoid
muscle.
STEP 5. Incise the middle layer of the deep cervical

Intraoperative fluoroscopy is usually available for
fascia vertically along the anterior border of the internal
cervical spine approaches. Use fluoroscopy to position
jugular vein (taking the middle thyroid vein) and then
an incision near the C-spine levels of interest. In
more deeply (and slightly anteriorly) along the common
general, access is easier in an inferior direction.
carotid artery. Retract the carotid sheath laterally (see
Position the incision slightly closer to the higher level
Figure 14-2).
of access required. WRCarroll
The middle layer of the deep cervical fascia that sur
rounds the thyroid or laryngotracheal complex sends
STEP 3. Elevate short subplatysmal flaps superiorly and investments to the carotid sheath, which must be divided
inferiorly to expose and incise the fascia along the ante- to allow for entry into the retropharyngeal or para
rior border of the SCM from the clavicle to the level of esophageal space and retraction of the carotid sheath
the thyroid cartilage notch (prominence) (Figure 14-2). laterally.
Generous incision of this fascia and posterior mobiliza
tion of the SCM muscle does more than anything else
The middle layer of the deep cervical fascia is named
to provide exposure and make the field as shallow as
variously by different anatomists and may be
possible. In the difficult neck it is occasionally useful to
confusing. Regardless of the name, develop a broad
incise the sternal head of the SCM of the clavicle, which
plane of dissection between the great vessels and the
helps mobilize it inferiorly.
central compartment structures as described here to
approach the retroesophageal area. WRCarroll
STEP 4. Retract the SCM muscle posteriorly, dissecting
it off the underlying soft tissues until the lateral surface
of the internal jugular vein is well seen. Identify the ante- STEP 6. Identify and divide the inferior thyroid artery
rior belly of the omohyoid muscle, which can be mobi- as it courses medially from behind the carotid artery
lized superiorly or divided as needed for exposure. (Figure 14-3).
CHAPTER 14 Operations on the Cervical Esophagus and Cervical Spine 135
Sternocleido-
Hyoid bone mastoid m.
Strap
muscles
Omohyoid m.
Common
carotid a.
FIGURE 14-2. The middle

layer of the deep cervical
fascia is incised anterior to the
carotid artery to allow entry
into the retropharyngeal space.
The middle thyroid vein usually
must be divided as well.
Omohyoid m.
Thyroid
gland Recurrent
laryngeal n.
Inferior
thyroid a.
Trachea
Sternocleido- Common
mastoid m. carotid a.
FIGURE 14-3. The inferior thyroid artery
traverses the plane of entry into the
retropharyngeal space. Division of the
inferior thyroid artery minimizes the
chance that traction on it will bring the
recurrent laryngeal nerve into the field
and expose it to injury.
The distal branches of the inferior thyroid artery inter

twine with the recurrent laryngeal nerve so that if the
artery is left intact the traction on it produced by lateral
traction on the carotid sheath and medial retraction or
rotation of the laryngotracheal complex may pull the
nerve out of the groove and increase the chance of
injury to it.
Omohyoid m.
If the patient has not been previously operated
on, the recurrent laryngeal nerve is not specifically
Thyroid
identified and dissected because its course (on the gland
left) in the paratracheal groove keeps it away from
direct injury if certain principles are adhered to (see Inferior
following text) and the surrounding tissues protect it thyroid a.
from direct trauma by retractors and, to some degree,
stretch injury.
Recurrent
laryngeal n.
I do not routinely identify the recurrent laryngeal

nerve. PEAndersen Trachea
Common Sternocleido-
carotid a. mastoid m.
If the right side is chosen for exposure the nerve
should be identified as it traverses the gap between the
carotid sheath and laryngotracheal complex to go
around the subclavian artery.
The nerve is most at risk on the right side when

low (C7-T1 range) dissection is required. Nerve FIGURE 14-4. Rotation of the laryngotracheal complex
identification is optimal in these cases. For higher improves exposure and is facilitated by traction on the thyroid
dissections, an alternative method involves keeping lobe. Incision of the esophageal fascia is done lateral and
the dissection well lateral (at the medial aspect of the posterior to the tracheoesophageal groove.
carotid artery) until reaching the prevertebral fascia.
The recurrent laryngeal nerve (RLN) lies medial and
superficial to the deep plane of dissection and is Using the thyroid lobe as a handle on the laryngotra
protected by a layer of fibrofatty tissue. WRCarroll cheal complex because of its tight attachment to it at
Berry’s ligament facilitates exposure without exposing
the recurrent laryngeal nerve to direct trauma by a
On the right side, a nonrecurrent laryngeal nerve may retractor such as a Richardson or army-navy in which
be seen in 1% of patients and significantly limits the tip inevitably tends to migrate toward the tracheo
exposure of the spine. BJDavidson esophageal groove where the nerve sits.
On the right side the easiest location to find the RLN Alternatively, a hook may be placed along the lateral
is low and lateral in the paratracheal grove, just after edge of thyroid cartilage ala and used to retract the
it emerges from deep to the subclavian laryngotracheal complex in order to visualize the
artery. PEAndersen region of the cricopharyngeal muscle and upper
cervical esophagus. BJDavidson
STEP 7. Grasp the lateral aspect of the thyroid lobe with

two Babcock retractors. Rotate the laryngotracheal Although occasionally in the short or fat neck infe
complex anteriorly and medially to expose the lateral rior sectioning of the sternohyoid or sternothyroid
and posterior aspects of the pharynx and esophagus. muscles is necessary for superior displacement of the
Although this direction of retraction is well tolerated, laryngotracheal complex and esophageal exposure, in
to prevent stretch injury to the recurrent laryngeal general preservation of these muscles helps guard against
nerve, superior retraction must be specifically avoided overly aggressive superior retraction and stretch injury
(Figure 14-4). to the recurrent laryngeal nerve.
Thyroid
gland
Thyroid
gland
Recurrent Carotid
Recurrent
laryngeal n. Trachea sheath
Trachea laryngeal n.
Carotid
Esophagus sheath Esophagus
A B
Trachea
Esophagus
Recurrent Carotid
laryngeal n. sheath
C
FIGURE 14-5. As one proceeds lower in the neck these sequential axial sections show that
the right recurrent laryngeal nerve (RLN) comes out of the tracheoesophageal groove and is
more exposed to direct injury, but more protected from injury when circumferential dissection
of the esophagus is done. The reverse is true for the left RLN.
Exposure of the Cervical Esophagus As one proceeds lower in the neck the left recurrent
for Esophagectomy laryngeal nerve runs more anteriorly, decreasing the
chance of direct injury if one stays on the esophagus
(Figure 14-5).
STEP 1. With the previous exposure, palpate the inferior
cornu of the thyroid cartilage, which serves to identify
the level of the cricoid cartilage and recurrent laryngeal STEP 2. Having entered the subfascial plane and working
nerve entry into the larynx. Working 1 to 2 cm below this with a right-angle clamp whose tip hugs the muscular
and behind, incise the esophageal fascia on the post layer, develop a circumferential plane around the esoph-
erolateral aspect of the esophagus vertically downward agus (Figure 14-6).
for a distance of 2 to 3 cm (see Figure 14-4). Gentle medial retraction on the trachea can facilitate
this as it tends to rotate the esophagus to a more left-
I simply spread bluntly in the prevertebral plane then lying position.
rotate the entire laryngo-tracheoesophageal complex Because the dissection is done from left to right and
away from me. The esophagus is then easily visualized is 3 to 4 cm below the cricoid, the right recurrent laryn
from behind. PEAndersen geal nerve is protected from direct injury because at this
level it has already traversed laterally off the esophagus
itself (see Figure 14-5).
Beginning higher on the esophagus like this and
working on its posterior aspect (4 or 5 o’clock position) STEP 3. Use the right-angle clamp to grasp a 1-inch
ensures that the recurrent laryngeal nerve is anterior to Penrose drain and bring it back around the esophagus.
this and not directly injured. Subsequent dissection is Use this drain for gentle lateral and superior traction and
done underneath this fascial layer, which protects the a combination of sharp and blunt (finger) dissection to
nerve from direct injury as it is displaced off the surface gradually mobilize and dissect the esophagus inferiorly
of the esophagus. from the surrounding soft tissues (Figure 14-7).
Trachea
Carotid
sheath
Recurrent Esophagus
laryngeal n.
Esophagus
FIGURE 14-6. A and B, Blunt dissection underneath the esophageal fascia directly, on its
muscle fibers, helps protect both RLNs from injury.
blunt finger dissection superiorly to the thyroid cartilage

Care must be taken to prevent injury to the posterior and inferiorly to the clavicle mobilizes the laryngotra-
tracheal wall during this maneuver. This is best cheal complex so it can be easily displaced to the
accomplished by blunt dissection if the operative field contralateral neck and expose the muscles overlying the
is not clearly visible. PEAndersen anterior aspects of C3-4 to C6-7 (Figures 14-8 and 14-9).
The most critical issue is to provide specific significant

downward countertraction on the thyroid lobe while The loose fascia between the viscera and the deep
the esophagus is dissected in this manner to prevent cervical fascia allows for rapid and safe exposure of
stretch injury on the nerve, which can easily occur if in the prevertebral fascia in previously undissected
the process of bringing the esophagus superiorly the necks. However, in the case of a reoperation on the
laryngotracheal complex is pulled up as well. cervical spine, scarring of this plane raises the risk of
If the esophagus is to be brought up into the neck or injury to constrictor muscles and pharyngeal mucosa.
transected and delivered inferiorly, specific attention to Dissection should proceed cautiously because these
this downward traction must be continued throughout injuries can further contribute to postoperative
the case to prevent nerve injury with these maneuvers. infections and pharyngeal diverticuli. BJDavidson
Cervical Spine Exposure Be careful in placing the self-retaining spine retractors

to ensure that the medial blade rests against the thyroid
STEP 1. After incision of the middle layer of the deep lobe or esophagus and not directly in the tracheoesoph
cervical fascia and division of the inferior thyroid artery, ageal groove, where the nerve resides.
Thyroid
gland
Thyroid
gland
Esophagus
Recurrent
laryngeal n.
Trachea
Recurrent
laryngeal n.
Trachea
FIGURE 14-7. To prevent RLN nerve injury, the importance of FIGURE 14-8. A long posteriorly placed incision of the middle
downward traction on the laryngotracheal complex (via the layer of the deep cervical fascia helps facilitate mobilization of
thyroid lobe) to counter any upper traction on the esophagus the laryngotracheal complex.
cannot be over emphasized.
In spine approaches, traction injury from the retractors If the spine surgeon is right handed, he or she may
is probably the greatest source of nerve damage. The prefer the approach to be done on the right side
retractors displace the central compartment structures for high C-spine approaches. This allows the
completely across the midline into the opposite side of surgeon to use the dominant hand to place the
the neck. WRCarroll instrumentation. PEAndersen
This issue is very important. The difficulty is imparting This nerve can be gently mobilized from its sur
and maintaining this same caution throughout the rounding fascial attachments superiorly to prevent
portion of the procedure performed by the spine stretch injury to it in all but the highest exposure situ
surgeon. It is best if both surgeons evaluate the ations (see Figure 14-10). Direct visualization of this
exposure and the retractor placement at the time of nerve and careful superior retraction are preferable to
handoff to ensure that the spine surgeon will be able blind superior retraction in this situation.
to complete his or her work without further dissection
or retractor manipulation. BJDavidson Protection of the superior laryngeal nerve during high
dissection is crucial. Injury to the nerve significantly
worsens postsurgical dysphagia. WRCarroll
STEP 2. If more superior exposure is desired (C2-3), the
omohyoid muscle should be sectioned and the plane
between the carotid sheath and laryngotracheal complex Head-and-neck surgeons are often consulted in
expanded superiorly. The ansa branches to the strap revision cervical spine surgery. In these cases, the
muscles must be sectioned (Figure 14-10). pharyngoesophageal musculature may be adherent to
the prevertebral muscles or the prior reconstruction
For the highest exposure, the superior thyroid artery plate. During exposure of the anterior spine, work
and veins are taken after first identifying the superior carefully through the fibrous scar tissue to avoid a
laryngeal nerve where it comes medially under the salivary fistula. WRCarroll
carotid artery.
Omohyoid m.
Esophagus
Recurrent Sup. laryngeal n.
laryngeal n.
Thyroid Omohyoid m.
gland Anterior
spine
Common
carotid a.
Esophagus
Thyroid
gland
Common
carotid a.
FIGURE 14-9. The laryngotracheal complex is displaced FIGURE 14-10. Visualization, mobilization, and gentle superior
across the midline into the contralateral neck, being careful displacement of the superior laryngeal nerve should allow for
not to place direct force on the tracheoesophageal groove its preservation in all but the highest cervical spine exposures.
and traumatizing the recurrent laryngeal nerve.
the pressure of the tube under the esophagus tends to
compress the esophagus and divert all secretions onto
Cervical Esophagostomy the neck where they can be collected with a stoma bag.
In the short and/or fat neck, a vertical skin incision,

STEP 1. With the esophagus exposed and mobilized as
which allows more latitude in the position of the under
previously, it is grasped with two forceps or Babcocks
lying tube, and sectioning of the strap muscles and/or
superiorly and inferiorly and a small opening in the
the sternal head of the SCM may be necessary to bring
mucosa made. A nasogastric (NG) tube is inserted
the esophagus up to the skin without undue tension.
through this down into the stomach and an absorbable
If total diversion is desired, the esophageal loop can
pursestring suture (that includes mucosa) is used to seal
be divided with an endoscopic gastrointestinal anasto
the opening and then tied to the tube (Figure 14-11A). The
mosis (GIA) stapler. The lower end is allowed to retract
NG tube is brought out through the incision, which is
into the chest and the upper end is brought out to the
closed loosely around it. The tube is secured with a tape
skin and matured in the incision.
anchored to it (as if it were a drain) and then tied around
the neck.
If the ostomy is to be placed in the neck, take care to
The tube should not be changed for 10 days to allow not place the matured esophagostomy too close to
this tract to mature because reinsertion can be difficult. the clavicle. Doing so will make it difficult to place an
Securing the tube to the esophagus with the pursestring ostomy bag. If the ostomy is to be permanent and
suture helps prevent inadvertent displacement. you have enough length of proximal esophagus, the
ostomy can be placed on the upper chest, which is
STEP 2. If a diverting esophagostomy is desired, the loop the best location for placement of the ostomy bag.
of esophagus is brought out to the skin and held in place Preoperative consultation with an enterostomal
by placing a section of chest tube (24 to 28 Fr) under it therapist can be helpful to identify the ideal location
and closing the incision under this (see Figure 14-11B). for the stoma. PEAndersen
The esophagus is opened just proximal to the tube, and
Omohyoid m.
Thyroid
gland Sternocleido-
mastoid m.
Recurrent
laryngeal n.
Esophagus
Esophagus
A B
FIGURE 14-11. A, After a purse string suture is placed, a nasogastric tube is placed through
an opening in the esophageal mucosa, and it is threaded down into the stomach. B, For a
diverting esophagostomy the esophagus is brought out to the skin and held in position by a
chest tube, which serves to also occlude its lumen and divert oral secretion on to the neck.
Dividing the esophagus as low as possible allows for Suggested Readings

more length and greater ease in bringing the end out to
the skin, as well as with subsequent reconstruction. Approach to the Cervical Spine
Audu P, Artz G, Scheid S, Harrop J, Albert T, Vaccaro A,
et al: Recurrent laryngeal nerve palsy after anterior cervical
spine surgery: the impact of endotracheal tube cuff defla
EDITORIAL COMMENT: Two themes emerge from tion, reinflation, and pressure adjustment. Anesthesiology
the text and commentary in this chapter. The first 105:898-901, 2006.
is the importance of preoperative communication Kriskovich MD, Apfelbaum RI, Haller JR: Vocal fold paralysis
between the different operative teams often after anterior cervical spine surgery: incidence, mechanism,
involved in operations in this area so that everyone and prevention of injury. Laryngoscope 110:1467-1473,
understands the exposure needs and attendant 2000.
Lu J, Ebraheim NA, Nadim Y, Huntoon M: Anterior approach
risks involved. The second is the significant
to the cervical spine: surgical anatomy. Orthopedics 23:841-
difference between first-time operations, in which
845, 2000.
the natural spaces and fascia allow for safe fairly Netterville JL, Koriwchak MJ, Winkle M, Courey MS, Ossoff
straightforward blunt dissection without specific RH: Vocal fold paralysis following the anterior approach to
nerve identification to achieve the necessary the cervical spine. Ann Otol Rhinol Laryngol 105:85-91,
exposure, as opposed to reoperative cases, in 1996.
which none of these anatomic assumptions can be Weisberg NK, Spengler DM, Netterville JL: Stretch-induced
relied on and tedious very targeted dissection is nerve injury as a cause of paralysis secondary to the anterior
needed. JICohen cervical approach. Otolaryngol Head Neck Surg 116:317-
326, 1997.
Cervical Esophagous/Esophagostomy Higaki F, Oishi M, Higaki T, Hayata Y: Old-fashioned but

Dobie RA, Cox KW, Larsen GL: Skin flap esophagostomy. modern tube cervical esophagostomy. Am J Surg 192:385-
A new procedure. Arch Otolaryngol 105:200-202, 387, 2006.
1979. Tucker HM, Broniatowski M, Chase S: Tube esophagostomy.
Fitz-Hugh SG, Sly DE: Elective cervical esophagostomy. Ann A new technique in the management of long-term swallow
Otol Rhinol Laryngol 76:804-809, 1967. ing disorders. Arch Otolaryngol 111:187-189, 1985.
CHAPTER
Cricopharyngeal Myotomy and Surgical
15 Management of Zenker’s Diverticulum
Commentary by William J. Richtsmeier and Joshua S. Schindler
complex without interdigitating itself into the “party”

Anatomic Considerations wall (see Figure 15-1D). Therefore, division of the party
A Zenker’s diverticulum is a mucosal outpouching wall alone (i.e., by laser) even without mucosal closure
of the pharyngoesophageal mucosa that occurs between (i.e., as occurs when a stapler is used) does not result in
the inferior fibers of the inferior constrictor muscle and a fistula as the investing fascia is not violated. This,
the superior fibers of the cricopharyngeus (CP) muscle however, assumes that the division of the party wall
(Figure 15-1A). Although the precise etiology of Zenk- does not extend beyond the inferior extent of the
er’s diverticulum is unknown there is a general consen- diverticulum.
sus that the cricopharyngeal muscle has an important The use of the stapling device for division of the
role. Therefore management (complete myotomy) of party wall eliminates the judgment issues needed
this muscle is critical to successful management of the with the use of a laser in the decision about how far to
diverticulum, perhaps even more than excision of the extend the myotomy because it allows for mucosal
diverticulum itself. closure at the time of party wall division eliminating the
risk of fistula. However, its design (the staple lines
extend beyond the length of tissue that it cuts) prevents
I agree this is absolutely true and would emphasize
as complete a division of the party wall at its distal end
this point. WJRichtsmeier
as can be achieved with a laser.
The position of the cricopharyngeal muscle within

the “party” wall between the lumen of the diverticulum The CO2 laser may be the most versatile instrument
and the esophagus allows for endoscopic management in the management of Zenker’s diverticula. This
of it in appropriately selected cases (see Figure 15-1B is because very small diverticula and even
and C). Improvements in technology (bivalved diver- cricopharyngeal muscle hypertrophy or dysfunction
ticuloscopes, telescopes, endoscopic staplers, and lasers) (without Zenker’s pouch) can be treated
have made performance of this endoscopic myotomy endoscopically with a laser if the surgeon is careful to
easier and safer than in the past. stop cutting once the transverse fibers of the CP have
been divided. Revision procedures are often best
performed with the laser and can allow anatomic
In my experience, the diagram of the cross-section dissection of remaining CP fibers. JSSchindler
(see Figure 15-1C) would show the esophagus being
much smaller than the diameter of the trachea (see
Figure 15-1B). WJRichtsmeier In the past the difficulty of secure mucosal closure
after excision of the diverticulum has led to alternate
approaches (diverticulopexy). The advent of laparo-
The most superior fibers of the CP muscle are scopic staplers has eliminated this difficulty, making
the most critical in terms of the performance of the excision of the diverticulum safe and therefore the pro-
cricopharyngeal myotomy. These are the most difficult cedure of choice.
to expose and cut in the external approach perhaps The more minimally invasive nature of the endo-
because of the inflammation and scarring at the mouth scopic approach makes it the preferred operation for
of the diverticulum. By contrast they are the fibers most patients with favorable anatomy and a diverticulum of
easily approached and divided in the endoscopic sufficient size. Very small diverticula and cricopharyn-
approach. geal myotomy alone are still probably better done exter-
The middle layer of the deep cervical fascia invests nally because this ensures complete division of the CP
the entire diverticulum and pharyngoesophageal muscle in these situations.
143
Inferior
constrictor
Cricopharyngeus m.
Diverticulum sac
A B
Cricoid
cartilage
Cricopharyngeus m.
Diverticulum sac
FIGURE 15-1. A to C, The intimate relationship of the Zenker’s

diverticulum and the cricopharyngeal muscle makes an endoscopic
approach possible. C
Endoscopic division of very small pouches can be Preoperative Considerations

performed with the laser but require an endoscopic and Patient Selection
retractor for adequate visualization of the muscle,
and the endoscopic suture closure is Because most patients with a Zenker’s diverticulum are
difficult. WJRichtsmeier older, there are often multiple factors contributing to
swallowing difficulties in addition to the diverticulum
CHAPTER 15 Cricopharyngeal Myotomy and Surgical Management of Zenker’s Diverticulum 145
1.5 cm
Cricopharyngeus m. Cricopharyngeus m.
D E
FIGURE 15-1, cont’d. D, The middle layer of the deep cervical fascia does not interdigitate
itself between the Zenker’s diverticulum and the esophagus. E, This minimizes the chance of
fistula when the party wall is divided, provided the division does not extend beyond the tip of
the diverticulum. However, the diverticulum must be long enough to allow for complete
division of the CP muscle.
itself. A modified barium swallow should be done to

The use of various food textures in the modified
assess these issues in addition to the length of the diver-
barium study is helpful in predicting
ticulum. This will help in counseling patients about
improvement. WJRichtsmeier
having realistic expectations about how much improve-
ment in swallowing will occur with the procedure.
In the case of patients with cricopharyngeal spasm
alone, this judgment about the degree to which the
A modified barium swallow with esophageal follow- cricopharyngeal spasm is contributing to the overall
through is essential to assess deglutition from entry swallowing difficulty as compared to other sources of
into the hypopharynx to passage through the lower dysphagia (oropharyngeal or esophageal dysmotility)
esophageal sphincter (LES). The surgeon should pay becomes particularly important. The external approach
careful attention to pharyngeal and esophageal muscle to the CP muscle or Zenker’s diverticulum by itself
activity as well as relaxation and reflux through the causes some dysphagia as the result of disruption of the
LES with recumbency. Without a comprehensive innervation of the muscles in this area (pharyngeal
evaluation, division of the CP muscle can lead to plexus).
worsening of swallowing and even intractable Because the CP muscle is at least 1.5 cm in vertical
aspiration. Complete passage of the bolus (except that dimension this means that a diverticulum of at least 2 to
retained in the Zenker’s pouch) should occur in 2.5 cm in length (as measured on a lateral view on
20 seconds or less to ensure adequate esophageal barium swallow (see Figure 15-1D and E) is required to
motility. JSSchindler ensure proper exposure for a complete myotomy if the
patient is being considered for an endoscopic approach.
Tongue
Cricopharyngeus m.
Diverticulum sac
Strip gauze
FIGURE 15-2. Packing the diverticulum with gauze facilitates identification at the time of
exposure.
Patients being considered for an endoscopic approach

Zenker’s diverticula of all sizes can be approached
must have sufficient mouth opening and neck mobility
endoscopically if they can be exposed with the
to allow for endoscopic exposure of the diverticulum.
diverticuloscope. Diverticula larger than 2.5 cm can be
Many patients with cricopharyngeal spasm/Zenker’s
divided effectively with an endoscopic stapler,
diverticulum have significant gastroesophageal reflux
whereas those less than 2 cm are best divided with a
and must be counseled that with cricopharyngeal
laser. Lesions between 2 and 2.5 cm may be treated
myotomy this may become more symptomatic and
with either method, and the final determination should
require correction. This is presumably because of the
be made based on the geometry and purchase
loss of the cricopharyngeal barrier to reflux.
obtained with the stapler before firing. If less than
complete purchase with a 3-cm stapler can be
obtained, the surgeon should strongly consider using
a laser. Diverticula longer than 2.5 cm may also be External Approach for Zenker’s
treated with the laser if the patient’s anatomy does not Diverticulectomy and/or
allow adequate opening of the diverticuloscope to Cricopharyngeal Myotomy
allow passage of the stapler. JSSchindler
STEP 1. Identification of the diverticulum is made easier
if direct laryngoscopy is performed at the beginning of the
case and the sac is lightly packed with 12 -inch Nu Gauze.
It is important to note that the patient does not have a The end of the gauze is brought out through the mouth to
distal esophageal stricture, which may allow pooling of facilitate its removal during the case (Figure 15-2).
secretions in the esophagus and make aspiration
worse after a cricopharyngeal myotomy unless
addressed first (see Step 3). WJRichtsmeier STEP 2. Identification of the cervical esophagus and the
cricopharyngeal myotomy is made easier if at the time
Tongue
Diverticulum sac
Strip gauze
FIGURE 15-3. Placement of an endotracheal tube in the esophagus facilitates its identification
and prevents stricture by overly aggressive retraction on the diverticulum at the time of
excision.
of laryngoscopy the cervical esophagus is intubated The balloon on this tube is used to distend the CP
with a No. 7 endotracheal tube. The anesthesia connec- muscle at the time of myotomy. The size of the tube
tor is removed from this tube so it is not confused during (No. 7) helps prevent overly aggressive resection of
the case with the one intubating the patient. This tube mucosa at the time of diverticulum excision and strictur-
is prepped into the field so that it can be manipulated ing at the site of closure.
during the case (Figure 15-3). The opening of the cervical esophagus is often ante-
rior at the time of laryngoscopy and its exposure and
intubation can be facilitated by the use of an intubating
A 45 Fr Maloney dilator may also be used instead of bougie over which the tube is advanced and performing
an endotracheal tube to distend the upper esophageal this before the diverticulum is packed.
sphincter (UES) and CP muscle. The semirigid dilator
provides a smooth, uniform dilation for cutting the
UES muscle fibers and has markings that may be The opening of the cervical esophagus is often small
read through the mucosa, indicating complete as well. WJRichtsmeier
division of the muscle fibers. This dilator should be
introduced after opening the neck and manually
passed through the UES to prevent perforation of the STEP 3. The retropharyngeal/esophageal area is exposed
diverticulum. JSSchindler as described in Chapter 14. The incision should be
placed at approximately the level of the cricoid. The
omohyoid can generally be retracted superiorly without
compromising exposure but it should be sectioned if
I have found that the stiffness of the Maloney dilator needed to facilitate this.
makes rotation of the laryngopharyngeal complex
more difficult than an endotracheal tube, but both are The diverticulum is approached from the left side for
options. JICohen the reasons previously reviewed in the chapter on cervi-
cal esophagus exposure.
Omohyoid m.
Fascia
Thyroid Diverticulum sac
gland
FIGURE 15-4. After the diverticulum is

identified, it is gradually freed up from the
surrounding fascia, working from its tip to its
neck.
dissected free up to its neck, working from distal (its tip)

The diverticulum is almost always on the left, but I to proximal (Figure 15-5).
have seen at least one that was predominantly to the
right and would have been difficult to approach from Working directly on the mucosa of the sac is important
the left. The endoscopy at the beginning of the to ensure that it is identified in its entirety up to its neck
procedure should give this information. WJRichtsmeier and that the cricopharyngeal muscle fibers that sur-
round the neck are fully identified.
In the absence of previous surgery in the area, the

recurrent nerve does not need to be specifically identi- STEP 5. With the sac retracted superiorly and the pos-
fied as the diverticulum arises above and posterior to terior midline of the neck of the sac and cervical esopha-
the entry of the nerve into the larynx. Limiting dissec- gus identified the endotracheal tube in the esophagus
tion to the capsule of the sac and posterior aspect of the can be palpated. Its balloon is gently inflated to distend
esophagus keeps the nerve out of the operative field. the pharyngoesophageal segment. The cricopharyngeal
If cricopharyngeal myotomy alone is being per- myotomy is then performed with a knife in the posterior
formed, the posterior midline is similarly exposed using midline, working from distal to proximal. The distention
the inferior cornu of the thyroid cartilage as a landmark from the balloon causes the muscle edges to retract and
for the level of the CP. the mucosa to bulge through, ensuring a complete
myotomy.
STEP 4. The sac (filled with gauze) is palpated on the

posterior aspect the pharynx or esophagus. The middle It is important to do the myotomy first because
layer of the deep cervical fascia is incised over its infe- the tissue becomes lax after the resection of the
rior tip, which is dissected free from the surrounding soft pouch, making finding the right plane more
tissues (Figure 15-4). It is grasped with a Babcock and difficult. WJRichtsmeier
the gauze is removed through the mouth. The sac is then
Inferior
constrictor m.
Diverticulum
sac
Cricophyaryngeus
m.
Thyroid
gland
FIGURE 15-5. The diverticulum is freed up completely

facilitating identification of the CP muscle, particularly
the most superior fibers.
Inferior Diverticulum
constrictor m. sac
Cricophyaryngeus
m.
Thyroid
gland
FIGURE 15-6. The CP muscle is divided under direct
vision from the neck of the diverticulum inferiorly for
at least a length of 2.5 cm. The mucosa should be
clearly seen and free of all overlying muscle fibers
when this is complete.
The myotomy begins in the cervical esophagus where Superiorly the myotomy is carried in the mucosal
the muscle fibers are normal and the plane of the mucosa plane right up to the plane of dissection of the mucosa
is most easily found. Beginning here and staying in this of the sac (Figure 15-6). These upper fibers are often the
plane ensures adequate myotomy length and complete thickest and most scarred and the myotomy is most
division of the more abnormal CP as one proceeds difficult, but this part of the operation is most critical
superiorly. to the success of the operation.
The myotomy is performed before the diverticulec- wall between the lumen of the esophagus and the
tomy because the mucosal incision line can complicate Zenker’s diverticulum (Figure 15-8). This is often
complete division of the upper cricopharyngeal fibers. the most challenging and time-consuming portion of
If cricopharyngeal myotomy alone is being per- the case.
formed, the myotomy is carried superiorly into the infe-
rior constrictor muscle at the level of the midthyroid The lumen of the esophagus is often quite anterior
cartilage. This ensures complete division of the CP and hardest to expose. Ideally the anterior blade of
muscle. the diverticuloscope is inserted into it (and therefore
the cricopharyngeal muscle sling), which stabilizes the
larynx anteriorly. The posterior blade should be inserted
Remember that the UES may be longer than the CP
sufficiently that when the diverticuloscope is opened it
muscle. If it looks longer on barium study, extend the
displaces the inferior margin of the inferior constrictor
myotomy if possible. WJRichtsmeier
posteriorly and exposes the sac lumen fully. A nasogas-
tric (NG) tube can be temporarily inserted down the
esophagus to ensure proper orientation. Ideally the
STEP 6. With the myotomy complete, the balloon on the
party wall will be under lateral tension when maximal
endotracheal tube is deflated and an endoscopic gas-
exposure is achieved.
trointestinal anastomosis (GIA) stapler (2.5-mm staples,
minimum length 3.5 cm) is used to transect the sac at
its base, simultaneously closing the mucosal edges
With patience, nearly all patients can have their
(Figure 15-7).
diverticula exposed transorally. The patient should be
The presence of the No. 7 endotracheal tube prevents fully relaxed by the anesthesia staff. A durable dental
overly aggressive resection and narrowing of the protector for the maxillary dentition is essential to
pharyngeal/esophageal lumen. prevent injury. A metal overlay protector can be added
There is no need to reinforce the stapled mucosal to reinforce this and distribute pressure across the
closure with a muscle layer closure. dentition. Water-based lubricant facilitates placement
With a very small diverticulum occasionally myotomy of the scope. Suspension of the laryngoscope from
alone resolves the mucosal redundancy and sac excision an external table (Mustard table or similar) can also
will be unnecessary. facilitate exposure. When exposure is inadequate but
additional exposure takes too much effort, suspend
the patient and allow a minute or two to allow the
If the sac is very small, it may be left in situ without tissues to relax and allow continued advancement of
resecting it. If it is intermediate in size and difficult to the diverticuloscope. JSSchindler
pass through the stapler completely, it can be
resected sharply. The resulting pharyngotomy may be
closed with 4-0 Vicryl suture using running Cannell Although the operation can be done with a bivalved
closure similar to that used to close the neopharynx laryngoscope the added length and narrowness of the
after total laryngectomy. JSSchindler diverticuloscope blades facilitate the operation.
Suturing the defect can be difficult if the edges are not The narrowness of the diverticuloscope is frequently
stabilized with sutures placed at each end of the the property that allows visualization of the CP
pharyngotomy prior to sac removal. Otherwise, the segment, especially in women with narrow mandibular
orientation of the closure can change and be hard to arches. In patients with chronic obstructive
reposition. JICohen pulmonary disease (COPD), in whom the larynx is
pulled farther into the chest, its length becomes more
important. WJRichtsmeier
STEP 7. The wound is closed in layers. Drainage is
unnecessary if it has been uncomplicated and the patient
can be fed a normal diet immediately as tolerated. STEP 2. The diverticuloscope is then opened proximally
sufficiently to allow the insertion of a telescope through
its side ports and the stapler down its lumen (Figure
Endoscopic Approach 15-9).
The operation is done more easily from this point using

STEP 1. A bivalved diverticuloscope is used to suspend endoscopes and an attached camera with the monitor
the patient’s larynx forward and expose the party at the patient’s foot. This facilitates visualization of the
Diverticulum
sac
Diverticulum
sac (excised)
FIGURE 15-7. Using the stapler, the neck of the

diverticulum is divided (A) and the pharyngotomy
B simultaneously closed securely (B).
Tongue
Cricopharyngeus m.
Diverticulum sac
Esophagus
Diverticulum sac
FIGURE 15-8. A and B, The bivalved diverticuloscope allows for

simultaneous exposure of the lumen of the diverticulum and
esophagus with sufficient room for the necessary instrumentation. B
A B
FIGURE 15-9. A and B, The ability to open the diverticuloscope proximally facilitates
simultaneous placement of both a telescope and a stapler
placement of the stapler, which is hard to see properly

directly because of the diameter of its shaft.
A 4- to 6-mm telescope works best. Often the length
of the telescope used with rigid esophagoscopy works
best because it keeps the camera head far enough from
the field so that it doesn’t interfere with the stapler. A
0- and 30-degree telescope may be needed if the esopha-
geal lumen is particularly anterior.
Esophagus
STEP 3. The stapler (endoscopic GIA stapler [2.5-mm

staples, minimum length 3.5 cm]) is inserted and opened Diverticulum sac
distally. The party wall between the sac and esophagus
is fully engaged and the stapler closed (Figure 15-10; see
Figure 15-1D).
The shorter blade of the stapler (the anvil) is inserted

into the sac to facilitate a maximal advancement of the
stapler (without perforating the sac) and thus maximal
division of the party wall.
If the esophageal lumen is very anterior it may FIGURE 15-10. The party wall between the esophagus and
be necessary to use a suture or laparoscopic grasper diverticulum is fully engaged in the stapler. The shorter blade
of the stapler is placed in the diverticulum.
to pull the party wall posteriorly enough to engage
the stapler.
Diverticulum
sac
FIGURE 15-11. The divided party wall between the

esophagus and diverticulum is sealed at its mucosal edges
by the stapler.
The surgeon should confirm that the mucosa of the

party wall extends all the way to the hinge of the
stapler (complete purchase) before firing. It is possible FIGURE 15-12. Functionally, after party wall division, the
to extend the division of the party wall for large diverticulum now empties into the esophagus rather than into
diverticula with additional staple firings. This must be the pharynx, minimizing regurgitation and aspiration
done with great care and careful visualization to symptoms.
prevent creating a perforation. JSSchindler
CP). These fibers are divided under direct vision and
retract laterally as they are divided (Figure 15-13).
STEP 4. When the proper positioning of the stapler head
This approach allows for a submucosal division that
is ensured it is fired, then opened and removed. The cut
extends beyond the mucosal incision itself although
and stapled edges of the party wall are retracted (Figure
this may be extended as needed. One should strive for
15-11) laterally by the CP muscle remnants and a
a 1.5-cm division of the muscle (in the vertical dimen-
“common” lumen created.
sion) to ensure complete myotomy but should not go
The procedure is repeated as needed to completely beyond the level of the inferior extension of the diver-
divide the party wall down to the sac base; however, as ticulum to avoid perforation of the investing layer of
long as 2 to 2.5 cm is divided, a complete myotomy is middle layer (visceral) layer of the cervical fascia and
ensured and further division may be unnecessary. In fistula.
addition, a cut of this length lowers the party wall suf-
ficiently that the residual sac empties asymptomatically Once the surgeon completes the cut through the CP
into the esophagus rather than the pharynx (Figure muscle fibers with the laser, the cut may be extended
15-12). inferiorly by dividing the cervical esophageal muscle
In the case of a smaller sac that precludes a full staple fibers, hugging the esophageal mucosa. This helps
or cut of sufficient length, the endoscopic scissors can prevent violation of the middle layer of the deep
be used to extend the cut a bit farther between the staple cervical fascia near the base of the diverticulum. It is
lines that extend beyond the cut made by the stapler. common, however, to expose the space between this
layer and the muscle of the esophagus. Although
disconcerting, because there may appear to be a deep
STEP 5. If a CO2 laser is being used instead of a stapler, “hole” extending down along the esophagus, this does
a mucosal incision is made at the apex of the party wall not seem to be dangerous because there is no
to expose the underlying muscle (the upper fibers of the
STEP 6. Assuming no operative problems, the patient

can be fed a normal diet immediately as tolerated.
EDITORIAL COMMENT: As one can see from the

text and commentary, most Zenker’s diverticula can
be dealt with endoscopically if the operator is
familiar with the laser; only larger (>2 cm) diverticula
are eligible for the stapling technique. Unfortunately,
the use of the laser, which does not involve mucosal
closure, requires more experience and judgment in
Esophagus terms of how far the myotomy can extend before
violation of the middle layer of the deep cervical
fascia becomes a significant risk. For this reason
patient selection is key.
However, a prerequisite to both approaches is
Diverticulum sac optimal exposure, which takes time (often the
majority of the case time), experience, and
sometimes the various “tricks” or maneuvers as
outlined here. JICohen
Suggested Readings
FIGURE 15-13. Alternatively, a laser can be used for dividing
the mucosa and underlying CP muscle. Hillel AT, Flint PW: Evolution of endoscopic surgical therapy
for Zenker’s diverticulum. Laryngoscope 119:39-44, 2009.
Miller FR, Bartley J, Otto RA: The endoscopic management
extravasation outside of the serosa of the esophagus of Zenker diverticulum: CO2 laser versus endoscopic sta-
pling. Laryngoscope 116:1608-1611, 2006.
into the retropharyngeal or mediastinal space. The
Palmer AD, Herrington HC, Rad IC, Cohen JI: Dysphagia
surgeon may distinguish this by filling the field with
after endoscopic repair of Zenker’s diverticulum. Laryngo-
saline and observing. If there has been a violation into scope 117:617-622, 2007.
the “danger space,” the saline will disappear into the Takes RP, van den Hoogen FJ, Marres HA: Endoscopic
mediastinum with exhalation while on the ventilator. If myotomy of the cricopharyngeal muscle with CO2 laser
there is any concern about possible violation of the surgery. Head Neck 27:703-709, 2005.
investing fascia, it is safest to place a thin nasal Veenker EA, Andersen PE, Cohen JI: Cricopharyngeal spasm
feeding tube, maintain nothing per mouth (NPO) status and Zenker’s diverticulum. Head Neck 25:681-694, 2003.
overnight, and perform a swallowing study before Visosky AM, Parke RB, Donovan DT: Endoscopic manage-
resuming oral intake. JSSchindler ment of Zenker’s diverticulum: factors predictive of success
or failure. Ann Otol Rhinol Laryngol 117:531-537, 2008.
CHAPTER
Defatting Tracheotomy
Commentary by Robert H. Maisel, Eben L. Rosenthal, and Mark K. Wax
Preoperative Considerations Operative Steps
Because closure of the defatting tracheotomy requires STEP 1. With the patient in a neutral position (i.e., not
a separate surgical procedure, patient selection is hyperextended) mark a horizontal skin incision that is
important to identify those patients who require about 2 to 3 cm in length at a position that seems most
long-term tracheotomy use. ELRosenthal natural for where the tracheotomy should lie—usually at
the level of the cricoid cartilage. Then mark a separate
horizontal incision just above the level of the clavicles
Although longer tracheotomy tubes are commercially extending to just beyond the posterior border of the
available for patients who have a particularly thick sternocleidomastoid muscles. The central 4 cm of this
neck, long-term use of these tubes can be associated lower incision is then erased and instead the lateral por-
with significant morbidity. The folds of the obese neck tions of the upper mark are extended downward to meet
tend to make access to and care of the tracheotomy site the lower incision (see Figure 16-1C).
difficult (the submental fat pad may completely overlie
the tracheotomy site), the length of the tract tends to Over time we have converted to a simple curvilinear
encourage the growth of granulation tissue, and the incision in a skinfold. As long as it is 2 cm or more
thickness of the overlying soft tissue can displace the above the sternal notch we have no trouble securing
tube superiorly or inferiorly, thereby rotating the trache- the lower skin flap to the trachea. MKWax
otomy tube so that it impacts the anterior or posterior
tracheal wall (Figure 16-1A). In addition, the length of
the tract makes accidental decannulation and tube dis- We use a similar incision having graduated from the
placement a significant risk. “H” incision with a horizontal limb that we had
originally used. The flap as described by Dr. Cohen
offers a central inferior-based skin tag that can be
Use of specialty tracheotomy tubes places a brought more easily to the inferior tracheal wall. This
significant burden on the patient and caregivers usually is the area that is most difficult to approximate.
because the tubes are not easily replaced and do not This incision overcomes that problem. RHMaisel
always have inner cannulas. Therefore this procedure
is critical in patients who may be going to nursing
facilities or patients of low socioeconomic This design creates an inferior skin flap that is about 2
status. ELRosenthal to 3 cm in length and serves to help overcome one of
the most significant problems in the obese individual—
providing adequate length to allow the skin to reach
The goal of a defatting tracheotomy, which is gener- over the sternum down to the trachea.
ally reserved for a situation in which long-term use in
an obese individual is anticipated, is to avoid these
problems by recontouring the neck to create a short, STEP 2. Using a horizontal shoulder roll, extend the
predominantly skin-lined tracheotomy tract that is easy patient’s neck as much as possible. In addition 2- to
to access and will fit a standard tracheotomy tube both 3-inch-wide tape placed over the chest and secured to
in length and configuration (Figure 16-1B). It is not the foot of the table is often needed to retract the soft
intended to create a skin-lined tract that will stay open tissues of the chest downward to expose the neck
without a tube in place. adequately.
156
CHAPTER 16 Defatting Tracheotomy 157
B
A
Incision
FIGURE 16-1. A, The submental fat pad can force the tracheotomy
tube faceplate into an unfavorable position impinging the distal tip
on the posterior tracheal wall. B, Defatting and recontouring help
create a tracheotomy tract that conforms to the configuration of a
standard length tracheotomy tube. C, The incision is designed to
accommodate the increased length of skin required to secure the
C inferior skin flap to the trachea.
This is particularly important in women, in whom large

pendulous breasts can “push” into the surgical
field. MKWax
STEP 3. The upper skin flap is elevated subplatysmally

to the mentum so that the entire area between the ante-
rior bellies of the digastric is undermined. The inferior
flap is elevated down to sternal notch centrally and later-
ally over the heads of the clavicle (Figure 16-2A).
Hyoid
bone
STEP 4. Subcutaneous adipose tissue is extensively
removed from the central aspect (4- to 5-cm width)
of both skin flaps so that they are thin and pliable,
especially where they will be directly sewn to the trachea
(see Figure 16-2B).
We also thin the inferior flap and remove the fat over
the sternum for 2 to 3 cm. This facilitates a retention
stitch in the skin to the sternal periosteum. MKWax
Wide undermining of the flaps improves their mobility

for later transposition down to the trachea and facili-
A tates eversion for defatting. In addition, it facilitates
mucocutaneous approximation when the flaps are even-
tually sewn to the trachea.
STEP 5. The fat pad between the anterior borders of

anterior bellies of the digastric is removed. Inferior to
the hyoid the fascia along the anterior borders of the
sternocleidomastoid muscles is incised, and working
from inferiorly, starting at the sternal notch, the entire
fat pad overlying the sternohyoid/sternothyroid muscles
is removed (Figure 16-3).
Exposure in the short neck may be limited, requiring

extension of the incision laterally in a curvilinear
fashion as in an apron incision. ELRosenthal
The anterior jugular veins are ligated as necessary and

divided superiorly and inferiorly during the dissection.
The anterior jugular veins are almost always very large

in the inferior part of the neck. They should be ligated
and not cauterized. MKWax
B
STEP 6. The strap muscles are separated and retracted
FIGURE 16-2. A, The skin flaps are elevated superiorly to the
level of the mentum and inferiorly to the level of the sternum. laterally. The thyroid isthmus is divided in the midline
B, The flaps are then extensively defatted to increase their and reflected laterally to expose the anterior aspects of
pliability and allow them to recontour more directly to the the first three or four tracheal rings, removing any
underlying neck structures. remaining fat in this area (Figure 16-4).
Strap Thyroid
musculature isthmus
Sternocleidomastoid Sternohyoid
muscle Trachea
muscle
FIGURE 16-3. The fat pad overlying the suprahyoid and FIGURE 16-4. The thyroid isthmus is divided and retracted
infrahyoid muscles is excised extending from one anterior laterally to widely expose the anterior face of the trachea.
border of the sternocleidomastoid muscle to the other.
For Step 6 we want a larger anterior and lateral wall of I usually open the trachea with a horizontal incision
trachea to work with and therefore divide the thyroid between two tracheal rings. It is dilated and a 3-0
isthmus in the midline, suture ligate each side, and Vicryl suture is placed around the inferior ring and a
reflect the thyroid isthmus laterally so that 120 second suture is placed around the superior ring. I do
degrees of the trachea is visible and debrided of not move the endotracheal tube. In instances when
fascias. RHMaisel the cuff is surgically deflated, the patient can be
ventilated by placing a gauze over the tracheal hole as
needed. MKWax
Although division of the thyroid isthmus is seldom We similarly instruct our anesthesiologists during Step
required for standard tracheotomy, in defatting trache- 7 to remove the tape holding the endotracheal tube to
otomy its reflection laterally facilitates subsequent the skin of the face, deflate the cuff on the
approximation of the skin flaps to the cartilaginous endotracheal tube, and advance the endotracheal tube
rings. 2 cm. We then make an incision in the trachea as
noted in Figure 16-6 and having observed the cuff to
be below that ask that it be reinflated to prevent
STEP 7. With the endotracheal tube cuff deflated, the anesthesia gases and oxygen from entering the
trachea is opened between the second and third or third wound. We do make an “H” incision in the trachea
and fourth rings, depending on which seems more between rings two and three or rings three and four,
appropriate (Figure 16-5). Under direct vision the endo- and then cut vertically along the lateral border so that
tracheal tube is advanced downward so that when the we have an upper and lower tracheal flap that can be
cuff is inflated it is well below the area where the skin sewed to the skin (see Figure 55.4 in Friedman,
flaps will be sewn to the trachea. The cuff is then 2009). RHMaisel
reinflated.
FIGURE 16-5. The first three or four tracheal rings are widely FIGURE 16-6. The anterior portion of the second or third
exposed. tracheal ring is removed to create a tracheal window.
Maintaining cuff integrity allows the subsequent sutur- 16-7). At this level three heavy (2-0 or 3-0 Vicryl) absorb-
ing of the flaps to the trachea to proceed in an orderly able sutures are placed in a horizontal row—through the
fashion without compromising either patient ventilation upper flap, either through the periosteum or around the
or surgical technique. body of the hyoid (centrally and at the lesser cornu), and
back through the flap. They are then tagged for later use.
STEP 8. A rectangular window is created in the trachea I place a heavy (0 Vicryl) suture around the center of
by excising a portion of the anterior second or third the hyoid to tack the skin down. A second suture in a
tracheal ring (Figure 16-6). like fashion is used to anchor the skin to the thyroid
cartilage. Because the mucocutaneous sutures have
been placed, these skin cartilage sutures are tied
An interiorly based tracheal ring flap may be created,
sequentially. MKWax
which can be sutured correctly to the inferior skin flap.
This creates a skin edge and may facilitate reinsertion
of the tracheotomy tube in the short term if it comes Step 9 is an advance in surgical technique for which I
out. It may also facilitate the initial suturing of the skin applaud Dr. Cohen. We have not sutured the hyoid
flap to the trachea if the trachea lies low in the periosteum or the hyoid itself to the skin but will
neck. ELRosenthal certainly consider that idea. The question is whether a
Seton suture would be useful in Step 12 to prevent
Although standard tracheotomy does not require exci- skin necrosis and still allow the skin flap to adhere
sion of a tracheal ring, in this situation it facilitates tightly to the deeper tissues and thereby reduce the
subsequent orderly suturing of the skin flaps to the dead space. RHMaisel
margins of the tracheal opening.
These sutures help approximate the skin to the sub
mental area, recontouring the neck, eliminating the sub-
STEP 9. The upper skin flap is draped down to where it mental swelling that can interfere with tracheotomy
will lie when sutured to the trachea, and the place where care, and obliterating dead space to avoid postoperative
it will lie over the body of the hyoid is marked (Figure seroma.
Hyoid bone
Penrose drain
FIGURE 16-8. The upper and lower skin flaps are then
FIGURE 16-7. The upper skin flap is now laid back down so sutured to the upper and lower margins of the tracheal
that its lower border approximates the upper tracheal window. window maturing the stoma as much as possible. A passive
This allows the surgeon to determine where it will overlie the drain is placed under the upper flap to prevent seroma.
body of the hyoid. Sutures are placed through the flap around
the hyoid (or through its periosteum) and back through the
flap. They are not tied at this point.
The same 0 Vicryl suture is used to anchor the skin to
the sternum periosteum. MKWax
The sutures are not tied yet because this could inter-
fere with subsequent placement of the mucocutaneous
sutures that anchor the flap to the trachea.
During Step 10 the endotracheal tube with the cuff
closer to the carina allows the exposed trachea to be
easily visualized and for the sutures to be put into the
STEP 10. The inferior and superior flaps are then sewn
tracheal ring without penetrating the cuff. Having the
to the trachea with interrupted 2-0 or 3-0 absorbable
cuff below the open trachea allows continued easy
(Vicryl) sutures.
ventilation without the need to either reintubate the
patient transorally or to require a transtracheal
intubation to complete the procedure. RHMaisel
We often suture the inferior and superior flaps in such
a way that we have a 360-degree closure to help
mature the skin to tracheal opening. This reduces
STEP 11. A single Penrose drain is left under the upper
granulation tissue formation and usually prevents
flap and brought out of the lateral margins of the incision
the serous or purulent drainage as the stoma
bilaterally. This stays in place for 2 to 3 weeks.
heals. RHMaisel
It is not necessary to completely “mature” the skin to During Step 11 we often use suction drainage rather
the tracheal opening around the entire circumference. than a Penrose drain and we use a flat Jackson-Pratt–
Rather three or four sutures on each flap to the upper type drain. We have been concerned that a seroma
and lower margins of the tracheal opening taking care can form in this large dead space that has lost some
to bring the skin over the exposed cut edges of the car- of its blood supply from the procedure. RHMaisel
tilage is sufficient (Figure 16-8).
FIGURE 16-9. The incision is then closed, allowing adequate

drainage laterally around the drain.
FIGURE 16-10. The upper sutures are now tied to secure the
upper skin flap to the underlying soft tissues, and a standard
tracheotomy tube is placed.
Although the wound is theoretically “drained” by the

This defatting and sculpting technique certainly
tracheotomy tube itself, the large dead space and signifi-
provides an advantage in allowing the surgeon to
cant movement of the neck and trachea predispose
place a standard tracheotomy tube (usually No. 6 for
the patients to seroma if a second drain is not used
women and No. 8 for men), making it much easier
(Figure 16-9).
during tracheotomy tube changes to find the
replacement tracheotomy tube in hospital central
supply, rather than to look for a custom developed
STEP 12. The upper submental stitches are now tied
proximal long tracheotomy tube. We agree that it is
down and the lateral aspects of the skin incision closed
not necessary to suture this tracheotomy tube in place
with absorbable suture to avoid the need for subsequent
because the stoma will be easily found should the
suture removal underneath the tracheotomy faceplate
patient accidentally be extubated. RHMaisel
(Figure 16-10).
This is done before the tracheotomy tube is inserted.

Otherwise the faceplate of the tracheotomy can interfere
with the suturing. EDITORIAL COMMENT: Although all of the
commentators agree on the general concepts of
the operation, each has his own variations related
STEP 13. A standard-sized (No. 8 for male and No. 6 for to how the skin flaps are best attached to the
female patients) tracheotomy tube is then inserted and trachea so as to accomplish a tension-free closure
secured with circumferential tracheotomy ties. that approximates skin and tracheal mucosa well.
These variations provide the reader with a number
Suturing the tracheotomy tube to the more “mobile” of different “tricks” to deal with the many
skin flap is not advisable because it can traumatize the variations in exposure that the excess adipose in
flaps or pull them out of position, increasing the chance the neck creates. JICohen
of wound breakdown or decannulation.
Suggested Readings syndrome and tracheotomy: long-term follow-up experi-

ence. Arch Intern Med 141:985-988, 1981.
Clayman GL, Adams GL: Permanent tracheotomy with cervi- Harmon JD, Morgan W, Chaudhary B: Sleep apnea: morbidity
cal lipectomy. Laryngoscope 100:422-424, 1990. and mortality of surgical treatment. South Med J 82:161-
Fedok FG, Houck JR, Manders EK: Suction-assisted lipec- 164, 1989.
tomy in the management of obstructive sleep apnea. Arch Olsen KD, Pearson BW: Sleep apnea tracheotomy. Laryngo-
Otolaryngol 116:968-970, 1990. scope 94:555-556, 1984.
Friedman M: Sleep apnea and snoring: surgical and non- Sahni R, Blakley B, Maisel RH: Flap tracheotomy in sleep
surgical therapy, Edinburgh, 2009, Saunders/Elsevier. apnea patients. Laryngoscope 95: 221-223, 1985.
Ghorayeb BY: Tracheotomy in the morbidly obese patient. Simmons FB: Tracheotomy in obstructive sleep apnea patients.
Arch Otolaryngol 113:556-558, 1987. Laryngoscope 89:1702-1703, 1979.
Guilleminault C, Simmons FB, Motta J, Cummiskey J, Rose-
kind M, Schroeder JS, Dement WC: Obstructive sleep apnea
SECTION A Neck Dissection
CHAPTER
Radical Neck Dissection
17 Author Peter E. Andersen
Commentary by Oleg Militsakh and John A. Ridge
STEP 2. A horizontal skin incision is made in a transverse

Operative Steps
neck crease at the level of the hyoid. A curvilinear
extension is brought down to the clavicle as illustrated.
STEP 1. Position the patient supine with a horizontally In men, if possible, the incision should be located
oriented shoulder roll; the patient’s head should be entirely below the lower border of the beard to make
turned away from the operative side. The table is rotated shaving much easier for the patient after the procedure
90 degrees, with the operative side of the patient away (Figure 17-2).
from the anesthesia machine (Figure 17-1).
It is possible to do the operation through a purely trans-
I prefer the patient to be completely relaxed with a verse incision but the exposure is more difficult.
nondepolarizing muscle relaxant.
When a neck dissection is performed alone without
entry into the upper aerodigestive tract prophylactic I prefer a transverse cervical incision for this
antibiotics are not necessary. If, however, entry into the procedure. I usually try to avoid a trifurcation-type
upper aerodigestive tract is anticipated, antibiotics that incision, especially in irradiated necks. If exposure is
cover oral flora are administered prophylactically. I difficult a McFee-type incision can significantly
prefer ampicillin/sulbactam 3 g intravenous (IV) or improve exposure, while leaving a bipedicle skin-
clindamycin 600 mg IV if the patient is allergic to muscle flap for carotid protection. OMilitsakh
penicillin.
I select the incision based on the site of the primary

I agree that clean-contaminated procedures require
tumor. I use an incision similar to the one depicted
an antibiotic prophylaxis. However, even clean
for oral cavity and oropharynx cancers. I use an
procedures such as radical neck dissections may call
“apron” incision for larynx and hypopharynx primary
for antibiotic prophylaxis. In particular, prophylaxis
sites. JARidge
should be considered in patients with multiple host
risk factors for local wound infection such as prior
irradiation, multiple medical comorbidities, diabetes, or
obesity. I routinely use cefazolin 1 g IV 30 minutes STEP 3. The skin flaps are elevated in a subplatysmal
prior to incision on all radical neck dissection for plane. The anterior border of the trapezius muscle is
non–penicillin-allergic patients. OMilitsakh defined from the mastoid tip to the clavicle (Figure 17-3).
In the posterior triangle there is no platysma muscle. Yet

there is still a well-defined plane that can be used to
In this setting I use cefazolin and metronidazole, prevent perforation of the skin flap.
which are less expensive when administered in my Deepen the dissection along the anterior border of
operating room. JARidge the trapezius from the superior aspect of the incision
167
168 UNIT II Neck and Salivary Gland
Anesthesia inferiorly to the clavicle until the next layer of muscle

machine is encountered. These are the levator scapulae and sple-
nius muscles.
Anesthesiologist If you elevate the skin flaps in the proper plane you
will have to deepen down through some of the subcu-
Assistant 1
taneous fat to find the trapezius. Once the trapezius is
found you can proceed along its anterior aspect to the
clavicle. The trapezius curves anteriorly as it approaches
the clavicle.
Assistant 2 It is very easy to angle posteriorly under the trapezius
muscle during this maneuver. Simply proceed radially
through the tissue until the next group of muscles is
reached. It is impossible to remove every bit of fat in
the neck.
However, node-bearing fat, which differs from

subcutaneous fat, should be removed as much as
possible. JARidge
Scrub nurse First surgeon
Mayo instrument
table
Reflect the tissue off of the levator scapulae and
FIGURE 17-1. Arrangement of key pieces of equipment and splenius muscles. Divide the attachment of the sterno-
personnel. mastoid muscle from the mastoid tip.
FIGURE 17-2. Location of operative incision.

CHAPTER 17 Radical Neck Dissection 169
Tail of
parotid gland
Great
auricular n. Cut spinal
accessory n.
External
jugular v.
FIGURE 17-3. Mobilization of superior
posterior triangle tissue.
Preoperative examination (both clinically and This observation is widely applicable. Structures
radiologically) as well as an intraoperative evaluation divided once must typically be divided twice during a
may indicate an intramuscular involvement of the lymphadenectomy, whether they are arteries, veins, or
superior portion of the sternocleidomastoid (SCM) nerves. JARidge
muscle by extracapsular spread of tumor. In such
case, the mastoid tip can be amputated and a portion
of the posterior belly of digastric muscle may need to
be sacrificed to complete an en block removal the If microvascular free tissue transfer is anticipated, it is
tumor. OMilitsakh helpful to avoid the injury to transverse cervical
vessels, or ligate them distally to provide a
reconstructive surgeon with ipsilateral vascular access
STEP 4. The remaining nodal tissue in the posterior tri- if needed. OMilitsakh
angle is freed from the anterior border of the trapezius
muscle and the clavicle. During this maneuver the infe-
rior belly of the omohyoid muscle will need to be divided
Divide the attachments of the sternomastoid muscle
and the transverse cervical vessels will often need to be
from the clavicle and the manubrium. On the left side
ligated. The external jugular vein is ligated as it passes
of the neck the thoracic duct is located in a variable
underneath the clavicle (Figure 17-4).
position lateral to the internal jugular vein.
Reflect the remaining nodal tissue off of the scalene The transverse cervical artery is reflected up with the
muscles and brachial plexus taking care not to injure specimen, and it is easy to forget that you have to ligate
the phrenic nerve, which will often be lifted off the it proximally.
anterior scalene muscle with the specimen. If the trans- I prefer to divide the muscle about 1 cm superior to
verse cervical vessels were ligated distally, they will need its bony attachment. This is easier than trying to divide
to be ligated again here. the periosteum off the bone.
Spinal accessory n. Splenius m.
Middle scalene m.
Anterior scalene m.
Levator scapulae m.
Transverse cervical
artery and vein
Omohyoid m.
FIGURE 17-4. Mobilization of inferior
posterior triangle tissue.
STEP 5. Divide the internal jugular vein, taking care not STEP 6. Reflect the entire specimen superiorly, dissect-
to injure the vagus nerve or common carotid artery ing the mass of nodal tissue off of the common carotid
(Figure 17-5). artery and vagus nerve. Take care not to incorporate the
sternohyoid muscle in the specimen. Multiple cervical
sensory roots need to be divided.
It is all too easy to include the vagus nerve when
mobilizing the distal jugular vein. I reflect the vein Continue reflecting the specimen superiorly off of the
laterally and identify the underlying vagus where it carotid bifurcation, internal and external carotid arter-
courses next to the carotid, in an effort to ensure that ies, and vagus nerve. Multiple cervical sensory roots will
it will not be taken with the jugular vein. JARidge need to be divided. At the posterior belly of the digastric
muscle, the internal jugular vein needs to be ligated and
the proximal end of the spinal accessory nerve divided
It is not necessary to divide the internal jugular vein (Figure 17-6).
inferior to the clavicle. Make sure you have a long These nerve roots are quite large. Low in the neck I
enough cuff of vein to ensure that the ligature does not like to divide them 1 to 2 cm distal to their origin to
slip off. lessen the risk of injury to the phrenic nerve.
Be aware that the middle thyroid vein may require The internal jugular vein will be collapsed and can
ligation as well as you reflect the specimen superiorly. easily be inadvertently divided. Just be cognizant that
because you have divided the vein at the inferior aspect
For internal jugular vein ligation I prefer a “stick-tie” of the specimen you will also have to do so at the supe-
technique, which prevents slippage of the ligature. The rior aspect.
suture is introduced through the body of the vein, tied
on itself around a 180-degree circumference of the The cervical sympathetic trunk is found posterior to
vessel, and then all the way (360 degrees) around the the carotid, and often encountered during dissection
entire circumference of the vein. OMilitsakh of level II. The ganglion, shaped like an almond,
should not be mistaken for a node, and should not be
included in the specimen. The sympathetic trunk is
I doubly ligate the jugular, proximally and distally. also exposed to injury low in the neck, if there is bulky
JARidge disease in level IV. JARidge
Spinal
accessory n.
Vagus n.
Carotid artery
Internal
jugular v.
Vagus n.
Phrenic n.
Brachial plexis
Cut inferior
belly of omohyoid m.
Clavicle
FIGURE 17-5. Ligation of inferior aspect internal jugular vein.
STEP 7. If dissection of level 1A is indicated identify and

the thin layer of fascia where the facial vessels cross the
skeletonize the anterior bellies of the digastric muscle
inferior border of the mandible.
on either side of the submental triangle. Dissect the soft
Proceed posteriorly, separating the specimen from
tissue off of the mylohyoid muscle inferiorly to the hyoid
the inferior border of the mandible and dividing the tail
bone, leaving the tissue attached to the main specimen
of the parotid gland. Ligate the retromandibular vein,
at the tendon of the digastric muscle. This completes
if present.
the dissection of level 1A (Figure 17-7).
Reflect the tissue off of the mylohyoid muscle, pro-
In the patient who has a generous amount of adipose ceeding all the way to the posterior aspect of the mylo-
tissue, it can be difficult to identify the contralateral hyoid muscle.
anterior belly of the digastric muscle because there is a Retract the mylohyoid muscle anteriorly to expose
tendency to continue elevating the skin flap into the the lingual nerve and the submandibular duct. Divide
contralateral side of the neck over the submandibular the submandibular ganglion and the submandibular
gland rather than directing the dissection more deeply duct, taking care not to injure the hypoglossal nerve.
into the neck to identify the muscle itself. Dissect the contents of the submandibular triangle
Identify the marginal branch of the facial nerve. off of the posterior belly of the digastric muscle and
Ligate the facial vessels preserving the nerve and ligate the facial artery.
separate the specimen from the inferior border of the
mandible proceeding until the mylohyoid muscle is
reached. This is another situation in which the surgeon should
Identification of the marginal branch of the facial remember that the facial artery must be divided twice
nerve is critical to avoiding injury to it. If the superior if it has been divided once. This is also true of the
skin flap has been elevated in the proper subplatysmal facial vein, but it may be less obvious because the
plane, the nerve will be located within a centimeter or anatomy is inconstant. JARidge
so of the inferior border of the mandible just deep to
Divided
Internal jugular v.
Divide spinal
Vagus n. accessory n.
Cut superior belly of

omohyoid m.
C2
Sternohyoid m.
Sternothyoid m. C3
Carotid artery C4
Internal jugular v.
FIGURE 17-6. Dissection of specimen off of carotid sheath structures and superior ligation of
internal jugular vein.
deep, it is easily to inadvertently find the lingual artery.

If I do not encounter bulky disease in level IB, the
This can look deceptively similar to the hypoglossal
facial artery may be preserved during this dissection.
nerve.
Commonly there are two main arterial side branches
(submental artery and the artery to the submandibular
gland) that need to be ligated close to the main trunk Annoying hemorrhage may ensue if small arterial
of the facial artery. OMilitsakh branches retract beneath the hypoglossal nerve,
where they are not readily cauterized, clamped, or
Identify the hypoglossal nerve inferior to the poste- clipped. JARidge
rior belly of the digastric muscle. Trace the nerve pos-
teriorly, ligating several veins that course external to it
and remove the specimen. STEP 8. Insert two suction drains through separate stab
I find that the easiest way to identify the hypoglossal incisions (Figure 17-8).
nerve below the posterior belly of the digastric muscle
is to proceed posteriorly from the digastric tendon and The lateral drain can be routed to come out in the
find the first large vein that courses deep to the inferior postauricular or scalp region. This placement allows
aspect of the posterior belly of the digastric muscle. for more cosmetically pleasing placement of the
The nerve can be located just anterior and deep to this drain hole scar. Drains are arranged in a “yin yang”
vein. If bleeding is encountered during this maneuver fashion to efficiently evacuate all dissected neck
take care not to inadvertently clamp the nerve when compartments. OMilitsakh
obtaining hemostasis. If the dissection is carried too
Facial a. Tail of
Marginal n. Facial v. External
parotid gland jugular v.
Lingual n.
Submandibular
ganglion (cut) Posterior belly
of digastric m.
Myohyoid m. Internal
jugular v.
Stylohyoid m. Hypoglossal n.
Facial a.
Carotid a.
Submandibular gland
Cut superior end
of omohyoid m.
Submandibular duct Specimen
Facial a.
FIGURE 17-7. Dissection of level I lymph

nodes and identification of hypoglossal nerve.
FIGURE 17-8. Wound closed with location of

suction drains.
I close the wound with the drains on “wall suction,” to I discourage use of dressings, which obscure the
reduce the chance of a clot forming beneath the flaps. surgical bed, and may delay detection of a hematoma
Once such a clot has formed, the underlying vessel beneath the flaps. JARidge
commonly continues to ooze because the flap does
not truly “set.” This bleeding will not stop, leading to
reoperation for wound exploration and hemostasis. If it EDITORIAL COMMENT: Although performed
proves necessary to explore the wound, remember to much less commonly than in the past because
displace the clots through gentle blunt techniques and acceptance of more selective lymphadenectomies
irrigation. Sharp dissection and vigorous maneuvers has grown, this operation remains the basis for
may lead to injury to nerves that have become all subsequent operations and the principles on
encased in clot. JARidge which the technique is based carry over to the
less radical procedures. Approaching the majority
of the operation from below and behind, with
The wound is closed according to surgeon preference. I
the wide exposure that the sacrifice of the
prefer a two-layer closure of running 4-0 Vicryl suture
sternocleidomastoid muscle affords, allows safe
for the platysmal layer and running 5-0 fast-absorbing
and early identification of the structures that must
gut for the skin. I dress the wound with bacitracin
be preserved, particularly in the situation of more
ointment.
advanced neck disease, which is mostly likely to
be the setting in which the operation is carried
It is unlikely, but possible, that I will need to open a out. Understanding and mastery of this operation
portion of the wound. As a result, I use interrupted with adherence to these principles, whether in the
sutures for the platysma and skin. If placed with setting of malignant neck disease or benign
proper tension and removed in a timely way, even disease made difficult by scarring, infection, or
staples afford an excellent cosmetic result. In my size, prevents unnecessary morbidity. JICohen
practice, men have proven more accepting of skin
staples than have women. JARidge
Suggested Readings
I agree with the use of the plain bacitracin Crile G: Excision of cancer of the head and neck. JAMA
ointment because many patients develop allergic or 47:1780-1786, 1906.
irritation-type skin reaction to neomycin, one of the Martin H, Del Valle B, Ehrlich L, Cahan WG: Neck dissection.
ingredients of a commonly used triple-antibiotic Cancer 4:441-499, 1951.
ointment. OMilitsakh Patel KN, Shah JP: Neck dissection: past, present, future. Surg
Oncol Clin N Am 14:461-477, 2005.
CHAPTER
Modified Radical Neck Dissection
Commentary by William M. Lydiatt, Ashok R. Shaha, and Jeffrey D. Spiro
Operative Steps When a neck dissection is performed alone without

entry into the upper aerodigestive tract, prophylactic
antibiotics are not necessary. If, however, entry into the
STEP 1. Position the patient supine with a horizontally upper aerodigestive tract is anticipated, antibiotics that
oriented shoulder roll; the patient’s head should be cover oral flora are administered prophylactically. I
turned away from the operative side. The table is rotated prefer ampicillin/sulbactam 3 g intravenous (IV) or
90 degrees, with the operative side of the patient away clindamycin 600 mg intravenous (IV) if the patient is
from the anesthesia machine (Figure 18-1). allergic to penicillin.
I generally prefer the anesthesiologist and the

I use cefazolin 2 g or clindamycin 600 for clean
endotracheal tube between the surgeon and the first
cases. WMLydiatt
assistant or between the first and second assistant,
depending on the side of the neck to be done. I prefer
to use a transparent drape on the chin area, which
STEP 2. A horizontal skin incision made in a transverse
gives much better visualization of the endotracheal
neck crease at the level of the hyoid. A curvilinear
tube and the connections. I generally do not prefer the
extension is brought down to the clavicle as illustrated.
anesthesia machine and the anesthesiologist at the
In men, if possible, the incision should be located
foot end of the patient. ARShaha
entirely below the lower border of the beard to make
shaving much easier for the patient after the procedure
(Figure 18-2).
I prefer to give anesthesia access to the arm opposite
the operative side by leaving an armboard attached on
that side and rotating the table 45 degrees away from I usually curve the posterior part of the horizontal
the anesthesia machine. The endotracheal tube is incision up toward the mastoid process. The
secured in the head drapes and then routed over the trifurcation point of this incision should be located far
head of the table, under the table, and then along the enough posteriorly that it does not overlie the carotid
armboard. The scrub nurse is then positioned below bifurcation, particularly in radiated patients. I tend to
the armboard opposite the surgeon. JDSpiro emphasize the curve in the vertical incision such that
the midportion runs parallel to the lines of relaxed skin
tension, because I find this tends to minimize
Minor point: I do not turn the table because it takes contracture of this part of the incision. JDSpiro
slightly more time in setup. I do not find it
necessary. WMLydiatt
I generally like to use a transverse incision in the skin
crease in a curvilinear fashion, with the vertical limb in
I prefer the patient to be completely relaxed with a a “T” fashion. The vertical limb should generally be a
nondepolarizing muscle relaxant. I do not use a nerve lazy “S,” so that the wound does not end up in scar
simulator to identify the spinal accessory nerve. The contracture once it heals. The T-junction should be
decision to use a nerve stimulator or nerve monitoring behind the carotid artery. The flaps are usually raised
can be made according to surgeon preference. under the platysma. The posterior flap is generally
raised up to the trapezius muscle, whereas the
A nerve stimulator to identify either the spinal anterior flaps generally do not cross the midline.
accessory nerve or ramus mandibularis is generally It is extended almost medial to the strap
not necessary. ARShaha muscles. ARShaha
175
Anesthesia It is possible to do the operation through a purely trans-

machine
verse incision, but the exposure is difficult.
Anesthesiologist
I do virtually all of my neck dissections through a
Assistant 1 purely transverse incision. It requires a slightly lower
incision line in a natural skin crease that extends just
across the midline. The disadvantage is slightly less
exposure in lower level V. The advantages are better
Assistant 2 cosmesis and no trifurcation in the incision with its
attendant potential for skin loss, particularly in the
postirradiated patient. WMLydiatt
STEP 3. The skin flaps are elevated in a subplatysmal

plane. The anterior border of the trapezius muscle is
defined from the mastoid tip to the clavicle. The spinal
accessory nerve is identified at the anterior border of
the trapezius muscle and dissected proximally to the
posterior belly of the digastric muscle. During this
maneuver the sternocleidomastoid muscle is divided.
Mayo instrument
table Care should be taken not to inadvertently follow the
branch of the spinal accessory nerve that innervates the
FIGURE 18-1. Arrangement of key pieces of equipment and sternocleidomastoid muscle (Figure 18-3).
personnel.
In the posterior triangle there is no platysma muscle.
Yet there is still a well-defined plane that can be used to

CHAPTER 18 Modified Radical Neck Dissection 177
Erb’s point
Great Spinal
auricular n. accessory n.
External
jugular v. Tail of
parotid gland
Posterior end of
digastric m.
FIGURE 18-3. Identification and

dissection of spinal accessory nerve in
posterior triangle of the neck.
prevent injury to the spinal accessory nerve and perfora-

carotid sheath. At the base of the neck with the
tion of the skin flap.
ligation of the internal jugular vein (see following text)
If you elevate the skin flaps in the proper plane you
the operation moves from inferior in the neck
will have to deepen down through some of the subcu-
superiorly. WMLydiatt
taneous fat to find the trapezius. Because you don’t
know the precise location of the spinal accessory nerve,
at this point I start this maneuver high in the neck where You may encounter multiple large nerves during this
the nerve is least likely to be injured. Once the trapezius maneuver. If they course superficial to the trapezius,
is found you can proceed along its anterior aspect to the they are simply sensory nerves that must be divided and
clavicle. The trapezius curves anteriorly as it approaches can be divided without concern that they represent the
the clavicle. spinal accessory nerve.
The spinal accessory nerve courses along a path that
I agree that finding the spinal accessory nerve is is more vertical than you might think.
easiest as it emerges under the posterior belly of the
digastric muscle and entering the sternocleidomastoid The accessory nerve can be identified in three
muscle. This is particularly important when you use a different ways. The dissection can be done in front of
single transverse skin incision. If a decision is made to the trapezius muscle, and generally at the junction of
perform a type IV modified neck based on direct the upper two thirds and lower one third, the nerve
extension of disease in the sternocleidomastoid (SCM) can be found anteromedial to the trapezius muscle.
muscle and jugular vein, the SCM can be It can be found by blunt dissection in the posterior
disarticulated from the mastoid once the nerve is triangle between the trapezius muscle and the
identified and preserved. The muscle is partially posterior border of the sternocleidomastoid muscle.
divided as the nerve is dissected down to the insertion This may be difficult because the location of the nerve
in the trapezius. The overall flow of the dissection is in is generally not constant. The third technique to find
a clockwise rotation from the posterosuperior aspect the nerve is to find the greater auricular nerve behind
of the neck moving in an anterior and inferior direction the sternocleidomastoid muscle. Generally the
over the levator scapulae and splenius muscles then accessory nerve is 1 to 1.5 cm above the greater
over the scalene muscle, stopping posterior to the auricular nerve (Erb’s point). ARShaha
FIGURE 18-4. Mobilization of posterior

triangle tissue superior to spinal
accessory nerve.
I raise only the posterior skin flap initially while I find it easiest to first divide the superior attachment
dissecting the posterior triangle. There is usually some of the sternocleidomastoid muscle right below the
platysma that can be identified inferiorly in the mastoid process. One can then cut down through the
posterior triangle, and this can be followed to the fibrofatty tissue deep to the muscle, and the splenius
clavicle and to the most inferior portion of the will be encountered. The splenius can be followed
trapezius. Superiorly, the sternocleidomastoid muscle inferiorly to the trapezius, and dissection can then
can be used to determine the plane of dissection for proceed medially as described. JDSpiro
the flap. By using these two landmarks to first elevate
the superior and inferior portions of the posterior flap,
It is very easy to angle posteriorly under the trapezius
the thickness of the middle portion of the posterior
muscle during this maneuver. Simply proceed radially
flap can be more easily determined. JDSpiro
through the tissue until the next group of muscles is
reached. It is impossible to remove every bit of fat in
the neck.
STEP 4. Deepen the dissection along the anterior border
If you stay in the plane of the muscles and do not
of the trapezius but superior to the spinal accessory
try to turn the corners at the digastric and trapezius
nerve, proceeding until the next layer of muscles is
muscles, it is virtually impossible to inadvertently injure
encountered. These are the levator scapulae and sple-
the nerve.
nius muscles (Figure 18-4).
Reflect the tissue off of the levator scapulae and splenius

muscles. Proceed all the way forward to the point where STEP 5. With a scalpel and nerve hook, carefully free the
the spinal accessory nerve exits under the posterior belly spinal accessory nerve from its surrounding soft tissue
of the digastric muscle and where it courses deep to the all the way from the posterior belly of the digastric to
anterior border of the trapezius muscle. the trapezius muscle. The nodal tissue lying superior to
Divide the attachment of the sternocleidomastoid the spinal accessory nerve can now be delivered under-
muscle from the mastoid tip. neath the nerve (Figure 18-5).
FIGURE 18-5. Mobilization of spinal

accessory nerve and delivery of superior
posterior triangle tissue underneath nerve
(inset).
of that process can be reassuring during the mobiliza-

The spinal accessory nerve needs to be dissected
tion of the tissue of the upper posterior triangle.
carefully in the posterior triangle, avoiding either
traction injury or devascularization. Minor bleeding is
always seen around the accessory nerve from vasa The transverse process of C2 is a very reliable
nervosum, which can easily be controlled with a landmark. Care must be taken when dissecting the
bipolar cautery. A Martin forceps is a large-tooth accessory nerve adjacent to the digastric because the
pickup that encircles and retracts the nerve easily relationship of the nerve to the jugular vein at that
without causing a major traction injury. ARShaha point is variable; usually the accessory nerve is
posterior to the jugular vein; however, it can actually
Many small vessels are divided during this maneuver. overlie the vein. If there is no bulky nodal disease in
Rather than controlling each bleeder as it occurs, if you this portion of the neck, I prefer to ligate and divide
rapidly and completely mobilize the nerve first, it can the jugular vein at the level of the digastric at this
easily be retracted away from the bleeders and can be point in the procedure. JDSpiro
controlled with electrocautery without fear of injuring
the nerve.
Dissection of level IIB may be achieved by
dissecting the accessory nerve, retracting the
Bipolar cautery is also useful when operating in
sternocleidomastoid high up and exposing the
proximity to nerves. WMLydiatt
splenius capitis. The dissection can be done from the
region of the digastric muscle on the splenius capitis,
and the fatty pad can be pushed around the nerve
This maneuver is greatly facilitated by taking the posteriorly to join the main specimen. Again, the issue
time to completely free up the tissue from the levator of the level IIB dissection is somewhat debatable
and splenius muscles prior to the attempt. because the incidence of metastatic nodal disease in
Remember that the internal jugular vein always lies this region is rare. ARShaha
anterior to the transverse process of C2 and palpation
Splenius m.
Middle scalene m.
Anterior scalene m.
Levator scapulae m.
Transverse cervical
artery and vein
Omohyoid m.
FIGURE 18-6. Posterior triangle dissection inferior to spinal accessory nerve (inset: extent of
dissection in inferior posterior triangle).
STEP 6. The remaining nodal tissue in the posterior tri- scalene muscle with the specimen. If the transverse cervi-
angle is freed from the anterior border of the trapezius cal artery was ligated distally it will need to be ligated
muscle and the clavicle. During this maneuver the infe- proximally here.
rior belly of the omohyoid muscle needs to be divided
and the transverse cervical vessels often need to be
I prefer to divide the cervical roots at this point, as
ligated. The external jugular vein is ligated as it passes
described in Step 8 (see later) because I find this
underneath the clavicle (Figure 18-6).
facilitates separation of the jugular vein from the
remaining carotid sheath structures. JDSpiro
I find it is usually possible to preserve the transverse
cervical artery because it is typically located fairly
deep in the posterior triangle. JDSpiro
Divide the attachments of the sternocleidomastoid
muscle from the clavicle and the manubrium. On the
left side of the neck the thoracic duct is located in a
Injury to the transverse cervical artery can lead to variable position lateral to the internal jugular vein.
troublesome bleeding and occasionally retraction of
the transverse cervical artery to its origin to the This point cannot be overemphasized because injury
thyrocervical trunk. Generally, if one knows the to the duct as it enters the posterior aspect of the vein
location of the transverse cervical artery, the injury can results in chyle leakage. Similar lymphatic drainage
be avoided by blunt dissection of the fatty pad in the into the jugular vein is found on the right side and
supraclavicular region. ARShaha should be ligated as well. WMLydiatt
Reflect the remaining nodal tissue off of the scalene The transverse cervical artery will be reflected up
muscles and brachial plexus, taking care not to injure with the specimen and it is easy to forget that you will
the phrenic nerve, which is often lifted off the anterior have to ligate it proximally.
Vagus n.
Carotid artery
Internal
jugular v.
Vagus n.
Phrenic n.
Brachial plexis
Cut inferior
belly of omohyoid m.
Clavicle
FIGURE 18-7. Ligation of inferior aspect internal jugular vein.
I prefer to divide the muscle about 1 cm superior to

The internal jugular should be transfixed with 3-0 silk
its bony attachment. This is easier than trying to divide
at the superior end and the inferior end. In the inferior
the periosteum off the bone.
portion the dissection should be done around the
adventitia of the internal jugular vein to avoid injury to
In the left side of the neck, utmost care should be
the vagus nerve, which may be closely adherent to
taken to avoid injury to the lymphatic channels; if the
the internal jugular vein in the carotid sheath. If the
thoracic duct is identified, it should be clamped
internal jugular vein is avulsed in the inferior portion, it
and ligated with nonabsorbable suture material,
can cause troublesome bleeding and may precipitate
such as silk. A harmonic scalpel may be used in
air embolism. Pressure with sponges and slow
this region; however, there are no definitive data
exposure of the jugular vein with appropriate suction
that this will reduce the incidence of chyle leak. The
can help find the stump of the jugular vein, which can
sternocleidomastoid muscle should be cut at least
be suture ligated. If the stump of the jugular vein is
1 to 1.5 cm above the sternoclavicular joint to avoid
avulsed superiorly, it also can cause troublesome
any subperiosteal hemorrhage on the clavicle or at the
bleeding, and finding the superior stump may be
sternoclavicular joint, which may lead to thickening of
difficult if it gets retracted in the jugular bulb area.
this joint at a later stage. ARShaha
Generally, pressure in this area can help control the
bleeding, and occasionally the stump of the
sternocleidomastoid muscle may be used to control
STEP 7. Divide the internal jugular vein, taking care not
the bleeding from the superior aspect of the internal
to injure the vagus nerve or common carotid artery
jugular vein. ARShaha
(Figure 18-7).
Because the dissection is done between the internal

jugular vein and the carotid artery, utmost care should It is not necessary to divide the internal jugular vein
be taken to avoid injury to the sympathetic chain, inferior to the clavicle. Make sure you have a long
which may lead to Horner’s syndrome. ARShaha enough cuff of vein to ensure that the ligature does not
slip off.
Internal jugular v.
C2
Vagus n.
Cut superior belly of

omohyoid m.
Sternohyoid m.
Sternothyoid m. C3
Carotid artery C4
Internal jugular v.
FIGURE 18-8. Dissection of specimen off of carotid sheath structures and superior ligation of
internal jugular vein.
I prefer to double ligate the vein proximally with a amount of bleeding and retraction of the medial
suture ligature and a tie below it. WMLydiatt aspect of the middle thyroid vein in the thyroid
substance. ARShaha
Be aware that the middle thyroid vein may require

STEP 8. Reflect the entire specimen superiorly, dissect-
ligation as well, as you reflect the specimen superiorly.
ing the mass of nodal tissue off of the common carotid
artery and vagus nerve. Take care not to incorporate the
I always ligate the jugular vein before actually dividing sternohyoid muscle in the specimen. Multiple cervical
it, to avoid losing control of the inferior stump with sensory roots need to be divided (Figure 18-8).
resultant bleeding and/or air embolus. This is done by
passing 2-0 chromic ligatures at least 1 cm proximal Continue reflecting the specimen superiorly off of the
and distal to the point of division, then placing a 2-0 carotid bifurcation, internal and external carotid arter-
chromic suture ligature above the inferior ligature. The ies, and vagus nerve. Again multiple cervical sensory
jugular vein is then divided, leaving two ligatures on roots need to be divided. At the posterior belly of the
the inferior stump. Ligating the jugular vein very low in digastric muscle the internal jugular vein needs to be
the left neck also increases the risk of injury to the ligated.
thoracic duct and subsequent chyle fistula. JDSpiro These nerve roots are large. Low in the neck I like
to divide them 1 to 2 cm distal to their origin to lessen
the risk of injury to the phrenic nerve.
The anatomy and location of the middle thyroid vein The internal jugular vein will be collapsed and can
should be kept in mind because dissection of the easily be inadvertently divided. Just be cognizant that
internal jugular vein may lead to inadvertent injury to because you have divided the vein at the inferior aspect
the middle thyroid vein, causing a considerable of the specimen, you will also have to do so at the
superior aspect.
Facial a. Tail of
Marginal n. Facial v. External
Lingual n.
Submandibular
ganglion (cut) Posterior belly
of digastric m.
Myohyoid m. Internal
jugular v.
Facial a.
Carotid a.
Submandibular gland
Cut superior end
of omohyoid m.
Submandibular duct Specimen
Facial a.
FIGURE 18-9. Dissection of level IA lymph

nodes and identification of the hypoglossal
nerve.
Dividing the jugular vein at the level of the digastric risk. The Hayes Martin maneuver (ligating the facial
earlier in the case helps to keep the vein collapsed. artery and vein and elevating them to retract the facial
If the sensory roots are already divided, this portion nerve) can be used to elevate the marginal nerve but I
of the dissection usually proceeds rapidly, requiring prefer to specifically identify and preserve it. WMLydiatt
only ligation of smaller veins feeding the jugular
vein. JDSpiro
Identification of the marginal mandibular nerve may
sometimes be difficult, especially if it is in the superior
STEP 9. If dissection of level IA is indicated, identify and aspect of the body of the mandible. Ligating the facial
skeletonize the anterior bellies of the digastric muscle vessels and retracting the facial vessels superiorly
on either side of the submental triangle. Dissect the soft generally avoid injury to the ramus mandibularis.
tissue off of the mylohyoid muscle inferiorly to the hyoid Occasionally, dissecting facial lymph nodes in this
bone, leaving the tissue attached to the main specimen region is likely to cause injury to the marginal
at the tendon of the digastric muscle. This completes mandibular nerve. ARShaha
the dissection of level IA (Figure 18-9).
Identify the marginal branch of the facial nerve. Ligate Proceed posteriorly, separating the specimen from
the facial vessels preserving the nerve and separate the the inferior border of the mandible and dividing the tail
specimen from the inferior border of the mandible, proof the parotid gland. Ligate the retromandibular vein,
ceeding until the mylohyoid muscle is reached. if present.
While crossing over the mylohyoid, multiple vessels will Dissecting and removal of the tail of the parotid are
be encountered. These can typically be cauterized. generally not indicated because the incidence of nodal
Some may be of a caliber that require ligation, however. disease in this region is rare unless there is gross
The marginal branch of the facial nerve can be identified metastatic disease in this area. Any dissection into the
coursing across the submandibular gland. Attention substance of the parotid gland can cause troublesome
must be paid to removing the facial nodes if they are at bleeding. ARShaha
is to proceed posterior from the digastric tendon and

I do not routinely divide the tail of the parotid gland;
find the first large vein that courses deep to the inferior
however, if there is suggestion of involvement of
aspect of the posterior belly of the digastric muscle.
intraparotid or periparotid nodes at this level,
The nerve can be located just anterior and deep to this
a portion of the parotid tail can be included in the
vein. If bleeding is encountered during this maneuver,
resection. JDSpiro
take care not to inadvertently clamp the nerve when
obtaining hemostasis. If the dissection is carried too
Reflect the tissue off of the mylohyoid muscle, pro- deep, it is easy to inadvertently find the lingual artery.
ceeding all the way to the posterior aspect of the mylo- This can look deceptively similar to the hypoglossal
hyoid muscle. nerve.
Retract the mylohyoid muscle anteriorly to expose
the lingual nerve and the submandibular duct. Divide
The hypoglossal nerve is often identified earlier in the
the submandibular ganglion and the submandibular
dissection when the jugular vein is separated from the
duct, taking care not to injure the hypoglossal nerve.
remaining contents of the carotid sheath superiorly
near the digastric. Pharyngeal vein branches overlying
The hypoglossal nerve is in a plane deep to these the nerve will still need to be divided to deliver the
structures but can be injured if bleeding is specimen. I find small hemoclips useful for securing
encountered and not controlled. WMLydiatt smaller vein branches that can be awkward to ligate in
this location. JDSpiro
The submandibular salivary duct is generally ligated

with absorbable suture material such as Vicryl or STEP 10. Insert two suction drains through separate
chromic catgut. ARShaha stab incisions (Figure 18-10).
The wound is closed according to surgeon preference.

Dissect the contents of the submandibular triangle I prefer a two-layer closure of running 4-0 Vicryl suture
off of the posterior belly of the digastric muscle and for the platysmal layer and running 5-0 fast absorbing
ligate the facial artery. gut for the skin. I dress the wound with bacitracin
Identify the hypoglossal nerve inferior to the poste- ointment.
teriorly, ligating several veins that course external to it,
Utmost care should be taken to close the T-junction
and remove the specimen.
carefully by approximating the platysma in this region
and placing sutures carefully without traction on the
skin edges. This T-junction should be closed securely
There are always two veins superiorly and inferiorly
to avoid any separation of the wound. Generally this
running along the hypoglossal nerve, which also can
T-junction is behind the carotid vessels. The drain site
cause bleeding because these veins are fragile.
should be securely closed to avoid any lymphatic leak
Bipolar electrocautery is helpful to control the bleeding
or air leak. The drain should be placed on suction so
in this region. ARShaha
that the flaps can collapse and adhere to the deeper
neck structures. Generally, I like to place the drains on
wall suction for a 24-hour period. ARShaha
In the patient who has a generous amount of adipose
tissue, it can be difficult to identify the contralateral
anterior belly of the digastric muscle because there is a
tendency to continue elevating the skin flap into the Unless skin has been resected during the procedure,
contralateral side of the neck over the submandibular I use 3-0 chromic sutures for the platysmal layer, and
gland rather than directing the dissection more deeply staples for the skin. To ensure proper function of the
into the neck to identify the muscle itself. closed suction drains, it is important that the deep
Identification of the marginal branch of the facial (platysmal) closure is “airtight.” I place the drains on
nerve is critical to avoiding injury to it. If the superior gentle suction when ready to place staples to help
skin flap has been elevated in the proper subplatysmal identify any potential air leaks. JDSpiro
plane, the nerve will be located within a centimeter or
the thin layer of fascia where the facial vessels cross the I typically just use one drain coiled to include all of the
inferior border of the mandible. areas in Figure 18-10. The drain is secured with a 3-0
I find that the easiest way to identify the hypoglossal silk suture and placed on bulb suction. WMLydiatt
nerve below the posterior belly of the digastric muscle
FIGURE 18-10. Wound closed with location of

suction drains.
Suggested Readings
EDITORIAL COMMENT: Accurate identification of
nerve XI early in this operation and careful Andersen P, Cambronero E, Spiro R, Shah J: The role of com-
handling are the key to preservation of not just its prehensive neck dissection with preservation of the spinal
“form” but more important its “function,” which is accessory nerve in the clinically positive neck. Am J Surg
the primary justification for performing this 168:499-502, 1994.
Crile G: Excision of cancer of the head and neck. JAMA
operation rather than a radical neck dissection.
47:1780-1786, 1906.
The author and commentators provide a number
Patel KN, Shah JP: Neck dissection: past, present, future. Surg
of useful tips and insights into how to do this Oncol Clin N Am 14:461-477, 2005.
while at the same time ensuring complete removal
of the nodal groups at risk. JICohen
CHAPTER
Selective Neck Dissection, Levels I-III
19 (Supraomohyoid Neck Dissection)
Commentary by Francisco J. Civantos, Bruce J. Davidson, Neal Futran, and Ashok R. Shaha
Operative Steps anesthesia connections can be continually visualized.

An anesthesia disconnection or kinking of the
STEP 1. Position the patient supine with a horizontally endotracheal tube can be seen easily with the
oriented shoulder roll; the patient’s head should be transparent drape. ARShaha
turned away from the operative side. The table is rotated
90 degrees, with the operative side of the patient away
from the anesthesia machine (Figure 19-1). Figure 19-1 shows the first assistant on the opposite
side of the table, but often the first assistant stands
at the head of the bed. That position can be more
Not every patient needs a shoulder roll. If the patient’s
ergonomically challenging because excessive neck
spine has some curvature, the head will extend
flexion is required to visualize the upper aspects of
naturally. Avoiding the shoulder roll can reduce the
levels I and II. BJDavidson
risk of pressure ulcers. In either case, excessive
hyperextension should be avoided to prevent chronic
cervical spine pain syndrome or even rare cases of When a neck dissection is performed alone without entry
paralysis. Special care should be taken in patients into the upper aerodigestive tract, prophylactic antibiot-
with a history of spinal stenosis or other cervical spine ics are not necessary. If, however, entry into the upper
pathology to avoid hyperextension. FJCivantos aerodigestive tract is anticipated, antibiotics that cover
oral flora are administered prophylactically. I prefer
ampicillin/sulbactam 3 g intravenous (IV) or clindamy-
I do not prefer a roll under the shoulder. The roll is cin 600 mg IV if the patient is allergic to penicillin.
unlikely to stabilize the body as compared to three
sheets stacked one on top of one another. The
Generally I prefer broad-spectrum antibiotics such as
scapula is a flat bone and well stabilized with stacked
cephalosporin if there is going to be any oral or
sheets rather than a roll. ARShaha
pharyngeal contamination. ARShaha
Another option is to keep the head toward anesthesia.

I prefer the patient to be completely relaxed with a
This is particularly helpful if the neck dissection is
nondepolarizing muscle relaxant. I do not use a nerve
bilateral or if it is being done along with an oral
simulator to identify the spinal accessory nerve.
cavity resection and nasal intubation has been
used. BJDavidson
I prefer to avoid paralysis because this allows the use
of a nerve stimulator not only in the dissection of the
The authors have shown the position of the anesthesia spinal accessory nerve, but also, more important, in
machine close to the feet of the patient. I generally the dissection of the marginal mandibular branch of
prefer the anesthesia machine between the surgeon the facial nerve. The Bovie unipolar electrocautery can
and the first assistant or between the two assistants make muscles contract, and for many parts of the
on one side of the corner of the head of the operating procedure a technique using bipolar cautery must be
table. This way the endotracheal tube can be used instead. The harmonic scalpel can be used at
visualized very well and the anesthesiologist is much certain points as well. I believe that avoiding paralysis
closer to the patient. I also prefer a transparent drape allows for feedback regarding nerve stimulation and
above the chin, which is helpful in most head and ultimately can result in a lower incidence of temporary
neck surgery because the endotracheal tube and the neurapraxia. FJCivantos
186
CHAPTER 19 Selective Neck Dissection, Levels I-III (Supraomohyoid Neck Dissection) 187
Anesthesia
machine
Anesthesiologist
Assistant 1
Assistant 2 Hyoid bone
External jugular v.
Omohyoid m.

Mayo instrument
table
FIGURE 19-1. Arrangement of key pieces of equipment and FIGURE 19-2. Location of operative incision.
personnel.
Asking the anesthesiologist to maintain one or two I tend to extend the incision up posteriorly, but often
twitches during the procedures allows for identification will preserve the greater auricular nerve and work
of motor nerves (e.g., marginal, spinal accessory and under this to reach level IIB. BJDavidson
hypoglossal nerves) as needed. The partial paralysis
avoids excessive muscle contraction stimulated by the
monopolar cautery device. A complete lack of A slightly curvilinear incision probably goes very well
paralysis can result in strong muscle contraction with the skin crease, which invariably goes in a
from the sternocleidomastoid muscle that will interfere curvilinear fashion posteriorly. This is also quite helpful
with the dissection and may result in inadvertent injury in case there is a need for posterior or anterior
to the accessory nerve. BJDavidson extension of the incision. ARShaha
This incision is preferred because even though it may

Another option, especially for the novice surgeon, is to ultimately need to be longer (to the contralateral lesser
keep the patient nonparalyzed until after the marginal cornu of the hyoid) to gain adequate exposure, it pro-
mandibular and spinal accessory nerves are duces a result that is cosmetically superior to an incision
identified. NFutran that curves superiorly either at its anterior or posterior
limits. In men, if possible, the incision should be located
entirely below the lower border of the beard to make
STEP 2. A horizontal skin incision made in a transverse shaving much easier for the patient after the procedure.
neck crease at the level of the hyoid is preferred If there is a need for significant dissection lower in the
(Figure 19-2). neck, it may be helpful to make the incision slightly
lower. Similarly, if dissection of involved level IA nodes
I agree that the tradition of curving the incision up to the is anticipated to be difficult or the incision is connecting
chin should be abandoned. By extending the incision in with a lip-splitting incision, the incision is curved supe-
the horizontal crease, and undermining widely, level IA riorly in the midline of the submental skin to the mentum.
can be accessed. With the advent of minimally invasive
approaches to primary tumors, lip-slitting incisions are
used less frequently as well, so there is less reason to STEP 3. Deepen the skin incision down to the level of
curve the incision upward. FJCivantos the platysma muscle but not through the muscle through-
out the entire length of the incision (Figure 19-3).
Great auricular n.
Hyoid
Platysma m. bone
External jugular v.
FIGURE 19-3. Incision through skin and platysma muscle. FIGURE 19-4. Elevation of superior and inferior subplatysmal
skin flaps.
The area of the anticipated skin incision is injected with Traction or countertraction is applied at this point (and
a solution of 1% lidocaine and 1 : 100,000 epinephrine. throughout the operation) in a manner that creates long
This is done purely for the vasoconstrictive effects of straight planes of dissection rather than curved or angu-
the epinephrine. A clean bloodless operative field is lated lines where injury can occur to the tissues at these
essential for the precision of this operation and is points.
facilitated by the use of electrocautery with either a
needle point or very thin blade tip for the majority of The best way to dissect subplatysmally is to use skin
the dissection. For most electrocautery units a setting hooks on the skin, retract the skin hooks vertically to
of blended coagulation provides the right amount of the ceiling, and pull the skin superiorly so that the
cutting and coagulation without excessive charring pro- white line under the platysma is well exposed, which
vided that adequate traction and countertraction are is generally an avascular plane. The skin retraction,
applied to the tissue being worked on. Whether the both superiorly and inferiorly, pulls the platysma away,
electrocautery in the cutting mode or a knife is used exposing an avascular plane. ARShaha
for the skin incision itself is a matter of personal
preference.
The platysma is not immediately divided because it If the dissection is done in the proper plane, hugging
provides a fairly reliable landmark for deepening the the undersurface of the platysma muscle, the branches
incision to the level of the superficial layer of the deep of the facial nerve such as the marginal mandibular
cervical fascia in the subcutaneous tissues posterior to nerve and cervical branch of the facial nerve will not be
the posterior aspect of the platysma muscle, where the injured. However, it is common to observe motion of
external jugular vein and great auricular nerve are the face due to stimulation of these nerves and the pla-
located and can be inadvertently injured. tysma muscle itself from the electrocautery.
I prefer to raise my superior flap with sharp dissection

Care should be taken in an older adult patient
and use bipolar cautery to allow visualization and
because loose skin and thin platysma muscle are
preservation of marginal mandibular nerves. This is
often encountered. This can result in the surgeon’s
essential if facial nodes need to be resected because
penetration through these layers to the deeper
the course of the marginal nerve is often immediately
structures without realizing it. NFutran
adjacent to these nodes. BJDavidson
STEP 4. Raise the superior and inferior skin flaps in a In the portion of the skin incision, behind the poste-
subplatysmal plane. (Figure 19-4). rior aspect of the platysma muscle, the external jugular
vein (if present), and the great auricular nerve should

not be elevated with the skin flap because the proper
plane for the elevation of skin flap runs superficial to
these structures. If dissection of level IA is planned,
wider undermining of the skin flap in the submental
area is necessary. The proper subcutaneous plane can be
Submandibular
difficult to visualize due to limited exposure and the gland
central dehiscence of the platysma muscle in this loca-
Posterior
tion. However, identification of the anterior border of belly of
the contralateral platysma muscle and continuing the digastric m.
dissection in a subplatysmal plane can help. The skin
Submental
flap can then held in position by self-retaining hooks. triangle
Specimen
Fish hooks, which are essentially self-retaining
retractors, are helpful in retracting the skin flaps. Silk
stitches may be placed on the flaps for retraction;
however, fish hooks are easily available and quick.
ARShaha
During this flap elevation, branches of the cervical FIGURE 19-5. Dissection of level IA (submental) nodes.
plexus such as the great auricular nerve and other
branches that run transversely from posterior to ante-
rior across the sternomastoid muscle, as well as branches
of the external jugular vein and anterior jugular veins, When dissection of level IA is indicated the dissection
should be left down and not elevated with the skin flap. is begun by identifying and skeletonizing the anterior
border of the contralateral anterior belly of the digastric
When elevating the superior flap in the area of the muscle. In the patient who has a generous amount of
submandibular gland, bipolar cautery is preferred for adipose tissue, this can be difficult because there is a
hemostasis, to minimize the risk of thermal injury to tendency to continue elevating the skin flap into the
the marginal mandibular nerve. NFutran contralateral side of the neck over the submandibular
gland rather than directing the dissection more deeply
into the neck to identify the muscle itself. A similar
As the flaps are raised, injury to the external jugular maneuver is then performed on the ipsilateral anterior
vein is likely because this vein is quite thin, or the belly of the digastric muscle. Between these two lines of
branches may be injured leading to injury to the main dissection the contents of the submental triangle are
trunk of the external jugular vein. Even though the then freed from the mandible superiorly and reflected
bleeding can be stopped temporarily with the use of inferiorly in the plane of the mylohyoid muscle to the
electrocautery, it is best to expose the vein completely level of the hyoid. The plane of dissection is transverse,
and clamp, cut, and ligate rather than cauterize alone. parallel to the mandible. Multiple small perforating
Electrocautery may stop the bleeding temporarily; blood vessels, which can be controlled using electrocau-
however, the bleeding may resume postoperatively tery before they are divided, may be encountered. At the
when the patient coughs or raises intrathoracic level of the hyoid bone the limit of the submental dis-
pressure. ARShaha section must be defined in the contralateral side of the
neck. This is done by rereflecting the dissected submen-
tal tissues superiorly and making a transverse incision
STEP 5. If dissection of level IA is indicated identify and through them just inferior to the body of the hyoid
skeletonize the anterior bellies of the digastric muscle bone. The submental tissue is then elevated off the body
on either side of the submental triangle. Dissect the soft of the hyoid bone, reflecting it back to the ipsilateral
tissue off of the mylohyoid muscle inferiorly to the hyoid digastric tendon. It is common during this maneuver to
bone leaving the tissue attached to the main specimen encounter branches of the anterior jugular veins that
at the tendon of the digastric muscle (Figure 19-5). must be ligated.
Level IA dissection should be considered in neck Because the specimen is retracted from front to back,
dissections associated with primary tumors of the from superior to inferior, it is important to keep the
mental skin or lower lip, and anterior tongue and fascial envelope together with the soft tissue,
buccal cancers. BJDavidson lymphoid, and glandular tissues. ARShaha
Facial v.
Facial a.
Marginal n.
Stylohyoid m.
Posterior
* belly of
Lingual n. digastric m.
Mylohyoid m. Hypoglossal n.
External
jugular v.
Proximal facial a.
(arrow indicates
direction of blood flow)
Submandibular
duct
Specimen
* Submandibular
ganglion
Facial a.
FIGURE 19-6. Dissection of level IB

(submandibular) nodes.
STEP 6. Identify the marginal branch of the facial nerve. Retract the mylohyoid muscle anteriorly to expose
Ligate the facial vessels, preserving the nerve, and sepa- the lingual nerve and the submandibular duct. Divide
rate the specimen from the inferior border of the man- the submandibular ganglion and the submandibular
dible, proceeding until the mylohyoid muscle is reached. duct, taking care not to injure the hypoglossal nerve.
In patients who require free tissue transfer

The hypoglossal nerve will remain deep to the plane of
reconstruction, the facial vessels can be dissected
dissection in most cases, but should be visualized.
proximally to their origin and preserved as possible
Excessive upward retraction (i.e., away from the
recipient vessels. NFutran
patient) of the submandibular triangle tissues can
displace the hypoglossal nerve superficially and
expose it to injury. BJDavidson
Ligating facial vessels early in this part of the
dissection allows the gland to be retracted inferiorly
and exposes the mylohyoid muscle and the lingual
nerve. In some cases, the artery courses behind the Dissect the contents of the submandibular triangle
submandibular gland and can be preserved with off of the posterior belly of the digastric muscle and
ligation of only those branches entering the gland. ligate the facial artery. Skeletonize the posterior belly of
BJDavidson the digastric muscle all the way to its insertion on the
mastoid tip (Figure 19-6).
Proceed posteriorly, separating the specimen from the

inferior border of the mandible and dividing the tail The muscle is exposed on its superior surface as the
of the parotid gland. Ligate the retromandibular vein, gland is retracted caudally. Direct exposure of the
if present. muscle inferior to the gland leads to a separation
Reflect the tissue off of the mylohyoid muscle proof level I contents from the remainder of the
ceeding all the way to the posterior aspect of the mylo- specimen. BJDavidson
hyoid muscle.
Identification of the marginal branch of the facial

lymph nodes in this area in our efforts to minimize
nerve is critical to avoiding injury to it. If the superior
marginal mandibular nerve dissection. If necessary
skin flap has been elevated in the proper subplatysmal
and indicated, these nodes can be removed separately
plane, the nerve will be located within a centimeter or
in order to minimize retraction of the marginal
mandibular nerve. FJCivantos
the thin layer of fascia, where the facial vessels cross the
inferior border of the mandible These vessels are identi-
fied where they cross the inferior border of the mandible Superior retraction on the mandible at the mentum
by palpation or by visual inspection. Gentle traction on and angle coupled with adequate inferior countertrac-
the overlying fascia to move it in a cephalocaudad direction on the specimen allows complete clearance of the
tion allows identification of the nerve as a transversely tissues up to the mylohyoid line on the mandible without
oriented structure often with an accompanying tiny having to work underneath it. As in the submental area,
vessel. The fascia is then incised over this structure and there are small perforating vessels through the mylohy-
the marginal nerve is identified. The nerve should be oid muscle that if divided in an uncontrolled fashion
dissected free anteriorly and posteriorly just enough to retract superiorly and can produce troublesome
ensure its identification and thereby avoid inadvertently bleeding.
injuring it during the dissection.
In patients with tongue or floor mouth primary tumors,
Identification of the marginal mandibular branch is the it is critical to dissect the facial lymph nodes from
most crucial part of this part of the operation, which the marginal mandibular nerve because these are
should be done very carefully by dissecting in the first-eschelon nodes and can harbor cancerous
subplatysmal plane and identifying the nerve just cells. NFutran
above the surface of the submandibular salivary gland
in the facial wrap. The nerve is generally along the
inferior border of the mandible; however, it can be If there is no obvious disease in this area, the
within 1 cm above or below the free border of the dissection could be done below the body of the
mandible. Dissection in this area should be done mandible without supraperiosteal dissection. If there
carefully, avoiding too much use of electrocautery. are suspicious facial nodes, they should be carefully
The small bleeding vessels in this region are best dissected bluntly, separating the nerve from the lymph
cauterized with a bipolar cautery to avoid major injury node. Invariably there are tiny branches from the facial
to the nerve. Any dissection along the nerve is likely to vessels to the lymph nodes that need to be carefully
lead to temporary weakness, which invariably will cauterized, preferably with a bipolar cautery. Ligating
improve in 3 to 6 weeks postoperatively. ARShaha the facial vessels just below the free border of
the mandible and retracting the vessels superiorly
protect the marginal mandibular branch and assist in
With the marginal nerve properly identified, the
dissecting this group of facial lymph nodes. It is
specimen can now be freed from the inferior border of
best to send these lymph nodes separately to the
the mandible. This maneuver is started in the anterior/
pathologist to get a better idea whether there is
superior aspect of the submandibular triangle where
presence of metastatic disease to these facial lymph
the anterior belly of the digastric joins it and working
nodes, which prognostically is crucial. ARShaha
in a supraperiosteal plane in a posterior direction back
toward the facial vessels aiming to join the previously
made fascial incision just anterior and inferior to the When the posterior aspect of the mylohyoid muscle
previously identified marginal mandibular nerve. If is reached, it is retracted anteriorly and the subman-
there are involved facial lymph nodes in this area, one dibular gland is pulled posteriorly and inferiorly. This
may have to displace the marginal mandibular nerve allows identification of the lingual nerve, which is
superiorly in order to adequately remove these nodes. bowed inferiorly by the retraction. The apex of the bow
This may result in a temporary palsy of the marginal is the submandibular ganglion, which must be divided
mandibular nerve, but ultimately the nerve should allowing the nerve to retract superiorly. After the sub-
recover as long as it is not divided. mandibular ganglion is divided, the submandibular
gland/duct and associated sublingual glands are retracted
We know from sentinel node mapping studies that the superiorly, and looking just inferior and deep to the
lymph nodes around and above the marginal submandibular duct and associated sublingual glands
mandibular nerve can be very important, particularly the hypoglossal nerve must be identified. There are often
for facial skin and buccal mucosa primary tumors, but two or three rather large veins that were run in the plane
occasionally for other sites as well. It is easy to leave of the hypoglossal nerve, all of which are one fascial
layer deeper than the submandibular gland and
therefore protected. It often appears that these veins

must be ligated, but in fact, if left down and not ligated
they will not be divided during the process of dividing Stylohyoid m.
the submandibular duct. With the lingual and hypoglos- Internal Posterior
sal nerves thus identified, the submandibular duct can jugular v. belly of
digastric m.
now be divided usually in a diagonal plane parallel to
Spinal
the fibers of the mylohyoid. accessory n.
Specimen
As long as the surgeon stays in a plane superficial to
Great
the digastric muscle, physical identification of the auricular n.
Omohyoid m.
hypoglossal nerve is not always necessary because it
External
lies deep to this muscle. NFutran jugular v.
I generally prefer the submandibular salivary duct to
be ligated with absorbable suture material, such as
Vicryl or catgut. I prefer to avoid silk in this area FIGURE 19-7. Dissection of levels II and III nodes.
because it can be a chronic nidus of infection,
especially with minor salivary leak. Dissection under
A prominent vascular pedicle that lies just superficial
the mylohyoid is tricky because there are many small
to the nerve as it enters the sternomastoid muscle can
vessels perforating the mylohyoid, which can cause
be a clue to the location of the nerve.
bleeding. If these vessels retract into the mylohyoid
musculature, they are difficult to identify and may
Maintaining a plane of dissection along the muscle
continuously ooze. ARShaha
allows for easy identification of the spinal accessory
nerve. NFutran
STEP 7. Incise the fascia overlying the anterior border
of the sternomastoid muscle from the mastoid tip to the The accessory nerve occasionally is best felt as the
approximate level of the omohyoid muscle. Dissection finger moves medial to the sternomastoid muscle in the
should proceed along the medial aspect of the muscle. deeper portion superiorly. If the muscle is retracted and
Identify the spinal accessory nerve. The spinal accessory finger dissection is performed medial to the superior
nerve enters the sternocleidomastoid muscle at approxi- portion of the sternomastoid muscle, a tight bend can
mately the junction of the upper 25% of the muscle in be felt, which is an accessory nerve. Once the nerve is
the lower 75% of the muscle, although this can be felt, the dissection can be done on the surface of the
variable. accessory nerve to avoid both trauma to the nerve and
any devascularization of the nerve. ARShaha
Occasionally an anatomic variant occurs in which the After the nerve is definitively identified at its entry
spinal accessory nerve branches very high, and the into the sternomastoid muscle it is traced superiorly up
principal branch that innervates the trapezius muscle to the posterior belly of the digastric muscle. The overly-
travels deep to the sternocleidomastoid muscle rather ing fibrofatty tissue is divided (Figure 19-7).
than through it. The danger here is that the surgeon The entire muscle should be mobilized as a unit in
may assume that the muscular branch to the this way rather than focusing in one area because this
sternocleidomastoid muscle represents the entire improves exposure particularly superiorly and avoids
spinal accessory nerve. The surgeon could the inadvertent injury to the structures medial to the
accidentally injure the main branch of the nerve that muscle due to differential levels of dissection. Small
comes off high and travels approximately a centimeter vascular pedicles coursing into the sternocleidomastoid
below, entering level V below the sternocleidomastoid muscle will be encountered and must be cauterized and
muscle and superior to the cervical plexus. Although divided.
this branching pattern is less common, it is not rare,
and surgeons should be aware of this anatomic
variation. The use of a nerve stimulator can help clarify STEP 8. If the level IIB nodes are to be dissected, this is
whether the nerve being dissected innervates the performed at this point (Figure 19-8).
trapezius muscle or only the sternocleidomastoid
muscle. FJCivantos After dissecting along the medial aspect of the sterno-
cleidomastoid muscle from the eleventh nerve up to the
Specimen
Spinal
accessory n.
Splenius capitis m.
Levator scapulae m.
B
Spinal
accessory n.
Specimen
Great
auricular n.
A
FIGURE 19-8. Dissection of level IIB nodes.
insertion of the posterior belly of the digastric muscle

An initial effort to expose and elevate gently the length
onto the mastoid tip, the dissection is directed radially
of the spinal accessory nerve through level II
deep into the neck in a manner similar to that done
expedites the mobilization of level IIB. The nerve
more inferiorly. However, there are no cervical rootlets
should not be directly grasped and use of a nerve
to limit the dissection and there is a tendency to con-
hook should be minimized. Fine scissors and bipolar
tinue this dissection too far posteriorly. Once the plane
cautery usually allow the nerve exposure to proceed
of the deep neck muscles is encountered (splenius capitis
quickly. BJDavidson
and levator scapulae), the triangle of tissue in the level
IIB area can be dissected anteriorly working along the
fascia of these deeper muscles. After the dissection has
proceeded anteriorly along the deep plane, as far as the
surgeon feels comfortable, the specimen is laid back
It is acceptable to remove the IIB nodes as a separate
along the deep plane muscles and dissection is begun
specimen in cases in which the surgeon feels this
along the inferior border of the posterior belly of the
will reduce retraction of the spinal accessory nerve.
digastric muscle to free the small triangle of fibrofatty
FJCivantos
tissue from the apex of the triangle up to the posterior
aspect of the internal jugular vein and spinal accessory
nerve. The specimen can now be brought underneath
the spinal accessory nerve, grasped from below, and
gently dissected free from the nerve. This completes the Isolating this superior extent of the spinal accessory
level IIB dissection. If the level IIB nodes are not to be nerve for 360 degrees allows gentle retraction with a
removed, then after freeing up the nerve an incision is nerve hook to avoid injury. The nodal tissue is then
made parallel and inferior to the spinal accessory nerve, dissected off the deep neck muscles in a safe
again working deeply into the neck until the deep neck fashion. NFutran
muscles are encountered.
It is important to avoid traction on the accessory accomplished by retracting or transecting the

nerve. It is also crucial not to skeletonize the nerve omohyoid muscle and dissecting along the internal
too much in this area because it may lead to jugular vein; however, on the left side utmost care
devascularization of a portion of the accessory nerve. should be taken to avoid any injury to the lymphatic
This is one of the most common reasons for trunks that may lead to excessive chylous drainage.
occasional shoulder weakness after a supraomohyoid If a chyle leak is noted during surgery, every effort
neck dissection and preservation of the accessory should be made to ligate these lymphatic branches
nerve. The level IIB lymph nodes are above the with nonabsorbable silk stitches. This area should be
accessory nerve. If these lymph nodes need to be visualized until the surgeon is satisfied there is no
removed, careful dissection should be done above the obvious chyle leak. Some surgeons have recently
nerve, avoiding any major bleeding in this area and been using the harmonic scalpel in this region and feel
taking the facial envelope above the accessory nerve, there is a reduction of incidence of chyle leaks. Once
dissecting it off the splenius capitis muscle, and the drains are placed in the wound, it is important to
retrieving this fatty pad with lymphoid tissue under the place drains on suction so that during the closure of
accessory nerve to join the main specimen of the entire wound, the drain does not get clotted off.
supraomohyoid neck dissection. ARShaha Irrigation of the drain is best avoided at this stage.
Whether the drain should be placed for self-suction or
wall suction depends on the individual preference of
STEP 9. Working along the entire length of the dissec- the surgeon; however, I generally prefer wall suction
tion, transition from the plane along the medial aspect for approximately 24 hours. ARShaha
of the sternomastoid muscle to the plane of the cervical
roots. This transition forms the posterior aspect of the
Identify the hypoglossal nerve inferior to the poste-
dissection of levels II and III.
Reflect the specimen anteriorly, working in the plane teriorly, ligating several veins that course external to it
just superficial to the cervical roots. and remove the specimen.
Dissect the specimen off of the great vessels. Remem- This transition is one of the more confusing parts of
ber to work along the entire length of the dissection. the operation. The cervical rootlets are the key to this.
At the anterior aspect of the internal jugular vein, Inferior to the level of the entry of the eleventh nerve
transition to a plane superficial to the ansa hypoglossi. into the muscle the posterior limit of the dissection is
Reflect the specimen superior in this plane. The common approximately at a point about 1 to 11 2 inches behind
facial vein needs to be ligated during this maneuver. the internal jugular vein. This roughly corresponds to
the point where one starts to have difficulty with seeing
around the overhang of sternocleidomastoid muscle; the
The common facial vein is an important venous
dissection is then directed toward the deep muscles that
channel frequently used for free flap venous
form the floor of the neck cutting through the fibrofatty
anastomosis and is best preserved with a considerable
tissue until the fascia overlying these muscles is seen.
length of the vein from the internal jugular vein.
One will encounter several rather sizable nerves that are
Similarly, the facial artery should be left with a long
not stimulated by electrocautery to produce motion of
trunk under the digastric muscle for a donor vessel
the shoulder. These nerves are the cervical rootlets and
during free-flap reconstruction and vascular
help define the posterior limit of the dissection in the
anastomosis. ARShaha
jugular chain. The dissection is turned forward at the
level of the omohyoid tendon, marking the inferior limit
of the dissection to meet the internal jugular vein thereby
With traction or countertraction across the length of
defining its inferior extent. The fibrofatty tissue anterior
the internal jugular vein, I prefer to dissect the nodal
and superior to this line of dissection is now dissected
contents off this vessel with a No. 15 scalpel blade.
forward off the underlying rootlets and fascia to suffi-
The proximal facial vein can often be preserved if
ciently to establish the plane of dissection.
there are no grossly positive lymph nodes adjacent
to it. NFutran
Clear identification and retraction of the spinal
accessory nerve and great vessels are necessary to
Controversy continues about level IV dissection in prevent inadvertent injury at this step of the neck
patients undergoing supraomohyoid neck dissection. dissection. NFutran
This may be important in patients with tongue cancer
because there is approximately a 10% incidence of
metastatic disease at level IV. Generally this can be When approaching the great vessels from behind,
there is a tendency to follow the cervical roots deep to
the carotid artery and rather than the desired plane If a microvascular reconstruction is planned, con-
superficial to the internal jugular vein. This can be sider leaving the common facial vein in situ or at least
assisted by identifying the ansa cervicalis nerve and fol- leaving a long stump for a microvascular recipient vessel.
lowing it to the more superficial plane.
If a microvascular reconstruction is planned, the blood
vessels need to be handled very differently throughout
Once the carotid sheath is identified, dissection can
the operation. Sufficient length must be obtained on
be done with clamp dissection and electrocautery, but
designated donor vessels, such as the external jugular
we prefer to perform dissection with a No. 15 scalpel.
vein, facial artery, and facial vein. Of equal importance
This can allow complete exposure of the carotid,
is the avoidance of unipolar electrocautery adjacent
vagus, and jugular. As the specimen is retracted
to vessels that may be used for microvascular
toward the midline, branches of the jugular vein will be
anastomosis because this can lead to unrecognized
seen on the anterior border of the jugular vein and can
endothelial injury and subsequent failed microvascular
be ligated as required. Preserving a small stump of
anastomosis. In order to avoid crush injury, vessels
each vein branch to be transected ensures that the
should never be grasped with a forceps. Instead,
jugular vein itself is not constricted where these
gentle grasping of the adventitia alone or gentle
ligatures are placed. BJDavidson
retraction with a sponge should be performed.
FJCivantos
The decision whether to sacrifice the ansa cervicalis
branch is one of personal preference of the surgeon. It I find that the easiest way to identify the hypoglossal
is helpful during this anterior reflection of the specimen nerve is to proceed posteriorly from the digastric tendon
to keep the plane of dissection long and straight along and find the first large vein that courses deep to the
the internal jugular vein, rather than concentrating in inferior aspect of the posterior belly of the digastric
one small area that can lead to poor visualization and muscle. The nerve can be located just anterior and deep
inadvertent injury to the internal jugular vein. Inferiorly, to this vein.
the phrenic nerve may tend to be lifted up off of the If bleeding is encountered during this maneuver, take
anterior scalene muscle with the specimen, and care care not to inadvertently clamp the nerve when obtain-
should be taken not to injure it. Similarly on the left ing hemostasis.
side low in the neck, it is common to encounter the large
lymphatic vessels of the thoracic duct, which may need
to be individually clamped and ligated. There is a small branch of the occipital artery that is
encountered draping over the hypoglossal nerve and
should be ligated. NFutran
If the surgeon stays strictly cephalad to the omohyoid
muscle, major lymphatic vessels are not encountered.
NFutran
If the dissection is carried too deep it is easy to inad-
vertently find the lingual artery. This can look decep-
tively similar to the hypoglossal nerve (Figure 19-9).
I enjoy using medium-sized automatic clips to clip all
tissue dissected around the jugular vein in level IV.
This saves some time over multiple ligatures and More inferiorly in the neck, the anterior deep plane of
seems to work well to prevent the occurrence of a dissection is the plane of the superior thyroid artery.
chylous fistula. FJCivantos This ensures that dissection is not deep enough to put
the superior laryngeal nerve at risk. BJDavidson
During the dissection along the internal jugular vein it

is common to injure tiny branches to the lymph nodes STEP 10. Orient the specimen for pathologic analysis.
or small vein off the internal jugular vein. These tiny
vessels can easily be cauterized with a bipolar cautery One of the difficulties with selective neck dissection has
or with the use of a microclamp along the internal always been that there are relatively few landmarks for
jugular vein. Patience and pressure are more likely to the pathologist to use to orient the specimen, and there-
be rewarded than suturing the internal jugular vein in fore to get accurate nodal counts of the lymph nodes
this area. Trying to suture these tiny veins off the removed from each nodal group, the specimen must be
internal jugular vein may cause more bleeding and oriented for the pathologist. Therefore the specimen is
lead to the future narrowing of the lumen of the divided into the nodal groups, and each of these speci-
internal jugular vein. ARShaha mens is submitted in separately labeled containers for
pathologic examination.
Posterior belly of
digastric m.
Hypoglossal n.
Stylohyoid m.
Facial v.
Marginal n. Facial a.
Sternocleido-
mastoid m.
Submental
triangle Cervical
roots
Ansa
Omohyoid m.
cervicalis
Spinal
accessory n.
Specimen
Internal
jugular v.
Great
auricular n. B
FIGURE 19-9. Dissection of specimen from great vessels and hypoglossal nerve.
STEP 11. Insert suction drain through a separate stab

incision. The wound is closed according to surgeon surgeon has found to facilitate its performance
preference. both under normal circumstances and allowing
for anatomic variations.
I prefer a two-layer closure of running 4-0 absorbable Although the operation is less “radical” than
suture such as Vicryl for the platysmal layer and a the radical neck dissection, it is no less
running subcuticular stitch of 5-0 Monocryl for the complicated and in fact requires more surgical
skin. I dress the wound with bacitracin ointment only. expertise in terms of the critical preservation of
the spinal accessory nerve. In addition, the
preservation and necessary retraction of the
I prefer a 10-mm flat Blake train because its flutes are
sternocleidomastoid muscle make a first
rarely obstructed by blood clots. Surgical staples are
assistant very important for its efficient
also adequate for skin closure in many cases. NFutran
performance. JICohen
EDITORIAL COMMENT: Selective neck dissection

has assumed a prominent role in the management
of malignancy of the head and neck, and the Suggested Readings
supraomohyoid neck dissection serves as a Byers RM: Modified neck dissection. A study of 967 cases
prototype for the principles that guide its from 1970 to 1980. Am J Surg 150:414-421, 1985.
execution. Givi B, Andersen PE: Rationale for modifying neck dissection.
The author and commentators of this chapter J Surg Oncol 97:674-682, 2008.
provide a unified concept for the technique of Shah J, Andersen P: The impact of patterns of nodal metastasis
the operation and the myriad “nuances” that each on modifications of neck dissection. Ann Surg Oncol 1:521-
532, 1994.
CHAPTER
Selective Neck Dissection,
20 Levels I-IV and II-IV (Anterolateral
and Lateral Neck Dissection)
Commentary by James I. Cohen, Neal Futran, and William M. Lydiatt
Operative Steps I prefer the patient to be completely relaxed with a

simulator to identify the spinal accessory nerve. The
STEP 1. Position the patient supine with a horizontally decision to use a nerve stimulator or nerve monitoring
oriented shoulder roll; the patient’s head should be can be made according to surgeon preference.
turned away from the operative side.
In older individuals neck extension may preclude neck Alternatively, no relaxation helps with safe
rotation, and in this circumstance rotation should have identification and preservation of both the spinal
priority in terms of ease of operation. If access to accessory and marginal mandibular nerves. NFutran
the lower neck is important, I prefer a shoulder roll
vertically between the shoulder blades because
this allows the ipsilateral shoulder to drop back STEP 2. A horizontal skin incision made in a transverse
and helps bring the structures in the lower neck neck crease at the level of the hyoid is preferred because
forward. JICohen even though it may ultimately need to be longer (to the
contralateral lesser cornu of the hyoid) to gain adequate
The table is rotated 90 degrees, with the operative side exposure, it produces a result that is cosmetically supe-
of the patient away from the anesthesia machine, which rior to an incision that curves superiorly either at its
allows positioning of an assistant at the head of the anterior or posterior limit (Figure 20-2).
table for the necessary retraction of the sternocleido-
mastoid muscle (Figure 20-1).
This is an important point. WMLydiatt
I prefer to not rotate the table because this adds

some additional time and I do not find it
In men the incision should be located entirely below the
necessary. WMLydiatt
lower border of the beard, if possible, to make shaving
much easier for the patient after the procedure. If there
When a neck dissection is performed alone without is a need for significant dissection lower in the neck,
entry into the upper aerodigestive tract prophylactic it may be helpful to make the incision slightly lower.
antibiotics are not necessary. If, however, entry into the Similarly, if dissection of involved level IA nodes is
upper aerodigestive tract is anticipated, antibiotics that anticipated to be difficult or the incision is connecting
cover oral flora are administered prophylactically. with a lip-splitting incision, the incision is curved supe-
riorly in the midline of the submental skin to the
Alternatively, 24-hour dosing of antibiotics can be
mentum.
done. NFutran
The midline superior extension of the incision is the

Although the infection rate in a clean case is very low, most problematic in terms of scarring. This can be
I typically give cefazolin 2 g prior to incision, minimized by making sure that it is dropped down in a
clindamycin for penicillin-allergic patients. I do not give midline curvilinear fashion rather than diagonally
any postoperative doses. WMLydiatt across the anterior submandibular region. JICohen
197
Anesthesia
machine
Anesthesiologist
Assistant 1
Assistant 2
Hyoid bone
External jugular v.
Omohyoid m.

Mayo instrument
table
FIGURE 20-1. Arrangement of key pieces of equipment and FIGURE 20-2. Location of operative incision.
personnel.
STEP 3. The area of the anticipated skin incision is

injected with a solution of 1% lidocaine and 1 : 100,000 not used in nerve identification in this procedure, so
epinephrine. This is done purely for the vasoconstrictive there is no disadvantage to doing this.
effects of the epinephrine. A clean, bloodless operative In individuals with loose skin and excess
field is essential for the precision of this operation and subcutaneous fat, it is easy to mistakenly stop the
is facilitated by the use of electrocautery with either a elevation too early because these soft tissues are
needle point or very thin blade tip for the majority of the retracted over the inferior border of the mandible even
dissection. After the skin incision is made, superior and though the dissection is not that high. This judgment
inferior skin flaps are elevated in a subplatysmal plane should be made after relaxing the retraction on the
to the inferior border of the mandible and the clavicle superior skin flap. By contrast, elevation of the flap too
(Figure 20-3). far superiorly increases the chance of injury to the
marginal mandibular nerve and increases the number
of the distal branches of the cervical division that are
Allow 3 to 5 minutes after injection and prior to divided. JICohen
incision for the vasoconstrictive effects to have
maximal effect. NFutran
If the dissection is done in the proper plane, hugging
the undersurface of the platysma muscle, the branches
For most electrocautery units a setting of blended coag- of the facial nerve such as the marginal mandibular
ulation provides the right amount of cutting and coagu- nerve and cervical branch of the facial nerve will not be
lation without excessive charring provided that adequate injured. However, it is common to observe motion of
traction and countertraction are applied to the tissue the face due to stimulation of these nerves and the pla-
being worked on. Whether the electrocautery is in the tysma muscle itself from the electrocautery. In the
cutting mode or a knife is used for the skin incision itself portion of the skin incision, behind the posterior aspect
is a matter of personal preference. of the platysma muscle, the external jugular vein (if
present), and the great auricular nerve should not be
The patient should be completely paralyzed (zero out elevated with the skin flap as the proper plane for the
of four twitches on the anesthesia monitor) for this elevation of skin flap runs superficial to these structures.
procedure, which minimizes (but not eliminate) the If dissection of level IA is planned, wider undermining
muscle twitching that can be problematic in terms of of the skin flap in the submental area is necessary. The
the precision of the operation. The nerve stimulator is proper subcutaneous plane can be difficult to visualize
due to limited exposure and the central dehiscence of
CHAPTER 20 Selective Neck Dissection, Levels I-IV and II-IV (Anterolateral and Lateral Neck Dissection) 199
Superior flap
Sternocleido-
mastoid m.
Submandibular
gland
Ex. jugular v.
Posterior
belly of
digastric m.
Submental
triangle
Specimen
Inferior flap
FIGURE 20-3. Exposure after elevation of skin flaps. FIGURE 20-4. Dissection of submental triangle (level IA).
the platysma muscle in this location. However, identify- electrocautery before they are divided, may be encoun-
ing the anterior border of the contralateral platysma tered. At the level of the hyoid bone the limit of the
muscle and continuing the dissection in a subplatysmal submental dissection must be defined in the contralat-
plane can help. The skin flap can then be held in posi- eral side of the neck. This is done by rereflecting the
tion by self-retaining hooks. dissected submental tissues superiorly and making a
transverse incision through them just inferior to the
body of the hyoid bone. The submental tissue is then
STEP 4. When dissection of level IA is indicated the dis- elevated off the body of the hyoid bone, reflecting it
section is begun by identifying and skeletonizing the back to the ipsilateral digastric tendon. It is common
anterior border of the contralateral anterior belly of the during this maneuver to encounter branches of the ante-
digastric muscle. In the patient who has a generous rior jugular veins that must be ligated.
amount of adipose tissue, this can be difficult because
there is a tendency to continue elevating the skin flap The muscle is easiest to find where it joins the
into the contralateral side of the neck over the sub mandible superiorly and can then be followed
mandibular gland rather than directing the dissection inferiorly, where it is more deeply situated. NFutran
more deeply into the neck to identify the muscle itself
(Figure 20-4).
Bipolar electrocautery allows the surgeon to rapidly
move through the small perforating vessels in this
The muscle is easiest to find where it joins the
area. NFutran
mandible superiorly and can then be followed
inferiorly, where it is more deeply situated. JICohen
STEP 5. Attention is now directed toward dissection of

A similar maneuver is then performed on the ipsilateral the level IB or submandibular lymph nodes. Identifica-
anterior belly of the digastric muscle. Between these two tion of the marginal branch of the facial nerve is critical
lines of dissection, the contents of the submental tri- to avoiding injury to it. If the superior skin flap has been
angle are then freed from the mandible superiorly and elevated in the proper subplatysmal plane, the nerve will
reflected inferiorly in the plane of the mylohyoid muscle be located within a centimeter or so of the inferior border
to the level of the hyoid. The plane of dissection is of the mandible just deep to the thin layer of fascia
transverse, parallel to the mandible. Multiple small per- where the facial vessels cross the inferior border of the
forating blood vessels, which can be controlled using mandible. These vessels are identified where they cross
Facial v.
I retract the nerve superiorly using gentle retraction
Facial a.
Marginal n. with a moist sponge. This tenses the fascia and
keeps the nerve protected, avoiding undue retraction
Stylohyoid m.
from your assistant. It is important not to “pin” the
Posterior
* belly of nerve against the mandible to avoid additional
Lingual n. digastric m. trauma. WMLydiatt
Mylohyoid m. Hypoglossal n.
External
jugular v.
With the marginal nerve properly identified the spec-
imen can now be freed from the inferior border of the
mandible. This maneuver is started in the anterior aspect
superior aspect of the submandibular triangle where the
anterior belly of the digastric joins it and working in a
supraperiosteal plane in a posterior direction back
toward the facial vessels aiming to join the previously
made fascial incision just anterior and inferior to the
Submandibular previously identified marginal mandibular nerve. If
duct there are involved facial lymph nodes in this area, one
may have to displace the marginal mandibular nerve
Specimen superiorly in order to adequately remove these nodes.
This may result in a temporary palsy of the marginal
* Submandibular
ganglion mandibular nerve, but ultimately the nerve should
Facial a.
recover as long as it is not divided.
If the fascia below the marginal mandibular nerve is

completely incised, allowing it to retract superiorly with
FIGURE 20-5. Dissection of submandibular triangle (level IB). the fascia and the specimen is completely freed from
the mandible prior to division of the facial vessels, the
facial nodes are easily displaced inferiorly away from
the nerve without having to displace it. JICohen
inferior border of the mandible by palpation or by visual The facial vessels are individually clamped, divided,
inspection. Gentle traction on the overlying fascia to and ligated just inferior to the marginal mandibular
move it in a cephalocaudad direction allows identifica- nerve. Usually there is one facial artery and two
tion of the nerve as a transversely oriented structure facial vein branches. The dissection is then carried
often with an accompanying tiny vessel (Figure 20-5). farther posteriorly in line with the inferior border
of the mandible back toward the sternocleidomastoid
muscle.
Be sure not to identify the lower branches of the
cervical division, which are generally smaller. If this
It is important to dissect the perifacial nodes from
occurs, removal of the lymph node group that
around the marginal mandibular nerve in patients with
surrounds the facial vessels will be limited. JICohen
floor of mouth and tongue carcinoma because these
can be easily missed and frequently contain metastatic
cells. NFutran
The fascia is then incised over this structure and the
marginal nerve is identified. The nerve should be dis-
sected free anteriorly and posteriorly just enough to Superior retraction on the mandible at the mentum
ensure its identification and thereby avoid inadvertently and angle coupled with adequate inferior countertrac-
injuring it during the dissection. tion on the specimen allow complete clearance of the
tissues up to the mylohyoid line on the mandible without
Horizontal incision or division of the fascia just inferior having to work underneath it. There are, as in the
to nerve over the entire section where it crosses below submental area, small perforating vessels through the
the mandible allows the investing fascia to retract it mylohyoid muscle that if divided in an uncontrolled
superiorly and minimize injury. JICohen fashion retract superiorly and can produce troublesome
bleeding.
When the posterior aspect of the mylohyoid muscle Post. belly of

is reached, it is retracted anteriorly and the subman- digastric m.
dibular gland is pulled posteriorly and inferiorly. This Submandibular 3rd cervical n.
allows identification of the lingual nerve, which is gland Hypoglossal n.
bowed inferiorly by the retraction. 4th cervical n.
Ex. jugular v.
Levator m.
Common carotid a.
I use a Green retractor to lift the mylohyoid muscle. Int. jugular v.
Specimen Phrenic n.
It is important to lift, rather than pull, the muscle to
create a better three-dimensional space to help
Omohyoid m.
identify structures. WMLydiatt
Transverse
cervical a.
The apex of the bow is the submandibular ganglion, Thoracic duct

which must be divided, allowing the nerve to retract Sternocleido-
mastoid m.
superiorly. After the submandibular ganglion is divided,
the submandibular gland/duct and associated sublingual
glands are retracted superiorly, and looking just inferior
and deep to the submandibular duct and associated A
sublingual glands, the hypoglossal nerve must be identi-
fied. With the lingual and hypoglossal nerves thus iden-
tified, the submandibular duct can now be divided,
usually in a diagonal plane parallel to the fibers of the Post. belly of
digastric m.
mylohyoid. 3rd cervical n.
There are often two or three rather large veins that
4th cervical n.
run in the plane of the hypoglossal nerve, all of which
Ex. jugular v.
are one fascial layer deeper than the submandibular Levator m.
gland and therefore protected. It often appears that Common carotid a.
Int. jugular v.
these veins must be ligated, but in fact, if left down and Specimen
Phrenic n.
not ligated, they will not be divided during the process
of dividing the submandibular duct. Omohyoid m.
All of the attachments of the submandibular gland Transverse
have now been divided and the gland and specimen cervical a.
should be reflected posteroinferiorly. The stylohyoid
and posterior belly of the digastric muscle are identified Sternocleido-
Thoracic duct
just posterior to the digastric tendon and dissected free mastoid m.
of the overlying fascia until the facial artery is identified,
and this is divided and ligated.
B
If a free flap is contemplated, it is wise to save as FIGURE 20-6. A and B, Dissection of level IIA, III, and IV
much length of the artery as possible. WMLydiatt nodes.
STEP 6. If level I has not been dissected, define the

The posterior belly of the digastric muscle is then
superior limit of level II by identifying the posterior belly
followed farther posteriorly and superiorly until it is
of the digastric muscle. I find that this is most easily
crossed by the anterior border of the sternocleidomas-
done by incising the fascia along the inferior aspect of
toid muscle. It is easy during this maneuver to inadver-
the submandibular gland. The facial vein is ligated and
tently follow the stylohyoid muscle rather than the
the submandibular gland retracted superiorly. This
posterior belly of the digastric muscle, and care should
exposes the posterior belly of the digastric muscle,
be taken to avoid this.
which can then easily be followed anteriorly and poste-
riorly, thus defining the superior limit of the dissection
(Figure 20-6A).
Staying in a plane on top of these muscles is a very
safe level of dissection and avoids injuring the major You may encounter the retromandibular vein as you
neurovascular structures just deep to them. NFutran follow the posterior belly of the digastric muscle toward
the mastoid tip.
Specimen
Spinal
accessory n.
Splenius capitis m.
Levator scapulae m.
B
Spinal
accessory n.
Specimen
Great
auricular n.
A
FIGURE 20-7. A and B, Dissection of level IIB nodes.
Incise the fascia overlying the anterior border of the

This is a critical point. Keeping the arc of dissection
sternomastoid muscle from the mastoid tip to the
wide maintains the proper sense of depth to maximize
approximate level of the omohyoid muscle. Dissection
safety. WMLydiatt
should proceed along the medial aspect of the muscle
(see Figure 20-6B).
Identify the spinal accessory nerve. The spinal acces- Small vascular pedicles coursing into the sterno-
sory nerve enters the sternocleidomastoid muscle at cleidomastoid muscle will be encountered and must be
approximately the junction of the upper 25% of the cauterized and divided.
muscle in the lower 75% of the muscle, although this
can be variable. A prominent vascular pedicle that lies
just superficial to the nerve as it enters the sternomas- STEP 7. If the level IIB nodes are to be dissected, this is
toid muscle can be a clue to the location of the nerve. performed at this point (Figure 20-7).
After the nerve is definitively identified at its entry
into the sternomastoid muscle, it is traced superiorly up After dissecting along the medial aspect of the sterno-
to the posterior belly of the digastric muscle. The overly- cleidomastoid muscle from the eleventh nerve up to the
ing fibrofatty tissue is divided. insertion of the posterior belly of the digastric muscle
onto the mastoid tip, the dissection is directed radially
deep into the neck in a manner similar to that done
Bipolar cautery should always be used around the
more inferiorly. However, there are no cervical rootlets
nerve to minimize the risk of thermal injury. NFutran
to limit the dissection and there is a tendency to con-
tinue this dissection too far posteriorly. Once the plane
The entire muscle should be mobilized as a unit in of the deep neck muscles is encountered (splenius capitis
this way rather than focusing in one area because this and levator scapulae), the triangle of tissue in the level
improves exposure, particularly superiorly, and avoids IIB area can be dissected anteriorly working along the
the inadvertent injury to the structures medial to the fascia of these deeper muscles. After the dissection has
muscle due to differential levels of dissection. proceeded anteriorly along the deep plane, as far as the
surgeon feels comfortable, the specimen is laid back

along the deep plane muscles and dissection is begun
along the inferior border of the posterior belly of the
digastric muscle to free the small triangle of fibrofatty Marginal n.
3rd cervical n.
Hypoglossal n.
tissue from the apex of the triangle up to the posterior Facial a./v.
4th cervical n.
aspect of the internal jugular vein and spinal accessory
nerve. The specimen can now be brought underneath Ansa cervicalis Levator m.
the spinal accessory nerve, grasped from below, and
gently dissected free from the nerve. This completes the
level IIB dissection. If the level IIB nodes are not to be
removed, then after freeing up the nerve an incision is
made parallel and inferior to the spinal accessory nerve, Transverse
again working deeply into the neck until the deep neck cervical a.
muscles are encountered.
The assistant should maintain careful vigilance of

the spinal accessory nerve during dissection and
A
retraction in this area to minimize the risk of injury
and inadvertent puncture of the internal jugular
vein. NFutran
3rd cervical n.
STEP 8. Working along the entire length of the dissec- Marginal n.
Hypoglossal n.
Facial a./v.
tion, transition from the plane along the medial aspect 4th cervical n.
of the sternomastoid muscle to the plane of the cervical
Ansa cervicalis Levator m.
roots. This transition forms the posterior aspect of the
dissection of levels II, III, and IV. At this point the inferior Vagus n.
Common carotid a.
belly of the omohyoid muscle can be divided and the Phrenic n.
Int. jugular v.
muscle removed with the specimen or the muscle can
be left in situ and the nodal tissue of level IV dissected Omohyoid m.
out from underneath. Either method is acceptable Transverse
cervical a.
(Figure 20-8A).
This transition is one of the more confusing parts of the Thoracic duct
Sternocleido-
operation. The cervical rootlets are the key to this. Infe- mastoid m.
rior to the level of the entry of the eleventh nerve into
the muscle the posterior limit of the dissection is approx-
imately at a point about 1 to 11 2 inches behind the
internal jugular vein. This roughly corresponds to the B
point where one starts to have difficulty with seeing FIGURE 20-8. A and B, Dissection of the specimen from
around the overhang of sternocleidomastoid muscle; the great vessels and hypoglossal nerve.
dissection is then directed toward the deep muscles that
form the floor of the neck cutting through the fibrofatty
tissue until the fascia overlying these muscles is seen.
Identifying the deep neck muscles posteriorly from the
One will encounter several rather sizable nerves that
level of the omohyoid muscle to the mastoid region
will not be stimulated by electrocautery to produce
provides a broad area to identify the cervical rootlets
motion of the shoulder. These nerves are the cervical
and maintain the appropriate level of dissection
rootlets and help define the posterior limit of the dissec-
toward the great vessels. NFutran
tion in the jugular chain. The dissection is turned
forward at the level of the omohyoid tendon, and
continued to where it crosses the internal jugular vein, Reflect the specimen anteriorly, working in the plane
thereby defining the inferior limit. The fibrofatty tissue just superficial to the cervical roots.
anterior and superior to this line of dissection is now When approaching the great vessels from behind
dissected forward off the underlying rootlets and fascia there is a tendency to follow the cervical roots deep to
sufficiently to establish the plane of dissection. the carotid artery rather than the desired plane
superficial to the internal jugular vein. This can be Identify the hypoglossal nerve inferior to the poste-
assisted by identifying the ansa cervicalis nerve and fol- rior belly of the digastric muscle. Trace the nerve pos-
lowing it to the more superficial plane. The decision teriorly, ligating several veins that course external to it
whether to sacrifice the ansa cervicalis branch is one of and remove the specimen.
personal preference of the surgeon. It is helpful during I find that the easiest way to identify the hypoglossal
this anterior reflection of the specimen to keep the plane nerve is to proceed posteriorly, from the digastric tendon
of dissection long and straight along the internal jugular and find the first large vein that courses deep to the
vein, rather than concentrating in one small area, which inferior aspect of the posterior belly of the digastric
can lead to poor visualization and inadvertent injury to muscle. The nerve can be located just anterior and deep
the internal jugular vein. Inferiorly, the phrenic nerve to this vein.
may tend to be lifted up off of the anterior scalene If bleeding is encountered during this maneuver, take
muscle with the specimen and care should be taken not care not to inadvertently clamp the nerve when obtain-
to injure it. Similarly on the left side low in the neck, it ing hemostasis.
is common to encounter the large lymphatic vessels of
the thoracic duct that may need to be individually
clamped and ligated.
There is a small arterial branch that loops around the
hypoglossal nerve as it crosses the carotid artery.
One may encounter significant lymphatic vessels on This should be controlled with HemaClips or other
the right side as well. WMLydiatt ligation. NFutran
At the completion of this portion of the procedure or

just prior to closure, request the anesthesiologist to If the dissection is carried too deep it is easily to
perform a Valsalva maneuver to check for chyle inadvertently find the lingual artery. This can look
leak. NFutran deceptively similar to the hypoglossal nerve.
Figure 20-8B shows the operative field after removal
of the specimen.
Dissect the specimen off of the great vessels. Remem-
ber to work along the entire length of the dissection.
STEP 9. Orient the specimen for pathologic analysis.
I prefer to use a No. 15 blade scalpel for this
One of the difficulties with selective neck dissection has
dissection. The key is proper retraction and
always been that there are relatively few landmarks for
countertraction. WMLydiatt
the pathologist to use to orient the specimen, and there-
fore to get accurate nodal counts of the lymph nodes
removed from each nodal group the specimen must be
I prefer to use a No. 15 blade along the edge of the
oriented for the pathologist. Therefore, the specimen is
internal jugular vein, which can be visualized as a fine
divided into the nodal groups, and each of these speci-
white line to maintain uniform elevation of the soft
mens is submitted in separately labeled containers for
tissue packet off this structure. NFutran
pathologic examination.
At the anterior aspect of the internal jugular vein,

transition to a plane superficial to the ansa hypoglossi. STEP 10. Insert suction drain through a separate stab
Reflect the specimen superiorly in this plane. The incision.
common facial vein needs to be ligated during this
maneuver. The wound is closed according to surgeon preference. I
If a microvascular reconstruction is planned, con- prefer a two-layer closure of running 4-0 absorbable
sider leaving the common facial vein in situ or at least suture such as Vicryl for the platysmal layer and a
leaving a long stump for a microvascular recipient running subcuticular stitch of 5-0 Monocryl for the
vessel. skin. I dress the wound with bacitracin ointment only.
Similarly, stay superficial to the superior thyroid

artery where it takes off from the external carotid
artery because this is a useful recipient arterial Closure with surgical staples or permanent
supply. NFutran monofilament suture is also acceptable. NFutran
Suggested Readings
EDITORIAL COMMENT: Although selected neck
dissections have been widely adopted as a Shah J, Andersen P: The impact of patterns of nodal metastasis
strategy for managing limited neck disease and on modifications of neck dissection. Ann Surg Oncol 1:521-
the results reported, the techniques for their 532, 1994.
performance remain less well defined. Because Shah J, Andersen P: Evolving role of modifications in neck
dissection for oral squamous carcinoma. Br J Oral Maxil-
the three-dimensional aspects of these operations
lofac Facial Surg 33:3-8, 1995.
are less anatomically delineated than the radical
Warren F, Cohen J, Spiro J, Burningham A, Wong R, Shah J,
and modified radical operations, attention to et al: Results of selective neck dissection in management of
technique is paramount. The author and the node-positive neck. Arch Otolaryngol Head Neck Surg
commentators in this chapter provide a 128:1180-1184, 2002.
comprehensive and nuanced view of the details
needed to properly understand and undertake their
performance. JICohen
CHAPTER
Posterolateral Neck Dissection
Commentary by Bruce J. Davidson, Jesus E. Medina, and Ashok R. Shaha
This procedure removes the suboccipital and retroau-

I prefer to place a bean bag under the patient’s torso
ricular nodes and nodal groups two through five and
so that the shoulder can be elevated off the table
preserves the sternomastoid muscle and internal jugular
enough to allow comfortable access to the posterior
vein. It is primarily indicated for cutaneous malignan-
midline of the neck. JEMedina
cies of the scalp and neck that lie posterior to a coronal
plane through the external auditory canal.
nondepolarizing muscle relaxant. I do not use nerve
Posterolateral neck dissection is an uncommon monitoring, but the decision as to whether nerve moni-
surgical procedure that is mainly performed for toring is useful can be made according to surgeon
metastatic disease in the posterolateral neck typically preference.
originating in the neck or scalp area. The most
common pathologies include skin cancers (squamous
Nerve monitoring is controversial. A majority of
cell carcinoma, melanoma) and adnexal skin tumors
surgeons, including myself, do not use a nerve
(sebaceous carcinoma, eccrine carcinoma). The major
monitor in neck dissection. ARShaha
issue in posterolateral neck dissection is identification
and careful preservation of the accessory nerve.
Occasionally the neck dissection may be extended to I prefer that the anesthesiologist maintain one or two
suboccipital lymph nodes if the primary is in the scalp twitches throughout the procedure. The use of no
region. ARShaha muscle relaxation can be frustrating because of the
strong muscle contractions caused by the cautery
device. The use of complete relaxation can interfere
STEP 1. Position the patient supine with a horizontally with identification of the spinal accessory nerve,
oriented shoulder roll; the patient’s head should be especially its small superior branches to the upper
turned away from the operative side. The table is rotated portion of the trapezius muscle. BJDavidson
STEP 2. I prefer an incision that descends from the
Depending on the primary tumor site (e.g., a posterior mastoid tip along the anterior border of the trapezius
scalp skin cancer), a lateral decubitus position may be muscle then turns to run parallel to the clavicle to the
required. BJDavidson sternal notch (Figure 21-2).
Because the dissection must extend up to the

I generally prefer the anesthesia machine and tubing posterior midline of the neck, I often add a horizontal
placed between the first and second assistant. This is limb to the incision, along the nuchal line, from the
a secure position for the anesthesiologist to watch the upper end of the incision outlined in the drawing up
neck and the surgical procedure, and monitor any to or near the posterior midline. JEMedina
issues with the endotracheal tube. A transparent drape
placed on the face, along with other drapes, is quite
helpful. The transparent drape allows visualization of Any number of incisions can be used depending on
the endotracheal tube–anesthesia connection and the surgeon preference and whether the primary malignancy
location of the endotracheal tube. ARShaha is in the skin of the neck or there has been previous neck
surgery.
206
CHAPTER 21 Posterolateral Neck Dissection 207
Anesthesia
machine
Anesthesiologist
Assistant 1
Great auricular n.
Assistant 2
Erb’s point
Spinal
Ex. jugular v. accessory n.
Platysma

FIGURE 21-3. Incision through skin and platysma muscle.
Mayo instrument
table
FIGURE 21-1. Arrangement of key pieces of equipment and with the vertical limb extending behind the carotid
personnel. artery in a vertical fashion up to the clavicle. This
incision gives much better exposure and can be
extended when necessary. ARShaha
STEP 3. Elevate the skin flap in a subplatysmal plane

(Figure 21-3).
In the posterior triangle the platysma is likely to be

absent, leading one to elevate the skin flap either too
thin (which risks perforating the skin flap) or too thick
Sternocleido- (which risks injuring the spinal accessory nerve). If you
mastoid m. are uncertain, start raising the flap from the inferior
rather than the posterior aspect. Always raise the flap
Trapezius m. over the external jugular vein and great auricular nerve
and you will be in the proper plane. With experience
Platysma this maneuver becomes less difficult.
In my experience the crucial portion of the flap is

posterior to the lateral end of the platysma and thus
there is no ready-made plane to follow. In elevating
this flap, one must keep in mind that some of the
suboccipital nodes are superficial and can either be
violated or, worse yet, included within a flap that is
too thick. JEMedina
STEP 4. Identify the spinal accessory nerve in the pos-

Even though the authors have shown a J-shaped or terior triangle and follow it proximally to the posterior
“hockey-stick” incision, I generally prefer the standard aspect of the sternomastoid muscle. Working superior
neck dissection incision that goes from the tip of the to the accessory nerve, deepen along the anterior aspect
hyoid to the mastoid process, or in the region of the of the trapezius muscle from the mastoid to the point at
suboccipital area for posterolateral neck dissection which the accessory nerve passes deep to the anterior
border of the trapezius.
The accessory nerve can be found approximately

1 cm above the greater auricular nerve behind the
sternomastoid muscle. The greater auricular nerve is
located in the posterior portion of the sternomastoid
muscle. The muscle is pulled anteriorly and after
incising the fascia on the muscle, the nerve can be
Great auricular n. branches visualized. Another point where the nerve may be
Ex. jugular v. (cut) found is near the trapezius muscle. Expose the
Levator m. trapezius muscle, and at the junction of the upper
Cervical nn. two thirds and the lower third, if the dissection is
Spinal performed in the fatty tissue, the nerve can be easily
accessory n. identified where it enters the trapezius
Sternocleido- muscle. ARShaha
mastoid m. Cervical nn.
Trapezius m.
Incise along the posterior aspect of the sternomas-
toid muscle and continue along its medial aspect until
the cervical roots are reached.
The sternocleidomastoid muscle is thin posteriorly

Transverse and a portion of the muscle may be transected to
Platysma cervical a./v. provide improved access to the upper aspect of
level II. BJDavidson
Omohyoid m.
During this maneuver remember that lymph nodes
FIGURE 21-4. Identification and dissection of spinal may be located along the external jugular vein; therefore
accessory nerve in posterior triangle. I make sure that all the nodal tissue along the course of
the vein is removed.
At this point I do the portion of this operation that
makes it a unique neck dissection—the dissection of Keep in mind that these nodes are more important in
the suboccipital area. Beginning at about the junction cancers from the skin and that many posterolateral
of the upper and middle thirds of the trapezius, I incise neck dissections are done in the context of
the trapezius in an oblique, posterosuperior direction skin cancer. In contrast, most anterolateral neck
aiming toward the junction of the nuchal line and the dissections are done for aerodigestive cancers,
posterior midline of the neck. Immediately deep to the and these superficial nodes would rarely be
trapezius is the splenius muscle. By staying superficial involved. BJDavidson
to it, a plane of dissection is easily developed and
followed superiorly; this then allows me to incise the
insertion of the trapezius in the nuchal line without STEP 5. Inferior to the point where the accessory nerve
bothering the insertion of the splenius. JEMedina passes deep to the anterior aspect of the trapezius
muscle, follow the anterior border of the trapezius to the
clavicle. Mobilize the tissue of the posterior triangle from
When you reach the splenius and levator scapulae the anterior border of the trapezius, ligating the trans-
muscles, work anteriorly along this deep plane to free up verse cervical vessels and dividing the omohyoid muscle.
the tissue superior to the accessory nerve (Figure 21-4).
Some surgeons describe lymph nodes deep to the I prefer to free the spinal accessory nerve early and
splenius capitis muscle, along the deep portion of the pass the superior portion of the specimen under it at
occipital artery, and advocate resecting the upper this point. Then I follow the plane of the splenius and
portion of the splenius to ensure their removal. I do the levator scapulae down as far as I can. This makes
not include the splenius in the resection and carry it easier to address the posteroinferior portion of the
the dissection in a plane immediately superficial to neck. If the metastases in the area permit, I stay in a
the splenius. As I continue the dissection forward, plane superficial to the fascia of the levator in order to
I may or may not include the sternocleidomastoid preserve the nerves that come into it from the cervical
muscle. JEMedina plexus. JEMedina
The transverse cervical vessels can be preserved in If you look closely, you will often see at least one or
the posterior triangle lateral to the internal jugular vein, two branches of the spinal accessory nerve that lead
because they run on the floor of the posterior triangle. to the upper portion of the trapezius. These can be
Dissection in the posterior triangle should be done saved along with the main trunk of the nerve, and
very carefully because there is fibrofatty tissue in front preservation will mean less atrophy of the upper
of the trapezius muscle and multiple tiny veins that trapezius postoperatively. This is one of the few
extend into the tip of the axilla. If torn, these vessels portions of neck dissection surgery in which surgical
retract behind the trapezius muscle and it can be loupes provide an advantage.
difficult to identify and control the bleeding. Because Dissection of the spinal accessory nerve should be
the dissection continues above the clavicle and behind as atraumatic as possible. I try to teach that using a
the sternomastoid muscle on the left side, one needs clamp to spread soft tissues along the nerve may
to be careful to avoid injury to the lymphatic channels cause more of a stretch on the nerve than sharp
and especially the thoracic duct. Any lymphatics in dissection with scissors. Likewise, the excessive
this region should be ligated with nonabsorbable (silk) use of a nerve hook on the nerve may also cause
ties. Utmost care should also be taken to avoid any unnecessary stretching. Pickups should be used on
injury to the tributaries of the jugular vein in this the adjacent soft tissues without directly grasping the
region. As the dissection continues superior and nerve or its branches. BJDavidson
medial to the accessory nerve, careful attention
should be paid to avoid traction injury to the spinal
accessory nerve. It is also important to avoid any
Free the tissue of the posterior triangle from the
injury to the vasa nervosum of the accessory nerve.
periosteum of the clavicle. Ligate the external jugular
Level IIB dissection can be tedious because the
vein. Elevate the nodal tissue from the brachial plexus
fibrofatty tissue needs to be separated from the
(Figure 21-5).
splenius capitis muscle and pushed medially under
the accessory nerve. As the dissection continues
below the digastric muscle, it is important to identify
STEP 6. Dissect along the anterior aspect of the sterno-
the jugular vein and avoid injury to the common facial
mastoid muscle. Continue along its medial aspect until
vein. ARShaha
the accessory nerve is reached. Follow the accessory
nerve proximally to the posterior belly of the digastric
There are several nerves in this area that are similar muscle dividing the overlying soft tissue.
in caliber and direction to the accessory nerve. These
are sensory nerves. As long as the nerves pass superficial
If the posterior superior aspect of the
to the anterior aspect of the trapezius muscle they
sternocleidomastoid muscle is transected, the muscle
cannot be the accessory nerve and can (in fact they
can be retracted forward enough to identify the
must) be divided.
digastric muscle and complete this aspect of the
dissection from behind. BJDavidson
Preserving these cervical sensory branches has an
advantage and disadvantages. The advantage involves
Continue along the medial aspect of the sternomas-
less sensory deficit to the clavicular area skin. The
toid muscle until you connect with the dissect that had
disadvantages include increased operative time, an
previously been done in the posterior triangle. Then
increased risk of leaving small nodes behind in this
deliver the entire contents of the posterior triangle into
area, and increased postoperative pain for the patient
the anterior triangle by passing it deep to the sternomas-
due to preservation of these sensory nerves. Usually
toid muscle.
the disadvantages of saving these nerve branches
outweigh the advantage. Depending on the oncologic
and anatomic circumstances, I occasionally attempt Again, I usually do this portion of the dissection by
to preserve a large sensory nerve if it presents retracting the muscle medially and working from
itself. BJDavidson behind. Partially transecting the posterior aspect of the
sternocleidomastoid muscle inferiorly may assist the
surgeon in exposing level IV. BJDavidson
It is very easy to follow the fibrofatty tissue of
the posterior triangle into the superior aspect of
the axilla. Dissect the specimen off of the carotid artery, inter-
Free the accessory nerve circumferentially from the nal jugular vein, and vagus nerve (Figure 21-6). During
surrounding tissue, then finally deliver the tissue supe- this last maneuver you will have to divide the cervical
rior to the nerve underneath the nerve. sensory roots.
Great auricular n. branches

Ex. jugular v. (cut)
Cervical nn.
Sternocleido-
mastoid m.
Spinal
accessory n.
Levator m.
Trapezius m.
Platysma Transverse
cervical a./v. (cut)
Omohyoid m.
A
FIGURE 21-5. Transposition of spinal accessory nerve.
Ex. jugular v.
Spinal
accessory n.
3rd cervical n.
4th cervical n.
Specimen
Levator m.
Sternocleido-
Omohyoid m. mastoid m.
Phrenic n.
Vegus n. Trapezius m.
Int. jugular v.
Common carotid a. Cervical nn.
Platysma Transverse
FIGURE 21-6. Dissection of levels II to VI.

Stylohyoid m.
Ex. jugular v.
Hypoglossal n.
3rd cervical n.
4th cervical n.
Specimen
Spinal
accessory n.
Levator m.
Ansa cervicalis
Sternocleido-
Omohyoid m. mastoid m.
Phrenic n.
Common carotid a.
Int. jugular v.
Cervical nn.
Platysma Transverse
FIGURE 21-7. Dissection of specimen off of

hypoglossal nerve.
As the dissection is performed lateral to the jugular I usually insert two drains, one along the posterior
vein, there may be tiny tributaries entering the jugular end of the dissection and one along the anterior
vein. These need to be carefully clamped and ligated. aspect. JEMedina
Any avulsion of these veins can cause bleeding from
the internal jugular vein, which may be difficult to
control. Most of the time these tributaries can be EDITORIAL COMMENT: The posterolateral neck
found and ligated; however, if the tear extends into dissection is performed with relative rarity
the main jugular vein, vascular nylon sutures may be compared with the more standard lateral and
placed on the jugular vein, making every effort to anterolateral neck dissections and as such is less
avoid luminal narrowing of the jugular vein. When the well understood. There are differences in the
entire specimen is removed, it is important that author’s technique and that of the commentators
the surgeon cut the specimen and send it to the in terms of:
pathologist in separate containers with appropriate • The degree to which complete removal of the
labeling of the levels of the lymph nodes, such as occipital nodes is emphasized (which usually
levels II, III, IV, or V. As the suction drain is placed in requires some detachment of the upper
the wound, it is important to have the drain away from trapezius and perhaps splenius). The primary
the accessory nerve to avoid any suction-related site may help determine the degree to which
trauma to the nerve. ARShaha this is emphasized.
• Whether the entire operation is accomplished
from an approach posterior to the
STEP 7. Dissect the specimen off of the hypoglossal sternocleidomastoid muscle working on its
nerve and divide the omohyoid muscle at its attachment undersurface forward to the internal jugular
to the hyoid bone (Figures 21-7 and 21-8). vein or joining a more limited posteriorly
approached dissection to a more standard
approach to levels II through IV from anterior to
STEP 8. Close the wound over a suction drain (Figure the sternocleidomastoid. JICohen
21-9).
Post. belly of
digastic m. Ex. jugular v.
3rd cervical n.
4th cervical n.
Omohyoid m.
Spinal
accessory n.
Levator m.
Sternocleido-
Ansa cervicalis
mastoid m.
Brachial plexus
Common carotid a. Phrenic n.
Int. jugular v. Cervical nn.
Transverse
Platysma
FIGURE 21-8. Wound at completion of operation.
Suggested Readings
Byers RM: Modified neck dissection. A study of 967 cases
from 1970 to 1980. Am J Surg 150:414-421, 1985.
Givi B, Andersen PE: Rationale for modifying neck dissection.
J Surg Oncol 97:674-682, 2008.
Shah J, Andersen P: The impact of patterns of nodal metastasis
on modifications of neck dissection. Ann Surg Oncol 1:521-
532, 1994.
Sternocleido-
mastoid m.
Drain
FIGURE 21-9. Drain placement and skin closure.

CHAPTER
Retropharyngeal Lymph Node Dissection
Commentary by Peter E. Andersen and Gary L. Clayman
Preoperative Considerations tongue-retracting mouth gag is inserted, depressing the

tongue inferiorly and opening the mouth. The retractor
Retropharyngeal lymph nodes (RPLNs) are found is suspended from an overlying Mayo stand, which helps
behind the posterior wall of the pharynx and are clas- align the posterior pharyngeal wall perpendicularly to
sified as lateral and medial groups. The lateral RPLNs, the surgeon’s line of vision. A Red Robinson catheter
often known as the nodes of Rouviere, lie superiorly placed through the nose is used to retract the ipsilateral
near the skull base, frequently at the level of the atlas. soft palate. The incision is outlined on the posterior
Close to the internal carotid artery and the sympathetic pharyngeal wall medial to the posterior tonsillar pillar
chain, the lateral RPLNs are separated from these struc- (Figure 22-2).
tures by areolar tissue (Figure 22-1).
Computed tomography (CT) and magnetic reso-
nance imaging (MRI) are the principal means of detect-
I try to make this incision well lateral on the posterior
ing disease within the RPLNs because they are usually
wall of the oropharynx. The RPLNs do tend to be
asymptomatic.
located more lateral than one might expect. Do not,
however, make the incision in a location that cannot
For thyroid cancer, transoral excision of RPLN may
be easily seen with retraction of the posterior tonsillar
require ultrasonic localization in order to facilitate
pillars. If the tonsils are present and obstructing,
identification of these metastatic foci. GLClayman
I would simply remove the tonsil on the side of
interest. PEAndersen
Extirpative approaches to metastatic disease in the
retropharyngeal space for squamous cell carcinoma
(SCC) involve a transcervical approach, typically as an
Before performing my incision, I prefer to perform
extension of a neck dissection already being performed.
transoral ultrasound to localize the metastatic lymph
The wider exposure afforded by this approach allows
node(s). Once identified, instill 0.1 mL of methylene
for a more complete and controlled excision of the
blue intranodally (25-gauge needle). The incision is
nodes when the extracapsular spread so common with
then designed based on the localization. Tonsillectomy
SCC in these nodes is present.
can be performed if the palatine tonsil is bulky or
The proximity of the RPLN to the posterior oropha-
overlies the metastatic node(s). These procedures
ryngeal mucosa and the usually well-circumscribed non-
should be performed with the use of loupe
invasive nature of thyroid cancer metastases, which lack
magnification. GLClayman
macroscopic extracapsular spread, make a direct tran-
soral approach to their removal technically feasible and
oncologically sound. The limited surgical access pro-
STEP 2. Using electrocautery, the mucosa and superior
vided by this approach should preclude its use in situa-
pharyngeal constrictor muscle are incised, exposing the
tions in which macroscopic extracapsular spread or
underlying buccopharyngeal fascia. By palpation and
invasion of surrounding structures is likely or suspected.
gently moving the fascia over the underlying structures,
the node(s) are located (Figure 22-3).
Surgical Technique
Transoral Approach The RPLNs, sympathetic ganglion, and internal carotid
artery all lie deep to the superior constrictor; therefore,
until the muscle is divided one need not be concerned
STEP 1. The patient is positioned with the head slightly about injuring them. PEAndersen
extended on the neck. A Crowe-Davis or similar
213
Buccopharyngeal
fascia
Superior constrictor m.
Retropharyngeal
lymph node
Vagus n.
Internal carotid a.
FIGURE 22-1. Cross-sectional anatomy of the
retropharyngeal space. Sympathetic trunk
FIGURE 22-2. Initial exposure with incision on the posterior FIGURE 22-3. Incising the superior constrictor.
pharyngeal wall.
Because the RPLNs sit in the groove lateral to the prom-

I find that this is easy to do using a right-angle
inence of the central portion of the vertebral body when
clamp to lift the fascia away from the deeper
palpated, the RPLNs tend to be pushed laterally into
structures. PEAndersen
this groove.
Because the RPLNs lie deep to the buccopharyngeal

In thyroid cancer the nodes may not be readily fascia and can “stick” to it, they may be retracted later-
palpable. Using a small cottonoid pledget to ally during exposure. Placing the fascial incision as lat-
displace the tissues allows the lymph node to be erally as possible ensures the nodes are not retracted
readily observed following methylene blue laterally with the fascia, which can make exposure more
instillation. GLClayman difficult (Figure 22-4).
STEP 3. After locating the internal carotid artery by STEP 4. The node(s) are first separated from the under-
palpating its pulse lateral to the nodes, the buccopha- surface of the fascia by sharp and blunt dissection.
ryngeal fascia is incised just medial to the artery
(and lateral to the nodes) using monopolar and The superior sympathetic ganglion can be mistaken for
bipolar cautery to coagulate the small vessels that run an RPLN if care is not taken to ensure that the mass is
within it. not continuous with a nerve inferiorly. Therefore the
CHAPTER 22 Retropharyngeal Lymph Node Dissection 215
Sympathetic
ganglion
Retropharyngeal
lymph node
Carotid artery
FIGURE 22-6. Beginning the circumferential dissection of the

retropharyngeal node from below.
FIGURE 22-4. Ascertaining the position of the internal carotid

artery by palpation.
These RPLNs may be superior, at the skull base or
more inferior within the lateral retropharyngeal space.
Inferiorly, the ascending pharyngeal artery can be
encountered prior to identifying the sympathetic
trunk and carotid artery. Meticulous fascial
release using bipolar electrocautery along the
circumferential dissection of the RPLN delivers the
specimen. GLClayman
STEP 5. Beginning inferiorly where exposure is best, the

node is freed up and retracted inferiorly as its superior
attachments are gradually skeletonized and divided,
carefully cauterizing the small vascular pedicle that sup-
plies it.
Beginning the dissection inferiorly also ensures that the

node is not mistaken for the superior sympathetic gan-
glion (Figure 22-6).
I tend the begin the dissection along the most medial

aspect of the node(s) continuing inferiorly or superiorly,
whichever is more accessible. GLClayman
FIGURE 22-5. Dissection of the overlying fascia that overlies
the retropharyngeal node.
STEP 6. After meticulously ensuring hemostasis, the
incision is closed with interrupted chromic sutures in a
single layer incorporating fascia, muscle, and mucosa in
carotid artery and sympathetic trunk with the fusiform
each bite. No more than three or four sutures are
swelling of the superior sympathetic ganglion are visual-
required.
ized before the fascial lateral attachments of the node(s)
are divided. The RPLNs’ medial attachments are then Because the majority of the incision lies behind the
taken down, thus freeing up the node(s) circumferen- faucial arch, the risk of infection is low and the patient
tially (Figure 22-5). is allowed to begin a regular diet as tolerated.
ously excised with these approaches, the retropharyn-

geal lymph nodes can be excised independently.
STEP 2. The posterior belly of the digastric/stylohyoid is

retracted superiorly (or divided if exposure is limited).
The hypoglossal nerve is retracted superiorly. This is
usually facilitated by division of the ansa hypoglossi,
which tends to tether it inferiorly (Figure 22-9A).
Unless the RPLN is exquisitely low lying,

ansa hypoglossi transection must be
performed. GLClayman
STEP 3. The lingual artery is divided and the superior

thyroid artery and veins retracted inferiorly. The superior
laryngeal nerve is identified as it emerges from under-
neath the carotid bifurcation and is retracted inferiorly
(see Figure 22-9B).
FIGURE 22-7. Wound closure.
At this stage comprehensive adventitial dissection of

If hemostasis is questionable, the superior aspect of
the external and internal carotid arteries is performed.
the incision that lies in the nasopharynx behind the soft
I like to use malleable retractors on these vessels and
palate is left open to prevent formation of a hematoma
vein retractors to displace the great vessels, gently.
(Figure 22-7).
I dissect the internal carotid artery under direct
visualization to its skull base entry to ensure its
Postoperative pain is similar to that of a unilateral safety. GLClayman
tonsillectomy. Placing patients on oral cavity care
(swish and spit) and 1% neomycin power sprays may
help reduce delayed postoperative inflammatory STEP 4. The common carotid and external carotid arter-
discomfort. GLClayman ies are gently retracted laterally while the larynx is
retracted and rotated medially by placing a double skin
hook on the posterior aspect of the thyroid cartilage ala.
Transcervical Approach
The superior laryngeal nerve is gently retracted inferi-
orly. This allows a broad-based entry into the retropha-
If this approach is done bilaterally, there could be a ryngeal space (Figure 22-10).
significantly negative effect on swallowing due to
traction injury to the superior laryngeal nerve and It is possible to approach the RPLNs by retracting the
division of the small branches of the pharyngeal great vessels anteriorly and creating your entry into
plexus. The patient should be appropriately the retropharyngeal space behind the carotid. This
counseled. PEAndersen should reduce the chance of injury to the superior
laryngeal nerve and pharyngeal plexus. However, the
exposure afforded by this approach is minimal and
STEP 1. If a neck dissection is not being done at the same the approach is quite challenging. PEAndersen
setting, the patient is similarly positioned and a horizon-
tal incision is outlined at about the level of the greater
cornu of the hyoid. Subplatysmal flaps are raised superi- Although theoretically broad based, the lateral
orly and inferiorly and the fascia along the anterior border retropharyngeal space access with an intact mandible
of the sternocleidomastoid is incised, allowing it to be and hypoglossal nerve is limited. Although inferiorly the
retracted posteriorly. The posterior belly of the digastric visualization may be adequate, the more superior the
muscle, the hypoglossal nerve, the internal jugular vein, dissection is required, the more limited visualization
and the carotid artery are identified (Figure 22-8). is noted. When extracapsular extension is known
with preoperative imaging along more superiorly
Neck dissection improves overall exposure for this oper- based disease, these cases can be challenging and
ation as does mandibulotomy. If, however, the primary mandibulotomy should be considered. GLClayman
lesion or cervical lymphatics are not being simultane-
Posterior belly of
digastric muscle Internal jugular
Hypoglossal vein
nerve
Carotid artery
FIGURE 22-8. Initial exposure of the carotid sheath.
Superior
laryngeal
nerve
Ansa
hypoglossi
Superior A
thyroid
artery
A
B B
FIGURE 22-9. A, Retraction of the hypoglossal nerve FIGURE 22-10. A, Retraction of the carotid posteriorly.
superiorly. B, Retraction of the superior laryngeal nerve B, Retraction and rotation of the pharynx anteriorly.
inferiorly.
Retropharyngeal
Superior sympathetic
lymph node
ganglion
within fat pad
Sympathetic chain
FIGURE 22-11. Identification of the retropharyngeal node or FIGURE 22-12. Beginning the circumferential dissection of
fat pad anterior to the superior sympathetic ganglion. the retropharyngeal node from below.
STEP 5. The retropharyngeal space is then progressively

opened in a superior direction toward the base of the The ganglion is easily mistaken for the RPLN. If
skull by division of the middle layer of the deep cervical uncertain, widen your exposure to identify whether it
fascia. continues inferiorly as a relatively small nerve. This
added exposure will enhance your comfort when
removing the RPLNs. PEAndersen
Division of the stylomandibular ligament may improve
the ability to displace the mandible anteriorly. If the
styloid process is long and obstructing the view, The internal carotid artery is closest to the retropha-
simply remove it. PEAndersen ryngeal pad at the base of the skull, and care must be
taken to ascertain its position as the highest cuts are
made.
There are usually several pharyngeal veins that cross
this space, and these must be cauterized and divided.
These highest cuts must be made with great care with
direct visualization with magnified loupes. GLClayman
STEP 6. The pharyngeal wall is retracted medially, and

the position of the internal carotid artery, which forms
EDITORIAL COMMENT: The commentary serves
the lateral limit of the dissection, is identified by palpa-
to emphasize that although the retropharyngeal
tion. Opening of the fascia that sits between these two
nodes are not that far from the posterior pharynx,
structures will identify a pad of lymphofatty tissue that
they are far from the “surface”; therefore removing
contains the RPLNs (Figure 22-11).
them safely is a very precise operation with many
potential pitfalls along the way, whether done
transorally or transcervically. Attention to
STEP 7. Excision of this pad begins inferiorly at the level
detail, careful structure identification, and
of the base of tongue and progresses superiorly, taking
appropriate patient selection minimize the risk
advantage of the progressive downward displacement
of complications. JICohen
of the fat pad that this approach affords (Figure 22-12).
This technique also avoids accidental excision of the

superior sympathetic ganglion that sits on the lateral Suggested Readings
aspect of this pad (and medial to the internal carotid). Davis WL, Harnsberger HR, Smoker WRK, Watanabe AS:
The ganglion is a fusiform swelling that tapers into the Retropharyngeal space: evaluation of normal anatomy and
sympathetic chain inferiorly, whereas the RPLN chain/ diseases with CT and MR imaging. Radiology 174:50-64,
pad tapers out at the level of the base of tongue. 1990.
Dileo MD, Baker KB, Deschler DG, Hayden RE: Metastatic Mancuso AA, Harnsberger HR, Muraki AS, Stevens MH:
papillary thyroid carcinoma presenting as a retropharyngeal Computed tomography of cervical and retropharyngeal
mass. Am J Otol 19:404-406, 1998. lymph nodes: normal anatomy, variants of normal, and
Gross ND, Ellington TW, Wax MK, Cohen JI, Anderson PE: applications in staging head and neck cancer. Part II.
Impact of retropharyngeal lymph node metastasis in head Pathology. Radiology 148:715-723, 1983.
and neck squamous cell carcinoma. Arch Otolaryngol Head McCormack KR, Sheline GE: Retropharyngeal spread
Neck Surg 130:169-173, 2004. of carcinoma of the thyroid. Cancer 26:1366-1369,
Leger AF, Baillet G, Dagousset F, Vincenot MI, Izembart M, 1970.
Clerc J, Barritault L: Upper retropharyngeal node involve- Morrissey DD, Talbot JM, Cohen JI, Wax MK, Anderson PE:
ment in differentiated thyroid carcinoma demonstrated by Accuracy of computed tomography in determining the
I-131 scintigraphy. Br J Radiol 73:1260-1264, 2000. presence or absence of metastatic retropharyngeal adenopa-
Mancuso AA, Harnsberger HR, Muraki AS, Stevens MH: thy. Arch Otolaryngol Head Neck Surg 126:1478–1481,
Computed tomography of cervical and retropharyngeal 2000.
lymph nodes: normal anatomy, variants of normal, and Robbins KT, Woodson GE: Thyroid carcinoma presenting
applications in staging head and neck cancer. Part I. Normal as a parapharyngeal mass. Head Neck Surg 7:434-436,
anatomy. Radiology 148:709-714, 1983. 1985.
CHAPTER
Sentinel Lymph Node Biopsy
Commentary by Francisco J. Civantos, Neil D. Gross, and Jeffrey E. Lee
Sentinel lymph node biopsy is primarily used for cut

For melanomas that map to the head and neck
aneous malignancies, especially malignant melanoma.
region, the superior anatomic detail provided by
However, the technique can be used for other cutaneous
lymphoscintigraphy fused with noncontrast computed
malignancies or primaries within the oral cavity. It is
tomography (CT) (lymphoscintigraphy CT) can be very
used only in cases in which the primary is known and
helpful. This study assists the surgeon in identifying
the patient is N0.
the precise anatomic location and number of sentinel
lymph nodes present, for example, differentiating
between a sentinel lymph node high in level II versus a
There is ongoing research and a limited number of sentinel node in the tail of the parotid. This allows for
publications regarding the use of sentinel lymph node a more directed dissection with minimal disruption of
biopsy for endoscopically accessible tumors, such as uninvolved tissue, and is especially appreciated by the
primary tumors of the larynx and hypopharynx. surgeon if reoperation for formal lymphadenectomy is
Some have proposed assessment of the subsequently required due to the finding of occult
contralateral neck by sentinel node biopsy in patients tumor within the sentinel node. JELee
with unilateral cervical metastases and primary tumors
close to the midline, but this topic requires further
study. FJCivantos In some body sites (e.g., breast), sentinel node biopsy
can be deferred until the day following injection.
This is ill advised for the head and neck for reasons
that have not been fully elucidated. I agree that
Prior to coming to the operating room (OR), the site of
4 hours is a good target for surgery following
the primary tumor is injected with technetium 99 (99Tc)
lymphoscintigraphy. NDGross
sulfur colloid and lymphoscintigraphy is performed to
identify the first node to which the radiotracer flows.
This is the sentinel node, and its location is marked on The radiation exposure to the patient and surgical
the skin. Ideally the sentinel node biopsy should be done staff is minimal and no particular precautions need be
as soon after the lymphoscintigraphy as possible to taken. However, I usually inform all the OR staff prior
avoid the time dependent decay of the tracer activity to the procedure that radiation is involved. Personnel
and diffusion of the tracer out of the primary site and who are pregnant will likely not want to be involved in
into lymph nodes more distal to the sentinel node. My such a procedure.
preference is to perform the sentinel node biopsy within
4 hours of the lymphoscintigraphy. Although in reality there is no evidence of danger to
pregnant staff, generally the desire to be overly cautious
results in excusing pregnant staff members. FJCivantos
Other radiocolloids are used in Europe, but 99Tc sulfur
colloid is the only available agent in the United States.
It can be used in filtered and unfiltered forms. The STEP 1. Position the patient supine with a horizontally
former maps more downstream lymph nodes, but oriented shoulder roll; the patient’s head should be
leaves less radioactivity at the primary site. The latter turned away from the operative side. The table is rotated
is advantageous because it maps less downstream 9 degrees, with the operative side of the patient away
lymphatic flow, but significant retention of radioactivity from the anesthesia machine. The handheld gamma
at the injection site, and confounding shine-through probe machine is positioned as shown. The probe and
effect, must be dealt with. FJCivantos its cord are covered with a sterile intraoperative ultra-
sound probe sleeve (Figure 23-1).
220
CHAPTER 23 Sentinel Lymph Node Biopsy 221
Anesthesia facial nerve, it is also acceptable to do a formal super

machine
ficial parotidectomy with identification of the facial
Anesthesiologist nerve.
Assistant 1
Gamma probe There are good data to show that this can be
done safely by experienced head-and-neck
surgeons. NDGross
My preference for both sentinel node biopsy and

neck dissection is to avoid paralysis in order to
allow observation for stimulation of both the spinal
accessory and facial nerves, either with a nerve
stimulator or inadvertently. I limit the use of Bovie
Assistant 2 cautery, to avoid “jumping” or muscle contracture,
during neck procedures, and use the bipolar cautery
for hemostasis. The Bovie or harmonic scalpel is used
for larger moves away from nerve structures. I use
Scrub nurse First surgeon facial nerve monitoring when performing intraparotid
Mayo instrument sentinel node biopsy. Using this approach I have been
table
able to avoid even transient weakness of the divisions
FIGURE 23-1. Arrangement of key pieces of equipment and of the facial nerve or the spinal accessory nerve in
personnel. several hundred sentinel node biopsies. For neck
dissection, transient spinal accessory nerve weakness
has also been infrequent. FJCivantos
Because sentinel lymph node biopsy is most

If a sentinel node biopsy is to be attempted, the
commonly and ideally performed at the same time as
patient should be consented for a formal parotidectomy
wide local excision of the primary site, the location of
and prepped and draped accordingly because it is some
the primary melanoma as well as the location of the
times not possible to identify the sentinel node and still
sentinel lymph nodes as identified on preoperative
feel certain that the facial nerve will not be injured. In
lymphoscintigraphy may dictate patient positioning
such a case one should convert to a formal parotidec
that is different from the standard described here. For
tomy approach.
example, occasionally a full lateral decubitus position
is preferable for a primary melanoma of the occiput
that drains to posterior cervical lymph nodes. JELee I believe that the decision regarding superficial
parotidectomy is best made before surgery. Therefore
I do not consent my patients for possible
parotidectomy. Head and neck melanomas have the
nondepolarizing muscle relaxant when the sentinel node
highest false-negative sentinel lymph node biopsy
is located in the neck. However, when the node is located
(SLNB) rate compared with all other sites. Primary
within the parotid gland, I prefer to not have the patient
sites draining to the parotid region are particularly
paralyzed.
problematic. A planned superficial parotidectomy may
be most appropriate depending on the size of the
I have found no reason to paralyze the patient primary defect and planned reconstruction. For
regardless of the surgical site. The procedures are example, a large primary defect of the cheek requiring
generally short and the dissection is relatively cervicofacial advancement flap closure is a good
superficial, so paralysis is not required. Further, it can candidate for planned superficial parotidectomy given
be beneficial not to have the patient paralyzed when (1) the proximity of the primary to the sentinel lymph
dissecting sentinel lymph nodes in the submandibular node (SLN) and risk of false-negative results and (2)
(marginal mandibular branch of the facial nerve) and the potential difficulty with a secondary procedure
posterior (spinal accessory nerve) triangles. NDGross after reconstruction. NDGross
Whether or not to attempt sentinel node biopsy of I do not use nerve monitoring, but the decision as to
an intraparotid node is up to the surgeon. Although it whether nerve monitoring is useful can be made accord
is certainly possible to do so with acceptable risk to the ing to surgeon preference.
Primary tumor
Sentinel lymph node Epidermis
Papillary dermis
Reticular dermis
Subcutaneous fat
FIGURE 23-2. Preoperative sentinel lymph node (SLN) FIGURE 23-3. Proper location for injection of isosulfan
location using gamma probe. blue dye.
field of view. Make sure you are familiar with the opera
A member of the surgical team should observe the tion of your model of gamma probe and that the device
face for twitching during portions of the dissection in has been properly tested and calibrated prior to the
the vicinity of the facial nerve. FJCivantos procedure.
STEP 2. Prior to prepping and draping the patient, use STEP 3. To further aid in identification of the sentinel
the gamma probe to confirm the location of the sentinel node, inject isosulfan blue into the primary lesion. This
node identified on the preoperative lymphoscintigraphy injection must be intradermal, not subcutaneous, for
(Figure 23-2). Design the margins of excision of the best results. I inject a total of 0.3 mL into the lesion
primary lesion according to the depth of the primary (Figure 23-3).
tumor and planned technique for closure of the wound.
When designing the incision for the sentinel node biopsy,
I have found a four-quadrant injection to be helpful
make sure that the incision will not interfere with a neck
and usually target to “stain” the 1- to 2-cm area to be
dissection and/or parotidectomy in the future should
excised. Great care should be taken to avoid subdermal
that be found to be necessary.
deposition. Slow intradermal injection is important
for filling the dermal lymphatic channels. There is a
This is an important point that is often overlooked by characteristic superficial blue, capillary-like appearance
less experienced surgeons. NDGross when the injection is done properly. NDGross
The gamma probe is directional; therefore, when search I perform the isosulfan blue injection prior to the injec
ing for the sentinel node, try to keep the probe pointed tion of any local anesthetic to minimize the risk that the
away from the primary site to avoid confusion due to lymph flow in the area of the lesion would be disturbed.
“shine through” from the primary. If your probe I wait 10 minutes after the isosulfan blue injection prior
has multiple collimators, use the one with the narrowest to injecting local or starting the procedure.
I prefer not to use local anesthetic if possible for these

cases. NDGross
Often one is presented with only a scar from a previ

ous excisional biopsy. In this circumstance one should
inject the blue dye around the scar. In my opinion this
scenario, although common, does increase the risk of
having a false-negative sentinel node identified.
Primary tumor
excised
It is reasonable to presume that a prior excision may Sentinel lymph
disrupt lymphatic drainage patterns around a primary node
melanoma site sufficiently to increase the false-
negative rate of sentinel lymph node biopsy. In
contrast to the concerns outlined above, investigations
of this issue have generally focused on the accuracy
of sentinel node biopsy following formal wide local
excision rather than following simple excisional biopsy.
Interestingly, these studies have suggested that in
most patients, sentinel lymph node biopsy is an
accurate way to stage the regional lymph nodes even
following a prior wide local excision. JELee
I warn the patient that the skin will be stained blue

for several days after the procedure. The dye should not
leave a tattoo. Rarely patients may note that their urine FIGURE 23-4. Primary tumor excision before commencement
is blue postoperatively. If isosulfan blue is not available, of sentinel lymph node biopsy (SLNB).
the sentinel node biopsy can be done reliably with only
radioguidance. I do not find that another blue dye such
as methylene blue works as well. Excising the primary tumor decreases the amount of
radiation coming from the radiotracer injected at the
I have had similar success using methylene blue when primary site. The specimen will be radioactive; in our
isosulfan blue was not available. I strongly prefer institution no particular precautions are taken with the
two methods of localization and would be reluctant specimen, but you should consider checking with the
to proceed if either radiotracer or blue dye is radiation safety officer of your institution if you are
unavailable. NDGross unsure about local policies.
I have not used blue dye in most cases because I STEP 5A. Open the incision planned for the sentinel node
have been concerned that discoloration of tissues biopsy (Figure 23-5A). Depending on the location, isolate
would affect the dissection around the primary tumor, the general area of the expected sentinel node. It is
particularly if nerves are present at the deep margin, helpful to obtain exposure that will allow the sensing end
such as the greater auricular or lingual nerves. If used, of the gamma probe to be pointed away from the primary
it is important to restrict to very small amounts, as location to minimize shine-through.
mentioned, and possibly diluted as well. FJCivantos
The amount of exposure varies according to the loca
tion of the sentinel node. For example, with an intrapa
STEP 4. Excise the primary tumor with adequate margins rotid node I separate the tail of the parotid from the
prior to performing the sentinel node biopsy (Figure 23-4). sternomastoid muscle while preserving the great auricu
lar nerve. If the node is located in level II, I isolate the
This is important in cases in which the SLN is close to level II area by dissecting along the sternomastoid
the primary site. It may be beneficial to start with the muscle and posterior belly of the digastric muscle.
SLNB in cases in which the SLN is farther from the Using the gamma probe and visual inspection, isolate
primary in order to allow more time for the blue dye to the putative sentinel node by blunt dissection.
travel to the node. NDGross If blue dye is used, the node will often not be a vivid
blue but blue tinged. However, one can usually see
Sentinel lymph Sentinel lymph

node node excised
A B
Sentinel lymph
node (excised)
FIGURE 23-5. A to C, Identification of SLN using gamma probe

and measurement of residual radioactivity in wound bed and
C excised SLN.
vividly blue lymphatic vessels and these can be followed

In addition, any lymph node in a distinct lymphatic
toward the sentinel node.
basin with activity greater than the quantity of three
square roots of the mean background count (i.e.,
This can be a subtle but important clue for locating standard deviation) added to the mean background
the SLN. NDGross count (this is referred to as the “3σ rule”). In other
words, if distinct radioactivity significantly greater than
background is encountered in a completely separate
Perform a 10-second count of the putative sentinel
lymphatic bed from the initial nodes removed (i.e.,
node using the gamma probe. Then excise the putative
contralateral), this should be considered significant
sentinel node.
even if the 10% level is not reached. FJCivantos
At our institution the pathology department pro
cesses a sentinel node differently than a routine node.
Thin sections are taken through the entire node and
immunohistochemistry done to detect micrometastasis. As indicated, when multiple sentinel nodes are
Therefore, at our institution the specimen name is identified, or when the surgeon has difficulty reducing
always appended with “sentinel lymph node,” that is, the count rate in the nodal basin below 10% of the
“right parotid, sentinel lymph node.” “hottest” sentinel node, judgment must be exercised
in deciding when a sufficiently extensive sentinel
lymph node biopsy procedure has been performed.
This is extremely important! Step sectioning and
This is another example of a situation in which
immunohistochemistry should be considered
lymphoscintigraphy CT can be helpful in identifying
mandatory. Some authors have gone as far as
not just the location but the number of sentinel lymph
suggesting that slices be examined at 150-micron
nodes likely to be present. Because it is very rare that
intervals, which is naturally a costly proposition. At a
a non–blue sentinel node with a low gamma count
minimum, sections should be evaluated at 2-mm
rate relative to the hottest node will contain occult
intervals and detection of micrometastases should be
melanoma metastasis when the hottest node is
augmented by immunohistochemistry. FJCivantos
negative, I agree that “stopping at four” is usually a
reasonable guideline. JELee
STEP 5B. Use the gamma probe to perform a 10-second

count on the wound bed from where the sentinel node
was removed (see Figure 23-5B). I do not send the node for frozen section analysis
because the interpretation is unreliable at my
institution. However, this is an accepted practice at
STEP 5C. Perform a 10-second count on the excised some very-high-volume centers. NDGross
sentinel node (see Figure 23-5C).
STEP 6. Close the wound appropriately (Figure 23-6).

For this I usually point the gamma probe vertically and
rest the SLN on the tip. This simultaneously avoids
background noise and eliminates the effect of Two other issues bear discussion: first, the use of
minor hand movements during the 10-second immediate frozen section of normal-appearing lymph
count. NDGross nodes is controversial. However, if suspicious lymph
nodes are encountered, frozen section should be
performed. The patient should be prepared and
If the the wound bed contains greater than 10% of consented for the possibility of neck dissection or
the count obtained in Step 5A, then the specimen either parotidectomy, as appropriate for the primary in
is not the sentinel node or there may be multiple sentinel question. If lymph nodes are grossly normal,
nodes. Return to Step 5A and explore further excising some have published regarding the use of frozen
additional nodes until you obtain the 90% reduction in section followed by later step sectioning and
initial activity. immunohistochemistry of remaining tissue. For
melanoma most authors advocate only longitudinal
It is common for a head and neck melanoma to yield section of the node in pathology and touch prep of the
more than a single SLN. NDGross cut surface, followed by step sectioning and IHC on
permanent sectioning. Frozen section is particularly
I usually do not continue to search past four nodes. unreliable for melanoma, and there has been a desire
Each node should be appropriately labeled as a sentinel to avoid conversion to radical procedures based only
node.
Second, if the gamma probe–guided neck exploration

is deemed negative, the surgeon should always
remember that repeat exploration may be needed.
With this in mind, we normally tag any nerve identified
at the time of the original procedure with an adjacent
Prolene suture, in order to facilitate repeat surgery if
necessary. We also request that our pathologists rush
the permanent pathology report. The physical
turnaround time required is actually only 72 hours, so
we can reexplore within 6 days if necessary, in order
to minimize the inflammatory change encountered.
The rate of reexploration is actually less than 10%
with appropriate patient selection and examination
of lymph nodes by touch prep and/or frozen section.
New technologies, such as rapid intraoperative
reverse transcriptase–polymerase chain reaction, may
someday minimize this issue. FJCivantos
EDITORIAL COMMENT: Sentinel lymph node

biopsy has assumed a distinct role in the
management of head and neck melanoma and
may over time become equally acceptable for
other histologies. Although simple in concept,
FIGURE 23-6. Wound closure. the nuances of the procedure and its evolution
over time, as described by the author and
commentators, help significantly with the success
of the procedure and shorten the well-
acknowledged learning curve that is a part of
acquiring of the necessary experience. JICohen
on frozen section of normal-appearing nodes. For

Suggested Reading
squamous cell carcinoma the same approach has
been used, although there appears to be some Gannon CJ, Rousseau DL, Ross MI, Johnson MM, Lee JE,
growing support for preliminary frozen sections as Mansfield PF, et al: Accuracy of lymphatic mapping and
well. Frozen section is more accurate for squamous sentinel lymph node biopsy after previous wide local exci
cell carcinoma than for melanoma. FJCivantos sion in patients with primary melanoma. Cancer 107:2647-
2652, 2006.
SECTION B Salivary Gland Operations
CHAPTER
Superficial Parotidectomy
Commentary by David W. Eisele and Dennis Kraus
Operative Steps A shoulder role is not critical for parotidectomy.

However, if a neck dissection is planned the shoulder
role can be helpful. Because parotidectomy, except in
STEP 1. Position the patient supine with a horizontally
cases of sialoadenitis, is a clean procedure I do not
oriented shoulder roll; the patient’s head should be
administer prophylactic antibiotics.
from the anesthesia machine (Figure 24-1). The ipsilateral face is sterilely draped with a
transparent, adhesive drape to allow visualization of
facial movements. DWEisele
The endotracheal tube is secured by tape solely on
the contralateral face. DWEisele
STEP 2. Typically a modified Blair incision is used. The
procedure can be done using a facelift-type incision as
well (Figure 24-2).
Positioning and illumination are critical in performing
The facelift incision requires a longer incision and more
this procedure. Many operating rooms are designed
extensive undermining of the skin flaps but ultimately
for general surgery procedures. If one is unable to
gives a superior cosmetic result. The facelift incision is
obtain reliable illumination, a headlight is a necessary
a poor choice for lesions that are located far anteriorly
adjunct. DKraus
in the gland because the exposure in this area is
suboptimal.

I routinely use a modified Blair incision to gain access
to the majority of parotid tumors. In tumors that arise
monitor; however, the decision to use a nerve stimulator
in the parotid tail, the incision is abbreviated starting
or nerve monitoring can be made according to surgeon
below the external auditory canal, with the inferior
preference.
limb being limited to the anterior border of the
sternocleidomastoid muscle. Incorporation of creases
and wrinkles allows for a superior cosmetic
We use electrophysiologic nerve monitoring routinely outcome. DKraus
as an adjunct during parotid surgery. With this,
long-term paralytic agents must be avoided. DWEisele
STEP 3. The anterior skin flap is elevated in a plane
deep to the platysma muscle and through the fascia
I routinely use a nerve monitoring system for all patients surrounding the parotid gland. The flap should be ele-
undergoing parotidectomies. In my hands it offers vated up to the anterior border of the parotid gland. The
additional protection of the facial nerve and provides posterior skin should be elevated off of the tail of the
support from a medical-legal perspective. DKraus gland and the superior aspect of the sternomastoid
muscle (Figure 24-3).
227
Anesthesia
machine In terms of instrumentation I increasingly use a
harmonic scalpel for hemostatic function. The use of a
Anesthesiologist particular coagulation device is largely a personal
preference. DKraus
Assistant 1
STEP 4. Mobilize the tail of the parotid gland from the

anterior aspect of the sternomastoid muscle from the
Assistant 2 external jugular vein up to the mastoid tip (Figure 24-4).
During this maneuver I routinely divide the great auric-

ular nerve.
The posterior branch of the great auricular nerve can

be preserved in the majority of cases. This has been
shown to improve quality of life after parotidectomy.
DWEisele

Mayo instrument However, I try not to ligate the external jugular vein
table in order to reduce the venous congestion within the
FIGURE 24-1. Location of key equipment and personnel. parotid gland during the facial nerve dissection.
Because the facial nerve will never enter the sterno-
mastoid muscle, this maneuver can be done quickly and
Some surgeons choose to elevate the anterior flap in a with absolute safety.
supraplatysmal plane. I find that elevation in the sub-
platysmal plane does not put the marginal branch of the
facial nerve at risk. The posterior flap should be elevated I routinely divide the external jugular vein, early in
in a plane superficial to the great auricular nerve and the procedure, and do not see any obvious effect in
external jugular vein. terms of venous congestion of the dissected parotid
gland. DKraus
Elevation of a thick flap is desirable to reduce the
occurrence of Frey’s syndrome. The flap should be
handled carefully and kept moist during the procedure STEP 5. Identify the posterior belly of the digastric
to prevent desiccation of the tip of the flap. DWEisele muscle and trace it posteriorly to the mastoid tip (Figure
24-4).
In many anteriorly placed parotid tumors, it is possible The posterior belly of the digastric muscle is easily iden-
to save the posterior branch of the greater auricular tified by dividing the fat below the tail of the parotid
nerve. It is my observation that these patients have along a line from the hyoid bone to the mastoid tip.
less numbness immediately postoperatively, with an Often one can see the muscle moving in response to
increased restoration of sensory function to the stimulation from the electrocautery prior to reaching the
ear. DKraus muscle. Because the facial nerve never crosses the digas-
tric muscle this maneuver can be done quickly and with
I use the monopolar cautery with a needle tip on a absolute safety.
setting of 20 cutting and 20 coagulation, using the blend
setting. The bipolar is set to 25. The bipolar is used close
to the facial nerve, otherwise the monopolar cautery is I agree with the anatomic landmarks used to identify
used. the facial nerve as described. DKraus
Many instruments are acceptable for dissection during

parotidectomy. We prefer to use the Hemostatix STEP 6. Mobilize the parotid gland from the tragal car-
scalpel, a thermal scalpel that allows safe, hemostatic tilage, taking care to leave the perichondrium on the
dissection without electrical current transmission. tragal cartilage. This mobilization can proceed along
DWEisele the tragal cartilage until the tragal pointer is reached
(Figure 24-5).
CHAPTER 24 Superficial Parotidectomy 229
Parotid gland
Tumor
Parotid duct
Masseter m.
FIGURE 24-2. Surgical incision.
Superficial
parotid gland
Tumor
Great auricular n.
FIGURE 24-3. Elevation of skin flap.

Cut great auricular n.
Tail of
parotid gland
Fatty tissue
Digastric m.
FIGURE 24-4. Skeletonization of anterior border of sternocleidomastoid muscle and posterior

belly of digastric muscle.
Tragal cartilage
SCM
FIGURE 24-5. Mobilization of parotid gland from tragal cartilage.

Bipolar
cautery
Tragal cartilage
Posterior belly of digastric m.
SCM
FIGURE 24-6. Dissection in tympanomastoid fissure to identify facial nerve.
At the far superior aspect of the wound avoid deviating

Hemostasis must be achieved carefully. Gentle
anteriorly because the superficial temporal vessels are
pressure with a moist gauze for a short period of time
located in this area.
may suffice. Gentle suction with a small velvet eye
The facial nerve will never be encountered prior to
suction tip can be helpful in identifying the site of
reaching the tragal pointer and therefore this maneuver
bleeding. Bipolar electrocautery should be used
can be done quickly and with absolute safety.
judiciously and precisely. DWEisele
If you find your exposure in the anticipated area of

the nerve is poor, open the plane of dissection superiorly
Effort is made to preserve the tragal cartilage because
and inferiorly. This redistributes the wound tension and
inadvertent injury can result in fracturing and distortion
enhances exposure of the nerve.
of the normal anatomic landmarks that are essential in
Take your time. Meticulous, gentle dissection will
identifying the facial nerve. DKraus
always lead you to the nerve. The nerve is large and
obvious. Do not get frustrated.
The nerve is located about 1 cm deep to the tragal
STEP 7. Finding the main trunk of the facial nerve is done
pointer in the general area of the junction of the external
at this point. There are some general principles to keep
ear canal, the mastoid tip, and the posterior belly of the
in mind during this maneuver.
digastric muscle.
Never try to find the nerve while working in a deep hole.
Dissection should proceed along a broad front lifting up Another reliable landmark for the facial nerve is the
and dividing thin layers of tissue (Figure 24-6). tympanomastoid suture. The facial nerve is medial to
Never divide tissue unless you are absolutely certain this palpable landmark. In select cases, in which the
that it is not the facial nerve. proximal facial nerve is obscured, retrograde dissection
If troublesome bleeding is encountered, do not clamp of a peripheral facial nerve branch is useful. DWEisele
blindly because this may result in injury to the nerve.
Exposed main
trunk of facial n.
FIGURE 24-7. Exposure of main trunk of facial nerve.
There is often a small artery that runs parallel and can be easily clamped and ligated without risk of injury
superficial to the main trunk of the nerve. This can to the nerve.
easily be mistaken for the nerve. Do not ligate this vessel Follow the upper division of the nerve, dividing the
until you are certain that it is not the nerve. parenchyma that lies superficial to the nerve. The
During this maneuver and subsequent steps I divide anatomy of the nerve is variable and therefore one must
tissue close to the nerve using bipolar electrocautery and take care not to injure small branches. The most vulner-
scalpel. able branches seem to be the frontotemporal branch and
the marginal mandibular nerve.
Follow the buccal branches of the facial nerve, divid-
The authors have nicely depicted the fascial band that
ing the parotid parenchyma as needed to remove the
typically sits directly over the facial nerve. This is a
specimen but not injure the nerve branches (Figure
useful anatomic landmark, and control of the artery
24-8).
prevents bleeding that could jeopardize the facial
During this maneuver the parotid duct may be
nerve. DKraus
encountered. It can resemble a nerve branch but is
usually larger.
STEP 8. Once the main trunk of the facial nerve is identi-
fied, follow it distally to the pes anserinus and then The authors allude to the pes anserinus. For the
follow the lower division of the nerve distally to the ante- uninitiated, this is the upper and lower division of the
rior border of the gland dividing the parotid parenchyma facial nerve. As noted by the authors, the ability to
(Figure 24-7). transect the parotid parenchyma is essential and
prevents working in small, confined spaces. It allows
While you are following the lower division of the nerve, for mobilization of the gland and complete delivery of
you will often encounter a small artery that crosses the the tumor. Meticulous dissection of the peripheral
nerve and must be divided. If this vessel is inadvertently branches under loupe magnification is essential to
injured, I find it easiest to simply completely transect it. preserve all nerve function. DKraus
The vessel will then fall away from the nerve, where it
Facial n.
Deep parotid gland
FIGURE 24-8. Dissection of peripheral branches of facial nerve and mobilization of superficial
lobe of parotid gland.
STEP 9. If the tumor is located in the deep lobe of the

parotid gland, one first identifies the facial nerve and lobe neoplasm, and deliver it with preservation of the
removes the superficial lobe. Then, depending on the facial nerve. I find this prevents the typical preauricular
location of the tumor, it is necessary to gently free the contour deformity of a total parotidectomy. DKraus
tumor from the nerve and the surrounding structures
and deliver the tumor out from underneath the tumor
(Figure 24-9). STEP 10. Inspect the wound for hemostasis. Place a
suction drain into the wound with its exit point behind
the ear. Close the wound using absorbable suture (Figure
Removal of the superficial lobe is not always 24-10).
necessary for resection of deep lobe neoplasms. In
select cases, the superficial lobe is divided to expose The suction drain need not be long. I run it parallel to
the facial nerve and provide access to the deep lobe. the posterior belly of the digastric muscle. I find the exit
The superficial lobe is then imbricated following tumor wound for the drain to be unattractive; therefore I place
removal. This minimizes the postoperative contour the exit wound in the postauricular area.
deformity. DWEisele I close my wounds with a running suture of 4-0
braided absorbable suture in the subcutaneous layer.
The skin is closed using a running suture of 5-0 fast-
There is no firm rule on how to deliver the tumor from absorbing gut. Care must be taken to ensure that the
underneath the nerve. The route that provides the least wound is airtight or the drain will not hold suction.
risk of traction on the nerve should be used. This may
be above or below the main trunk of the nerve or even Hemostasis using multiple Valsalva maneuvers is
between two branches for more peripherally located essential to prevent postoperative hematoma. I request
tumors. multiple Valsalva maneuvers. I also place Surgicel over
the raw edges of the parotid wound. Emphasis is made
to anesthesia colleagues to awaken the patient within
I find that I can typically deliver the deep lobe the depths of anesthesia and prevent immediate
neoplasms without removing the superficial lobe. I postoperative stimulation that would result in Valsalva
identify the main trunk and dissect the lower division, maneuvers or other events that would increase venous
including the marginal mandibular and buccal pressure. I also close my wounds with a self-absorbing
branches. In this way I am then able to identify the deep subcuticular suture. DKraus
Parotid duct
Deep parotid gland
Tumor
FIGURE 24-9. Technique for removal of deep lobe tumor.
FIGURE 24-10. Drain location and wound

closure.
Suggested Readings
EDITORIAL COMMENT: The author and
commentators all appropriately emphasize the Califano J, Eisele DW: Benign salivary gland neoplasms.
importance of a systematic approach to wide Otolaryngol Clin North Am 32:861-873, 1999.
exposure and the use of anatomic landmarks Sinha U, Ng M: Surgery of the salivary glands. Otolaryngol
rather than technology (loupe magnification, nerve Clin North Am 32:887-906, 1999.
monitoring, cautery versus harmonic scalpel) as
the keys to a safe and successful operation. These
technologic advances may prove helpful to
individual surgeons or in specific situations and
should not be ignored but should not be seen as a
substitute for the guiding principles outlined
here. JICohen
CHAPTER
Submandibular Gland Excision
Commentary by Neil D. Gross and Mark K. Wax
Operative Steps I often start with an incision that is only 2 to 3 cm in

size. This is adequate for excision of the submandibular
gland for sialadenitis, but when neoplasm is suspected
make a more generous incision.
90 degrees, with the operative side of the patient away I find that a small incision requires more retraction and
from the anesthesia machine (Figure 25-1). increases the possibility of injury to vascular
structures. I usually use a 4-cm incision. The classic
teaching of two fingerbreadths below the edge of the
mandible is, in my experience, low. I look for a nice
monitoring, but the decision as to whether nerve moni-
rhytid 1 to 2 cm below the edge of the
toring is useful can be made according to surgeon
mandible. MKWax
preference.
I have also elevated the skin flap in a supraplatysmal

I do not use nerve monitoring or testing in these plane and then split the fibers of the platysma muscle
procedures. Division of the platysma causes twitching vertically. This may result in less trauma to the platysma
of the lower lip. Careful attention to the plane of muscle and decrease incidence of lower lip asymmetry
dissection obviates any need to monitor. MKWax in the immediate postoperative period.
It is important not to place the incision too close to

The marginal mandibular branch of the facial nerve is the jaw line. A lower incision allows broader access to
at high risk of injury during submandibular gland the neck if more extensive dissection is required (e.g.,
surgery. Although formal nerve monitoring is subsequent neck dissection) and provides a better
unnecessary in most cases, I have found no cosmetic result. NDGross
advantage in paralyzing the patient. In fact, it can be
reassuring to have an assistant or scrub nurse observe
the lower face for twitching during critical portions of STEP 3. Identify the marginal branch of the facial nerve
the dissection. NDGross as it runs within the fascia investing the submandibular
gland (Figure 25-3).
STEP 2. The incision should lie along a transverse neck

rhytid. I make the incision along the inferior aspect of I have found that ligating the vessels on the inferior
the gland. After the incision is made, divide the platysma portion of the gland and reflected this tissue superior
muscle and elevate skin flaps superiorly and posteriorly is adequate to protect the marginal branch. I do not
(Figure 25-2). routinely seek it out or identify it. I believe that some
of the transient weakness reported is due to the
dissection of this nerve. MKWax
There is no need to raise the superior flap above the
mandible. More extensive superior dissection can
traumatize the marginal nerve. NDGross Ligate the facial artery and vein below the nerve and
separate the gland from the inferior border of the
236
CHAPTER 25 Submandibular Gland Excision 237
Anesthesia mandible. Dissect deep, all the way to the mylohyoid

machine
muscle, which can be identified by the vertical orienta-
tion of the muscle fibers.
Anesthesiologist
Assistant 1
It is possible to remove the submandibular gland
without identification of the marginal nerve. In these
rare cases, a superior subplatysmal flap is not raised.
Rather, dissection is initially directed to the inferior
surface of the gland and proceeds cautiously along
the capsule from inferior to superior until the facial
vessels are ligated and reflected superiorly. This
approach should only be performed by experienced
surgeons. NDGross
Assistant 2
STEP 4. Follow the anterior aspect of the gland around
to the tendon of the digastric muscle and then along the
inferior aspect of the gland following the posterior belly
of the digastric muscle (Figure 25-4).
Mayo instrument
table Anteriorly, having the fibers of the mylohyoid muscle
FIGURE 25-1. Location of key equipment and personnel. in view guarantees that you will not inadvertently injure
the hypoglossal or lingual nerves because they lie deep
to the mylohyoid muscle. Similarly, when working
along the inferior aspect of the gland, following the
posterior belly of the digastric muscle prevents injury
to the hypoglossal nerve or branches of the external
carotid artery. There will likely be a large vein along
the posteroinferior aspect of the gland. This facial vein
FIGURE 25-2. Location of skin incision.

Facial v. Facial a.
Marginal branch
of facial nerve
Tail of parotid gland

Mandible
FIGURE 25-3. Ligation of facial vessels and identification of marginal branch of facial nerve.
Posterior belly
of digastric m.
Tendon
of digastric m.
FIGURE 25-4. Mobilization of submandibular gland
from posterior belly of digastric muscle.
can be ligated and divided with impunity as long as you

The dissection should proceed in the fascial
are superficial to the posterior belly of the digastric
plane above the gland. Often dissection will proceed
muscle.
adequately and quickly in one area. It will then be
narrowed and be like dissecting in a “hole.” At
Clear identification of the posterior belly of the this point I change orientation and dissect from
digastric and mylohyoid muscles is mandatory to safe another direction until the space opens up.
submandibular gland surgery. NDGross MKWax
Submandibular
Lingual n. ganglion
Submandibular duct
Hypoglossal n.
FIGURE 25-5. Identification of lingual and

hypoglossal nerve.
Lingual n.
Submandibular duct Submandibular
ganglion
Hypoglossal n.
FIGURE 25-6. Division of submandibular

gland duct.
STEP 5. Reflect the submandibular gland posteriorly off STEP 6. Divide the submandibular ganglion and ligate
of the mylohyoid muscle. When the posterior aspect of the submandibular duct (Figure 25-6).
the mylohyoid muscle is reached, place a retractor and
retract the mylohyoid muscle anteriorly to expose the
lingual and hypoglossal nerves and the submandibular
I use cautery to come across the duct and do not
duct (Figure 25-5).
routinely tie it. MKWax
I usually retract the gland anteroinferiorly to put some
tension on the branch of the lingual nerve to the gland. I
divide this branch and use a 3-0 tie on both ends. There If the patient has a stone in the duct, make sure
is usually a vessel that runs in this pedicle. MKWax that you ligate distal to the stone and remove the
stone.
Hypoglossal nerve
Submandibular Submandibular
duct (cut) ganglion (cut)
Facial a.
Submandibular
FIGURE 25-7. Ligation of proximal facial artery. duct (cut)
STEP 7. Ligate the facial artery just cephalad to the

It is common for there to be salivary tissue along the posterior belly of the digastric muscle and remove the
course of the submandibular duct as it exits the gland. gland (Figure 25-7).
This can partially obscure the duct and increases the
risk of injury to the hypoglossal nerve. Therefore the
lingual and hypoglossal nerves must be clearly STEP 8. Close the wound (Figure 25-8).
visualized prior to ligating the submandibular ganglion
and duct. NDGross The decision to use a drain is made according to the
surgeon’s preference. I close the wound with an
absorbable braided suture in the subcutaneous tissues.

In the skin I use an absorbable monofilament suture in stones may create significant scarring in the areas
a subcuticular fashion. of greatest risk in terms of unwanted lingual or
hypoglossal nerve injury. The author and
commentators focus on the principles that help
I also use absorbable suture and do not use a drain the surgeon avoid the common pitfalls that go
for routine submandibular gland excision. NDGross along with this more limited but equally
challenging operation. JICohen
EDITORIAL COMMENT: Most submandibular gland

excisions are performed and learned as part of a
level I neck dissection. Unfortunately, the wider Suggested Readings
exposure, excision of periglandular lymph nodes, Ichimura K, Nibu K, Tanaka T: Nerve paralysis after surgery
and normal nature of the gland itself make that in the submandibular triangle: review of university of Tokyo
operation very different from the one described hospital experience. Head Neck 19:48-53, 1997.
here. Working on the gland capsule through a Talmi Y, Wolf M, Bedrin L, Horowitz Z, Dori S, Chaushu G,
smaller incision requires a reorientation of the et al: Preservation of the facial artery in excision of the
surgeon’s perspective, and chronic infection or submandibular salivary gland. Br J Plast Surg 56:156-157,
2003.
CHAPTER
Excision of Ranula
Commentary by Leon A. Assael, Salvatore M. Caruana, Bruce J. Davidson,
and William W. Shockley
Ranula is a mucous pseudocyst arising from the sublin

In my opinion there is no reason for a neck incision or
gual gland. The most common presentation is a cystic
for excision of the lining of a plunging ranula. The
mass in the floor of the mouth known as a simple
plunging generally occurs in the dehiscence anterior to
ranula. However, on occasion the ranula herniates
the mylohyoid muscle and lateral to the genioglossus
though a dehiscence in the mylohyoid muscle to present
and anterior to the anterior belly of the digastric into
as a ballotable mass in the submandibular triangle,
the submental space. Removal of the gland and a
known as a plunging ranula.
simple intraoral drain make recurrence impossible.
Simple ranulas can be managed with a transoral
There is no epithelial lining of the ranula, so removal of
approach. I prefer excision of the entire affected sublin
the lining is unnecessary. LAAssael
gual gland because this leads to the lowest recurrence
rate. However, one must be careful to preserve drainage
of the submandibular gland and not injure the distal
branches of the lingual nerve. Although many texts continue to describe the
transcervical approach for treatment of a plunging
ranula, the literature supports removal of the
I too have found complete sublingual gland excision to sublingual gland with evacuation of the ranula as
be the best approach to a simple ranula to minimize sufficient treatment. This author no longer manages
likelihood of recurrence. SMCaruana plunging ranulas through the transcervical
approach. WWShockley
In addition, failure to remove the sublingual gland The key maneuver in treating a plunging ranula is to
often results in more difficult subsequent treatment of identify the dehiscence in the mylohyoid muscle and
recurrent ranulas due to retraction and scarring. excise the herniated sublingual gland and repair the
Because the source of the ranula is usually the dehiscence. If one simply excises the pseudocyst in the
underside of the sublingual gland, marsupialization is neck, the recurrence rate is quite high. In my experience
ineffective more than 50% of the time. LAAssael in treating recurrent plunging ranulas, the initial surgeon
usually mistakenly diagnoses the mass as a lymphatic
malformation and fails to address the true source of the
problem (the sublingual gland). In this situation recur
Definitive management for ranulas is excision of the rence can be virtually guaranteed. The dehiscence is
entire sublingual gland. However, with proper patient usually located high and anterior near the attachment
counseling we sometimes offer marsupialization as an of the anterior belly of the digastric muscle to the genial
option, acknowledging that this has a much higher tubercle.
recurrence rate. When marsupialization is performed,
iodoform packing is sutured into the defect for
7 days. WWShockley STEP 1. Position the patient supine, with a horizontally
Management of a plunging ranula is most commonly 90 degrees, with the operative side of the patient away
done through a transcervical approach in my practice from the anesthesia machine (Figure 26-1). I prefer to
but there is controversy as to the need for a transcervical have the patient nasotracheally intubated to increase
approach. There is general agreement that the source of the working space in the mouth if transoral excision is
the problem is the sublingual gland, and failure to needed. Administer prophylactic antibiotics consisting
address this results in failure to cure the plunging ranula. of ampillicin/sulbactam or clindamycin.
242
CHAPTER 26 Excision of Ranula 243
Anesthesia
machine
Anesthesiologist
Assistant 1
Assistant 2
Tongue
Ranula
Sublingual
gland

Mayo instrument
table
Probe in
FIGURE 26-1. Location of key equipment and personnel. submandibular
duct

FIGURE 26-2. Insertion of lacrimal probe into submandibular
monitoring, but the decision as to whether nerve moni
gland duct.
preference.
For Simple Ranula
STEP 2. Cannulate the submandibular gland duct with a
STEP 3. Incise the mucosa around the ranula (Figure
lacrimal probe (Figure 26-2).
26-3).
I prefer complete excision of the ranula and the sur

I use an operating microscope under high rounding sublingual gland. Although the procedure is
magnification and do not routinely cannulate the duct. more extensive than simple marsupialization, the recur
With the microscope the duct can be visualized rence rate is much lower.
directly throughout the procedure. SMCaruana
I have found the same to be true and completely
excise a diseased gland. SMCaruana
Having the probe in the submandibular gland duct
greatly facilitates finding and preserving the duct.
The mucosa that needs to be removed should include
the ducts of Rivinus, which number six to eight and
serve as egress of the sublingual gland. LAAssael
Cannulating the duct is surgeon preference and in a
given case may not be done because it can distort
anatomy or cannulation may be difficult. LAAssael
The technique of removal of the sublingual gland is
seldom described, even in advanced atlases of head
and neck surgery. Generally an ellipse is performed to
I typically cannulate the submandibular duct prior to include the multiple orifices of the sublingual gland.
excision of the sublingual gland. WWShockley We do not remove the ranula. WWShockley
Lingual n.
Sublingual gland
Incise to remove
Tongue injured duct
Ranula
Probe in
submandibular
duct
Injury
Submandibular
duct
FIGURE 26-3. Dissection of ranula and sublingual gland off
of lingual nerve and submandibular duct.
FIGURE 26-4. Technique for reimplantation of submandibular

Marsupialization has been recommended as the
gland duct.
treatment of choice in some oral surgery literature.
However, except for small, superficial ranula, I have
not found it to be very effective. I prefer to excise
While maintaining traction on the gland either with a
the entire sublingual gland in order to reduce the
suture or an Allis clamp, the sublingual gland is
possibility that residual sublingual tissue could lead to
carefully dissected by “hugging the gland” while
a second ranula. BJDavidson
preserving the surrounding tissue. Extreme care is
taken to avoid the lingual nerve. WWShockley
Pull the ranula and the underlying sublingual gland

up into the mouth. Carefully dissect the sublingual STEP 4. I leave the wound in the floor of the mouth open
gland from the surrounding soft tissue, taking care not to heal by secondary intention. My experience has been
to injure the lingual nerve branches in the floor of the that there is a substantial dead space, and closure of the
mouth. If the submandibular duct can be freed from the wound without excessive tension is difficult. Because of
sublingual gland and is in good condition, it can be left the mobility of the tongue, the sutures often tear free.
in situ. If this happens, the wound heals by secondary intention
without difficulty. When excising a simple ranula, I do
not place a drain (Figure 26-4).
I use the CO2 laser to perform this dissection. Careful,
gentle dissection here is the rule. SMCaruana
I usually close the floor of the mouth with 4-0 Vicryl.
When necessary I do ductal repairs according to the
same technique as the author. SMCaruana
It is worth mentioning that the crossing of the lingual
nerve from lateral superior to inferior to then medial to
the submandibular duct in the region lingual to the There is no reason not to primarily close the wound,
second molar at the level of posterior margin of the loosely and with a drain if necessary, but three to
sublingual gland can serve as a marker for avoiding five interrupted sutures allow it to heal with less
injury to the sublingual gland. LAAssael scarring. LAAssael
Because the ranula is a pseudocyst, there is no cyst

wall; however, a space has been created. We
generally suture a drain into this space to allow
collapse of the surrounding tissues while allowing
egress of any residual saliva. The mucosal defect is
sutured closed, leaving a drain in the “ranula
space.” WWShockley Ranula
If the submandibular duct has been transected or injured

in the process of removing the sublingual gland, it may
be spatulated and reimplanted in the posterior floor of
mouth using several absorbable sutures. Submandibular
gland
For Plunging Ranulas

I have had success with transoral excisions of
plunging ranulas. Again, the submandibular duct and
the lingual nerve must be meticulously preserved the
plunging portion is usually found toward the posterior
end of the sublingual gland when viewed from the
intraoral perspective. SMCaruana
FIGURE 26-5. Transcervical exposure of plunging ranula.
In my opinion there is no reason to do this. If it is The wall of the pseudocyst is very thin and fragile and
done, the ranula is in the submental triangle so the easily perforated.
submandibular component including exposing the
submandibular gland, marginal branch, and so on, is
unnecessary as well. A submental incision in a “smile” STEP 6. Identify the marginal mandibular nerve. Usually
fashion in the submental crease anterior to any the submandibular gland does not need to be removed
marginal branch risk is all that is needed. LAAssael but can be retracted posteriorly and preserved (Figure
26-6).
We no longer perform a transcervical approach for I have also found that the submandibular gland is
plunging ranulas. We perform sublingual gland frequently uninvolved and can be preserved.
excision with evacuation of the ranula, leaving a drain SMCaruana
in place as described here. WWShockley
It is rare to have a mucous retention cyst arise

As demonstrated by the commentary, there is some from the submandibular gland, but if present, the
controversy as to the best approach for a plunging submandibular gland should be excised. Also, when
ranula. The technique I describe has worked well in the plunging ranula is very large, it may track along
my experience. The transoral approach has an the mandible to the posterior submandibular triangle.
increasing amount of support in the literature. We all A ranula of this size may merit submandibular gland
agree that the key step is excision of the pseudocyst’s resection for improved access and excision of the
site of origin in the sublingual gland. The controversy entire ranula. BJDavidson
is only whether the pseudocyst in the neck requires
excision. PEAndersen
STEP 7. Dissect around the cyst anteriorly, superiorly,
and inferiorly. Identify the mylohyoid muscle and follow
STEP 5. Make a transverse incision at the level of the the cyst tract anteriorly and superiorly until the dehis-
hyoid bone. Elevate the superior and inferior skin flaps cence in mylohyoid muscle is found. Deliver the sublin-
in a subplatysmal plane (Figure 26-5). gual gland into the neck through the dehiscence in the
mylohyoid muscle and cross clamp the gland above the

origin of the plunging ranula. Excise the cyst and ligate
the gland above the clamp (Figure 26-7).
Ranula
Large or recurrent ranulas may be addressed through
a neck dissection approach. With the thin nature of
the cyst walls, preserving an additional soft tissue
Ant. belly of the envelop around the cyst is recommended. This
digastric m. Facial a. approach involves identification of the critical
Facial v. structures such as the marginal mandibular nerve
and then resecting the fascial envelope of the
Mylohyoid m.
Marginal submandibular and submental triangles to reduce the
mandibular n. possibility of rupture or incomplete resection of the
Submandibular ranula. BJDavidson
gland
The presence of the lacrimal probe in the submandi

bular gland duct helps prevent inadvertent injury to
the duct.
STEP 8. Close the dehiscence in the mylohyoid muscle

using 3-0 Vicryl suture (Figure 26-8).
FIGURE 26-6. Relative position of plunging ranula and
structures within the submandibular triangle. The muscle often does not hold sutures well. Place the
sutures perpendicular to the muscle fibers, take large
bites, and don’t tie them too tightly.
Ranula
Sublingual
gland Ranula
Ant. belly of the

digastric m.
Mylohyoid m.
Submandibular
gland Facial a.
Facial v.
Marginal
mandibular n.
Submandibular
gland
A B
FIGURE 26-7. A and B, Ligation of ranula as it passes through the mylohyoid muscle.
STEP 9. Inspect intraorally to make sure that saliva can

still be expressed from the orifice of the submandibular
duct (Figure 26-9).
If not, then the duct has likely been injured and

it is prudent to go ahead and remove the submandi
bular gland to prevent an obstructive problem
postoperatively.
STEP 10. Place a suction drain into the wound and close
in the standard fashion (Figure 26-10).
Ant. belly of the
digastric m. Facial a.
Facial v.
Mylohyoid m. The surgical approach in Dr. Andersen’s chapter

Marginal
mandibular n. certainly effectively addresses the clinical problem of
Submandibular ranulas. The approach in the comments should be
gland viewed as an alternative to those methods, not a
repudiation of them. LAAssael
Dr. Andersen has offered a thoughtful approach to

ranulas, following traditional principles and
techniques. WWShockley
FIGURE 26-8. Repair of dehiscence in mylohyoid muscle.
Papilla of Wharton's
(submandibular gland)
duct
FIGURE 26-9. Confirmation of patency of

submandibular gland duct.
Suggested Readings
Harrison JD: Modern management and pathophysiology of
ranula: literature review. Head Neck 32:310-1320, 2010.
McGurk M, Eyeson J, Thomas B, Harrison J: Conservative
treatment of oral ranula by excision with minimal excision
of the sublingual gland: histological support for a traumatic
etiology. J Oral Maxillofac Surg 66:2050-2057, 2008.
Mortellaro C, Dall’Oca S, Lucchina A, Castiglia A, Farronato
G, Fenini E, et al: Sublingual ranula: a closer look to its
surgical management. J Craniofac Surg 19:286-290, 2008.
Zhao Y, Jia Y, Chen X, Zhang W: Clinical review of 580
ranulas. Oral Surg Med Oral Pathol Oral Radiol Endod
98:281-287, 2004.
Drain
EDITORIAL COMMENT: An improved

understanding that obstruction of the sublingual
glands is the underlying cause of a ranula has
resulted in a gradual focusing of our surgical
approach to this entity on management of the
gland(s) rather than the fluid collection itself—
whether the ranula is primary or recurrent. This
has all but eliminated the need for transcervical
operations except perhaps in the individual who
has experienced multiple recurrences after
multiple operations that may have buried some
sublingual tissue in a position that is not easily
approached transorally. Literature supports the
clinical validity of this evolving concept with
low recurrence rates with transoral operations
alone. JICohen
CHAPTER
Parapharyngeal Space Tumor
Commentary by Brian B. Burkey and Paul L. Friedlander
Numerous tumors can involve the parapharyngeal

I agree. The key to exposure of the parapharyngeal
space. A useful classification is to divide them into
space is lateral retraction of the mandible, and this is
those in the prestyloid parapharyngeal space and those
accomplished surgically by dividing the stylomandibular
in the poststyloid parapharyngeal space. The location
ligament. The choice of intubation method probably
of internal carotid artery is key in making this determi
does not affect the difficulty of the operation. BBBurkey
nation. Prestyloid parapharyngeal space tumors push
the internal carotid artery posterior and are most
commonly benign salivary neoplasms (Figure 27-1A).
Poststyloid tumors push the internal carotid artery inte When prepping and draping the patient, I prep out the
riorly and are most commonly paragangliomas and lateral face and neck and use a transparent Ioban to
nerve sheath tumors as in the glomus vagale tumor in prep or drape the face to allow for the facial nerve to
Figure 27-1B. be monitored visually, in case facial nerve dissection is
necessary. BBBurkey
Preoperative evaluation is best done with magnetic Positioning: The patient is typically intubated orally.
resonance imaging (MRI), but computed tomography The bed is initially positioned as depicted in
(CT) scans with contrast are acceptable. Preoperative Figure 27-2 with the nonoperative side facing the
tissue evaluation with a fine-needle biopsy is often anesthesiologist. I have found it useful to place the
inconclusive and not mandatory; however, one must bed at a diagonal with the foot of the bed adjacent to
be aware of the potential pathologies that may be the anesthesia machine and the head of the bed
encountered and counsel the patient accordingly. For angled away from the anesthesiologists. This allows
example, deep lobe parotid lesions may require for comfortable positioning of the surgical assistants.
extension of the operation with facial nerve trunk In addition, we routinely use a nerve monitor to
identification. BBBurkey monitor the facial nerve and sometimes the vagus
nerve. PLFriedlander

oriented shoulder roll; the patient’s head should be STEP 2. The incision is similar to the modified Blair inci-
turned away from the operative side. The table is rotated sion for parotidectomy. However, I bring the transverse
90 degrees, with the operative side of the patient away portion of the incision anteriorly to the lesser cornu of
from the anesthesia machine (Figure 27-2). the hyoid (Figure 27-3).

nondepolarizing muscle relaxant. I do not use a nerve I do not routinely use the preauricular limb of this
monitor; however, the decision to use a nerve stimulator incision, unless the facial nerve trunk needs to be
or nerve monitoring can be made according to surgeon identified, for example, with a deep lobe tumor. For
preference. patients with a concern for cosmesis, a modified
Some surgeons prefer to intubate the patient naso facelift incision can be used, incising only the
tracheally. This is said to allow anterior dislocation of postauricular portion and extending posteriorly and
the mandible to enhance access to the parapharyngeal inferiorly in the hairline, with a small anterior extension
space. I do not find this to be especially helpful and do into a midneck crease for anterior rotation. BBBurkey
not routinely do this.
249
Internal
carotid artery
Internal
carotid artery
A B
FIGURE 27-1. A, Axial magnetic resonance imaging (MRI) of parapharyngeal pleomorphic

adenoma. B, Axial MRI of glomus vagale.
Anesthesia inferior skin flap is elevated in a subplatysmal plane to

machine the midneck. In vascular tumors such as paraganglio-
mas the inferior flap must be raised far enough to obtain
Anesthesiologist
vascular control below the tumor (Figure 27-4).
Assistant 1 Some surgeons choose to elevate the anterior flap in a
supraplatysmal plane. I find that elevation in the sub
platysmal plane does not put the marginal branch of the
facial nerve at risk. The posterior flap should be elevated
Assistant 2 in a plane superficial to the great auricular nerve and
external jugular vein.
When only the horizontal portion of the Blair incision is

used, the superior flap should be raised to the level of
the mandible in a subplatysmal plane, and the marginal
branch of the facial nerve identified and released
superiorly to the level of the mandible. BBBurkey
Scrub nurse First surgeon STEP 4. Mobilize the tail of the parotid gland from the
Mayo instrument anterior aspect of the sternomastoid muscle from the
table external jugular vein up to the mastoid tip (Figure 27-5).
FIGURE 27-2. Location of key equipment and personnel. During this maneuver I routinely divide the great
auricular nerve.
STEP 3. The anterior skin flap is elevated in a plane deep
to the platysma muscle and through the fascia surround- I find this is often not necessary, although if preserved,
ing the parotid gland. The flap should be elevated up to this nerve must be released laterally. Division of the
the anterior border of the parotid gland. The posterior external jugular vein may or may not be helpful, but is
skin should be elevated off of the tail of the gland and of little consequence. BBBurkey
the superior aspect of the sternomastoid muscle. The
CHAPTER 27 Parapharyngeal Space Tumor 251
FIGURE 27-3. Operative incision.
Superficial
parotid gland
Great auricular n.
External
jugular v.
SCM
FIGURE 27-4. Elevation of skin flaps.

Mobilized
superficial
parotid gland
Mandible
Submandibular
gland
Divide great auricular n.
Ligated external
jugular v.
SCM
FIGURE 27-5. Skeletonization of anterior border of sternocleidomastoid (SCM) muscle.
tragal cartilage. This mobilization can proceed along

During mobilization of the parotid gland we routinely the tragal cartilage until the tragal pointer is reached
divide the external jugular vein as well as the greater (Figure 27-7).
auricular nerve. PLFriedlander
At the far superior aspect of the wound, avoid devi
ating anteriorly because the superficial temporal vessels
Because the facial nerve never enters the sternomas are located in this area.
toid muscle, this maneuver can be done quickly and The facial nerve is never encountered prior to reach
with absolute safety. ing the tragal pointer, and therefore this maneuver can
be done quickly with absolute safety.
STEP 5. Identify the posterior belly of the digastric

muscle and trace it posteriorly to the mastoid tip STEP 7. Finding the main trunk of the facial nerve is done
(Figure 27-6). at this point. There are some general principles to keep
in mind during this maneuver (Figure 27-8).
The posterior belly of the digastric muscle is easily iden
tified by dividing the fat below the tail of the parotid n Never try to find the nerve while working in a deep
along a line from the hyoid bone to the mastoid tip. hole. Dissection should proceed along a broad front,
Often one can see the muscle moving in response to lifting up and dividing thin layers of tissue.
stimulation from the electrocautery prior to reaching the n Never divide tissue unless you are absolutely certain
muscle. Because the facial nerve never crosses the digas that it is not the facial nerve.
tric muscle, this maneuver can be done quickly and with n If troublesome bleeding is encountered, do not clamp
absolute safety. blindly because this may result in injury to the nerve.
n If you find your exposure in the anticipated area of
the nerve is poor, open the plane of dissection supe
STEP 6. Mobilize the parotid gland from the tragal car- riorly and inferiorly; this redistributes the wound
tilage taking care to leave the perichondrium on the tension and enhances exposure of the nerve.
Mastoid tip
Tail of External
Posterior belly of
digastric m.
Fatty tissue
FIGURE 27-6. Skeletonization of posterior belly of digastric muscle.
Tragal cartilage
FIGURE 27-7. Separation of parotid gland from tragal cartilage.

Bipolar
cautery
Exposed main
trunk of facial n.
Tail of digastric m.
FIGURE 27-8. Identification of main trunk of facial nerve.
n Take your time. Meticulous, gentle dissection will Often a small artery runs parallel and superficial to
always lead you to the nerve. The nerve is large and the main trunk of the nerve. This can easily be mistaken
obvious. Don’t get frustrated. for the nerve. Do not ligate this vessel until you are
certain that it is not the nerve.
I agree with these key points. Also, I use bipolar

cautery for control of minor bleeding, and have an This is a key anatomic relationship that is almost
assistant watch for any facial stimulation. More always present and causes problems for the surgeon
significant bleeding is controlled with small surgical who is not aware of this relationship. BBBurkey
clips. BBBurkey
During this maneuver and subsequent steps I divide
tissue close to the nerve using a bipolar electrocautery
A key point to remember during identification of the and scalpel.
facial nerve is that the nerve exits the skull base from
the stylomastoid foramen prior to entering the parotid
gland. The ideal area to identify the nerve is in the STEP 8. Dissect along the medial aspect of the sterno-
avascular plane between the periosteum and the cleidomastoid muscle until the spinal accessory nerve
parotid. We use a technique similar to Dr. Andersen’s is identified. Dissect the spinal accessory nerve up to
in which we gently spread through thin layers of tissue the posterior belly of the digastric by dividing the overly-
and divide these layers using a bipolar cautery and ing soft tissue. Identify and dissect free the hypoglossal
scalpel. A broad area of exposure is critical for a safe nerve. Identify the internal jugular vein, internal carotid
identification of the facial nerve. PLFriedlander artery, and vagus nerve (Figure 27-9).
Depending on the tumor type these maneuvers may not

The nerve is located about 1 cm deep to the tragal be absolutely needed. However, knowing the location
pointer in the general area of the junction of the external of these structures is greatly helpful while working in
ear canal, the mastoid tip, and the posterior belly of the the relatively small confines of the parapharyngeal
digastric muscle. space, especially if bleeding reduces visibility.
Spinal accessory n.
Vagus n.
Posterior belly
of digastric m.
Internal jugular vein
Reflected
sternocleidomastoid m.
Carotid
artery
Hypoglossal n.
FIGURE 27-9. Identification of hypoglossal, vagus, and spinal accessory nerves and carotid
artery.
For prestyloid tumors, extensive dissection below the digastric muscle and then divide the ligament. Of note,
digastric is usually less helpful, but such dissection and the ligament always runs in a deeper plane than the
identification are absolutely necessary for poststyloid nerve. BBBurkey
tumors and tumors of vascular origin, for example,
vagal paragangliomas. In the latter instance I routinely Division of the stylomandibular ligament greatly in
perform a level IIA nodal dissection to facilitate great creases exposure. This structure is difficult to visually
vessel and nerve identification. BBBurkey identify but easy to palpate. I pass a right-angle clamp
deep to the stylomandibular ligament, then divide it.
This is where having preidentified all the vital structures
STEP 9. Divide the posterior belly of the digastric muscle in the neck in Step 8 is helpful because you can then be
anteriorly and posteriorly, and remove. Divide the styloid certain that the structure you have identified as the
musculature (stylohyoid, styloglossus, and stylopharyn- stylomandibular ligament is not one of these other
geus). Identify and divide the stylomandibular ligament structures.
(Figure 27-10).
STEP 10. Place a vascular loop around the external

The importance of dividing the stylomandibular carotid artery and retract it anteriorly (Figure 27-11).
ligament cannot be overemphasized because it is the
one crucial maneuver that assists in retraction of the I prefer this technique rather than ligation of the exter
mandible and providing tumor exposure. If the facial nal carotid artery. I believe this may decrease the inci
nerve has not been previously identified, one must dence of first bite pain postoperatively.
ensure that the ligament, not the nerve, is being
divided. The ligament runs from the tip of the styloid The facial artery can usually be kept intact, but the
process to the inner aspect of the mandibular angle. I posterior facial vein is usually sacrificed to allow
routinely identify the styloid process after dividing the exposure of the parapharyngeal space. BBBurkey
Divide stylomandibular
ligament
Cut posterior belly

of digastric m.
External carotid artery
Mandible
Cut belly
of digastric m. Internal jugular vein
Cut stylohyoid m.
Facial Carotid
artery artery
FIGURE 27-10. Division of stylomandibular ligament.
Styloid process
External artery
retracted anteriorly Tumor space
Vascular loop
FIGURE 27-11. Mobilization of internal carotid artery for removal of a poststyloid

parapharyngeal space tumor.
STEP 11. For prestyloid tumors, pass your fingers along

the medial aspect of the tumor along the wall of the True deep lobe parotid tumors require cutting through
pharynx until you reach the top of the tumor. Sweep the parotid, so facial nerve identification is mandatory.
around and above the tumor and gently deliver the Accessory lobe tumors “shell out” and do not
tumor out of the parapharyngeal space into the neck mandate facial nerve identification. BBBurkey
(Figure 27-12A).
Prestyloid tumor
Tumor pulled out of

parapharyngeal space after
blunt dissection
Vessel loop around

external carotid artery
Poststyloid tumor
Tumor pulled out of

parapharyngeal
space after blunt
dissection
Vessel loops
around Internal
jugular vein
Vessel loop around
external carotid artery
B
FIGURE 27-12. A, Delivery of prestyloid parapharyngeal space tumor out of parapharyngeal
space. B, Delivery of poststyloid parapharyngeal space tumor out of parapharyngeal space.
Take your time during this maneuver. For benign sali

Most poststyloid tumors are of neural origin and are
vary gland tumors it is easy to separate them from the
either schwannomas or paragangliomas. In either
surrounding soft tissue. However, if you move too fast,
case, control of the vasculature is key as is isolation
you may rupture the capsule of the tumor. If the styloid
of the tumor with proximal and distal control. Sacrifice
process is long, either remove it or simply break it off
of the nerves in these cases is usually necessary and
with your fingers to facilitate the delivery of the tumor
so preoperative counseling with patients is crucial
into the neck.
to patient satisfaction. In select cases of neural
schwannomas, the tumor may be peeled off of the
nerve fibers and the nerve preserved, but this can
be done in only 25% or less of cases, in my
I divide the styloid process with a cutting rongeur
experience. BBBurkey
forceps, in order to avoid potential traction on the
facial nerve trunk. Avoiding tumor spillage is important,
but large tumors may rupture with retraction, and
STEP 12. Close the wound over a suction drain (Figure
extensive irrigation of the wound is paramount in these
27-13).
situations. BBBurkey
I close my wounds with a running suture of 4-0 braided
absorbable suture in the subcutaneous layer. The skin is
closed using a running suture of 5-0 fast-absorbing gut.
For poststyloid tumors, follow the internal carotid Care must be taken to ensure that the wound is airtight
artery and vagus nerve cephalad into the parapharyn or the drain will not hold suction.
geal space, and remove the tumor (see Figure 27-12B).
For tumors involving the carotid artery it is neces
sary to obtain proximal and distal control of the vessels I admit the patient overnight for airway observation, in
prior to removing the tumor. It is also prudent to case of bleeding, and then discharge. Most drains are
have a vascular surgeon available to assist you should able to be removed on postoperative day 1 or 2.
replacement of the carotid artery with a vein graft be BBBurkey
required.
FIGURE 27-13. Wound closure and drain

placement.
Suggested Readings
EDITORIAL COMMENT: The three-dimensional
aspects of the parapharyngeal space and the Carrau RL, Johnson JT, Myers EN: Management of tumors
various structures within it constitute one of the of the parapharyngeal space. Oncology 11:633-640, 1997.
more difficult concepts in head and neck surgery. Cohen SM, Burkey BB, Netterville JL: Surgical management
The approach described here by the author and of parapharyngeal space masses. Head Neck 27:669-675,
2005.
supported by the commentators provides for safe
Hamza A, Fagan JJ, Weissman JL, Myers EN: Neurilemomas
excision of masses within this complex area. It
of the parapharyngeal space. Arch Otolaryngol Head Neck
ensures identification of the important structures Surg 123:622-626, 1997.
that are at risk and locates them three Khafif A, Segev Y, Kaplan DM, Gil Z, Fliss DM: Surgical
dimensionally in the surgeon’s mind prior to management of parapharyngeal space tumors: a 10-year
excision. As one’s experience in this area review. Otolaryngol Head Neck Surg 132:401-406, 2005.
increases, the need for identification of some of
these structures may diminish under some
circumstances—the comments of the two very
experienced “parapharyngeal space” surgeons
reflect this. However, when there is doubt, one
should always fall back on the “complete
identification” approach to ensure a safe
outcome. JICohen
CHAPTER
Resection of Carotid Body Tumor
Commentary by William M. Lydiatt and Ashok R. Shaha
Operative Steps I do not use a shoulder roll. I generally use three

sheets under the shoulder in a stacked fashion, which
STEP 1. Preoperative embolization of carotid body stabilizes the shoulder and scapula. Nerve monitoring
tumors can be extremely helpful. The reduction in hem- is not necessary in this surgical procedure. The major
orrhage not only reduces the need for blood transfusion nerve of concern is the vagus and hypoglossal nerve,
but also makes identification and preservation of cranial which can be easily seen during surgical dissection. In
nerves easier. The larger the tumor, the greater the Figure 28-2 the anesthesia machine is shown at the
benefit from embolization. I do not generally embolize feet of the patient and lower end of the operating
tumors less than 3 cm in diameter (Figure 28-1). table. I generally use an endotracheal tube and
anesthesia machine between assistant one and
assistant two. A transparent drape on the face is
I have not used embolization, and at Memorial helpful so that the position of the endotracheal tube
Sloan-Kettering Cancer Center we have not used can be evaluated throughout the surgery. ARShaha
embolization for carotid body tumors. Preoperative
evaluation includes carotid angiogram or magnetic
resonance angiogram (MRA). Appropriate evaluation STEP 3. I prefer a transverse incision at the level of the
should be made for the extent of disease and carotid bifurcation. The commonly used incision along
Shamblin classification. If meticulously dissected with the anterior border of the SCM muscle gives excellent
generous use of bipolar cautery, bleeding generally exposure of the carotid sheath but is cosmetically infe-
can be minimized. ARShaha rior (Figure 28-3).
I agree that a horizontal incision is cosmetically

superior. It also affords excellent exposure with less
potential risk to the marginal mandibular nerve. I make
the incision in a natural skin crease. WMLydiatt
The best incision for a carotid body tumor is a
curvilinear or transverse incision at the level of the
hyoid. Incision along the sternomastoid is best
I prefer not to rotate the table, to allow the assistant to
avoided because it is anatomically not a sound
work across from the surgeon. WMLydiatt
incision in the neck. ARShaha

nondepolarizing muscle relaxant. I do not use nerve STEP 4. The skin incision is made and subplatysmal skin
monitoring, but the decision as to whether nerve moni- flaps are elevated (Figure 28-4).
preference. Bipolar cautery works well to control the numerous
veins encountered superficially in this dissection.
Patients with paragangliomas tend to have an
I agree this provides ease in retraction of the increased number of these small to medium-sized
sternocleidomastoid (SCM) muscle and less muscle veins that can prove troublesome if not adequately
flexion during use of the cautery. WMLydiatt controlled. WMLydiatt
260
CHAPTER 28 Resection of Carotid Body Tumor 261
A B
FIGURE 28-1. A, Preembolization angiogram of carotid body tumor. B, Postembolization

angiogram of carotid body tumor.
Anesthesia
machine
Anesthesiologist
Assistant 1
Carotid body tumor

Assistant 2
Incision
Sternocleido-
mastoid m.
Common
carotid a.

Mayo instrument
table
FIGURE 28-2. Location of key equipment and personnel.
STEP 5. Identify and skeletonize the posterior belly of

the digastric muscle (Figure 28-5).
I find that this is best done by identifying the inferior
aspect of the submandibular gland and incising the
capsule of the gland. The gland can then be swept
upward to reveal the posterior belly of the digastric
muscle. Follow the digastric posteriorly to the mastoid
tip, ligating the facial vein.
The posterior belly of the digastric can be easily seen

below the submandibular salivary gland. Invariably
there is a tiny lymph node in the jugulodigastric area
that should be removed for better exposure. There are
multiple small pharyngeal vessels going to the internal
jugular vein that should be clamped and ligated
carefully. ARShaha
To facilitate exposure and in the rare event of

Carotid body tumor metastatic spread, I prefer to remove the nodes
overlying the carotid body tumor at this
time. WMLydiatt
STEP 6. Mobilize the sternocleidomastoid muscle and

identify the spinal accessory nerve (Figure 28-6).
Begin the dissection along the anterior aspect of the

SCM. The external jugular vein and great auricular
nerve often need to be sacrificed. Continue along
the medial aspect of the SCM, working from the mastoid
tip to at least the tendon of the omohyoid muscle.
When the spinal accessory nerve is located, dissect
it proximally to the posterior belly of the digastric
muscle.
FIGURE 28-4. Elevation of skin flaps.

Submandibular gland
Facial v. Submandibular gland Ex. jugular v.

Stylohyoid m.
Post. belly of
digastric m.
Spinal
accessory n.
Carotid body tumor
Carotid body tumor Sternocleido-

mastoid m.
Sternocleido-
mastoid m. Greater
auricular n.
FIGURE 28-6. Dissection along the anterior border of the

FIGURE 28-5. Skeletonization of the posterior belly of the sternocleidomastoid muscle with identification of spinal
digastric muscle. accessory nerve.
Submandibular gland
There are always small veins along the hypoglossal
Ex. jugular v. nerve that may cause bleeding as the mass is
exposed and dissected off the hypoglossal nerve.
Bipolar electrocautery is helpful to avoid injury to the
Stylohyoid m. hypoglossal nerve. ARShaha
Post. belly of
digastric m.
Hypoglossal n. STEP 8. Circumferentially dissect the internal jugular
vein (Figure 28-8).
Spinal Circumferentially dissect the internal jugular vein from
accessory n. the digastric muscle to the omohyoid tendon. Ligate the
common facial vein and all other branches of the inter-
Carotid body nal jugular vein. Temporarily occlude the internal
tumor
jugular by passing a vascular loop around it at the top
and bottom of the dissection, and use these loops to
retract the vein posteriorly out of the operative field.
Sternocleido-
mastoid m. STEP 9. Remove the fibrofatty tissue lying superficial to
the carotid artery (Figure 28-9).
Doing this enhances exposure and allows examination of

regionally lymph nodes for metastatic paraganglioma.
FIGURE 28-7. Identification of hypoglossal nerve.
Malignant paraganglioma is rare and preoperative

suspicion should be raised based on the age of the
Incising the sternomastoid fascia and dissecting along
patient, size of the tumor, and nerve involvement or
the sternomastoid gives enhanced exposure. ARShaha
suspicious enlarged lymph nodes. The surgical
procedure under the circumstances of suspicious
malignant paraganglioma is different and requires
STEP 7. Identify and dissect the hypoglossal nerve
radical resection and sacrifice of the involved nerves.
(Figure 28-7).
This clearly leads to neurologic deficit, causing
The nerve can be found by looking for the most anterior aspiration and dysphagia. ARShaha
large vein just inferior to the posterior belly of the digas-
tric muscle. The nerve is found just deep to this vessel.
Dissect the nerve proximally, ligating several small STEP 10. Identify the vagus nerve coursing along the
vessels that course superficial to it. posterior aspect of the common and internal carotid
arteries. Establish vascular control of the carotid artery
and its branches (Figure 28-10A).
This approach works well in small to medium-sized
tumors; however, in those that engulf the hypoglossal, This is a crucial step that should not be missed. If inad-
I prefer to leave this step until later. Instead, I start by vertent entry into the carotid artery were to occur during
isolating the jugular vein, then dissecting the common resection of the tumor, it can be very difficult to control
carotid just caudad to the beginning of the tumor. The without temporary occlusion of the vessel. Therefore,
vagus nerve can be identified here as well. Establish a prior to manipulating the tumor, establish proper control
vessel loop around the carotid and leave this tagged of the vessel. I do this by circumferentially dissecting
for emergent control. I then prefer to dissect the vagus around the common carotid artery below the tumor and
cephalad in small to medium tumors. It is important to the internal carotid artery above. These vessels are then
be mindful of the superior laryngeal nerve during this looped with vascular loops. Appropriate-sized and
dissection. The nerve exits tangentially in the superior angled vascular clamps are then selected for each vessel,
aspect of the dissection. Identifying this now is very and a discussion is had with the operative team that this
helpful though not always possible in larger tumors. will facilitate control of hemorrhage should rapid action
Then I circumferentially dissect the carotid artery. The be needed. I find that the Debakey atraumatic vascular
surgeon can get into the proper subadventitial plane clamp works well for the common carotid artery and
of dissection and work cephalad. WMLydiatt the Gregory profunda clamp works well for the internal
carotid artery (see Figure 28-10B).
Ex. jugular v.
For tumors with circumferential involvement, I prefer to
Stylohyoid m.
consult a vascular surgeon to be prepared to replace
Post. belly of the artery with a vein graft should the wall be too
digastric m. thin. WMLydiatt
Hypoglossal n.
STEP 11. Begin removal of the tumor by establishing a
subadventitial plane of dissection. The starting point is
based on the precise nature of the tumor (Figure 28-11).
Carotid body
tumor
I find the Silverglide bipolar cautery works extremely
well to help control bleeding. Patience and extreme
Int. jugular v. care are needed during this dissection. The surgeon
should not cauterize on the artery but just adjacent to
it. This allows for a careful reflection of the tumor
from the artery. I prefer to work on the lateral aspect
of the common and then internal carotid first. Then I
Common carotid a. dissect the external carotid, this time on the medial
aspect of the tumor. Finally, the deep dissection is
performed by elevating the tumor from the scalene
fascia but carefully avoiding the sympathetic chain
and the phrenic nerve. My goal is to approach the
bifurcation with as much exposure as possible
because this is where the ascending pharyngeal artery
FIGURE 28-8. Isolation of internal jugular vein.
typically feeds the tumor, and gaining control of this
and ligating it greatly facilitate removal. Next the
internal carotid artery is completely dissected free.
The external carotid artery can then be dissected
Ex. jugular v. or ligated depending on the nature of the tumor.
Working caudad to cephalad, the hypoglossal nerve
Stylohyoid m. needs to be dissected now if it was unable to be
Post. belly of freed earlier. WMLydiatt
digastric m.
Carefully work around the tumor in this plane. Take

Hypoglossal n.
care in the area of the carotid bifurcation because the
vessel wall becomes thin in this area and there is often
a feeding vessel that must be controlled. If necessary or
Carotid body simply convenient, you may ligate the external carotid
tumor artery and remove it with the tumor.
Should an inadvertent arteriotomy occur temporally,
Vagus n. occlude the vessel involved and repair the injury using
Common 5-0 or 6-0 Prolene suture. When doing so, take care
carotid a. to incorporate all layers of the vessel in the closure. If
Int. jugular v.
the vessel wall is fragile and does not accept sutures
well, the use of Dacron pledgets may enhance the
closure.
Just deep to the tumor you will find the superior
laryngeal nerve. Be on the lookout for it.
It is best found on the lateral superior border of the

FIGURE 28-9. Removal of fatty tissue and lymph nodes deep tumor coursing inferomedially. WMLydiatt
overlying carotid artery and carotid body tumor.
Stylohyoid m.
Post. belly of
digastric m.
Carotid body
tumor
Vagus n.
Common
carotid a.
Int. jugular v.
B C
FIGURE 28-10. A, Obtaining control of carotid artery proximal and distal to tumor. B, Gregory
profunda clamp. C, Debakey atraumatic vascular clamp.
Dissecting on the superior part of the carotid artery handled with bipolar electrocautery. Once the
may be difficult because the internal carotid artery dissection starts at the carotid bulb area, the carotid
may be deep and obscured by the carotid body body tumor should be retracted superiorly and the
tumor. The best technical aspect of carotid body dissection continued in the subadventitial plane. The
tumor surgery is to dissect with bipolar electrocautery superior retraction should avoid any traction injury to
in the subadventitial plane, starting from the carotid the hypoglossal nerve and, similarly, minimal retraction
bulb, extending superiorly along the internal carotid should be used along the vagus nerve. One needs to
artery and the external carotid artery. There are be extremely careful to avoid injury to the ramus
generally multiple feeding branches, both from the mandibularis during retraction of the submandibular
internal and external carotid artery that are best salivary gland. ARShaha
Carotid body
tumor
Incision
Vagus n. Sternocleido-
mastoid m.
Common
carotid a.
JP drain
FIGURE 28-11. Dissection of tumor off of carotid bifurcation. FIGURE 28-12. Wound closure and drain placement.
STEP 12. After removal of the tumor, remove all the Suggested Readings
vessel loops used to for vascular control and inspect for
bleeding. Netterville JL, Reilly KM, Robertson D, Reiber ME,
Armstrong WB, Childs P: Carotid body tumors: a review of
30 patients with 46 tumors. Laryngoscope 105:115-126,
1995.
STEP 13. Place a suction drain and close the wound Shamblin WR, ReMine WH, Sheps SG, Harrison EG Jr:
according to surgeon preference (Figure 28-12). Carotid body tumor (chemodectoma). Clinicopathologic
analysis of ninety cases. Am J Surg 122:732-739, 1971.
EDITORIAL COMMENT: Although the principles

that govern the initial wide exposure are the same
as in a standard neck dissection, the plane used in
the actual resection of a carotid body tumor is
different and requires a shift in mindset by the
surgeon. As outlined by the author and
commentators, time spent prior to tumor resection
in developing wide exposure, ensuring the
capability for vascular control (including in some
instances preoperative embolization) should this
be needed (usually in a hurry) during the operation,
and identifying or isolating nerves at risk is time
well spent, and although it often then makes the
resection of the tumor itself seem anticlimactic, it
will never be regretted. JICohen
SECTION A Transoral
CHAPTER
Transoral Resections
29 Author William M. Lydiatt
Commentary by William B. Armstrong, David W. Eisele, Jonas T. Johnson, and Alan T. Richards
Partial Glossectomy or Additional questions include medical preparedness of

Hemiglossectomy Without the patient, second primary tumors, and distant
Mandibulectomy metastases. DWEisele
Cancer of the tongue commonly presents as a painless Partial glossectomy is an operation to remove
lump or plaque on the lateral aspect of the tongue. A less than half the tongue. This operation is performed
punch biopsy is ideal for diagnosis because it usually for T1 through T3 tumors of the lateral and ventral
gives enough tissue to perform histology and determine tongue and includes portions of mucosa and the
depth of invasion. Alternatively, an incisional biopsy intrinsic muscles of the tongue surrounding the
may also be selected using a No. 15 blade knife. Both tumor. Most tongue cancers are removed with a partial
are performed under local anesthesia in the clinic. glossectomy.
A hemiglossectomy is performed for large and infil
trative tumors that require removal of half of the tongue
Punch biopsies are almost always performed because from the tip to the circumvallate papillae. Hemiglos
they are less traumatic, accurately provide a diagnosis, sectomy is reserved for large, longitudinally based
and are better tolerated by patients. WBArmstrong cancers that begin within 2 to 4 cm from the tip of the
tongue and are deeply infiltrative. For larger tumors,
Radiation and surgery are options for tongue cancer. more than a hemiglossectomy may be required depend
Use only one modality whenever oncologically sound. ing on the depth of invasion. This is particularly true in
Surgery is the favored approach according to the recurrent tumors following radiation therapy in which
National Comprehensive Cancer Network (NCCN) margin status may be clinically underappreciated.
Guidelines for oral cavity cancers. The plan for the operation must begin with an assess
ment of the extent of tumor at the primary site and in
the neck. Local extension of the tumor must be assessed
Surgery is recommended for the majority of
in the clinic using physical examination supplemented
patients. Only a small, select group of patients is
by appropriate imaging studies. Imaging studies, such
considered for external beam radiation therapy or
as occlusal films, panoramic radiographs, or magnetic
brachytherapy. DWEisele
resonance imaging (MRI), may be helpful in deter
mining mandibular invasion. Computed tomography
Questions that must be asked and answered in prep (CT) or MRI may be helpful in determining occult
aration for surgical therapy include: neck disease but is usually not as sensitive for detecting
n Determination of the need for radiographs, anes tongue involvement.
thetic considerations
n Type and extent of operation
n Need for removal of part or a segment of mandible
Office-based ultrasonography is very useful for the
n Strategy for management of the neck
assessment of neck nodes. DWEisele
n Available reconstruction options
269
270 UNIT III Oral Cavity and Oropharyngeal Operations
Inspection of the tongue helps determine mobility. If

documentation of a node-negative status may render
the patient is able to protrude the tongue and move it
the morbidity of radiation unnecessary. In my
side to side, mandibular invasion is unlikely to be
judgment the only patients who are unlikely to benefit
present. Involvement of the mandible can often be sug
from this information are those judged too frail to
gested by physical findings of exposed bone and fixation
undergo postoperative adjuvant care. JTJohnson
of the tongue or floor of mouth mucosa to the mandible.
Physical examination using palpation and inspection is
the best predictor of disease extension in the untreated
primary especially in T1 and T2 carcinomas. If the
tumor is mobile and a finger can be inserted between If a radial forearm is selected to reconstruct the floor
the mandible and the tumor, mandibular invasion is of mouth or tongue, vessel exposure and preparation
extremely unlikely. If the extent of tumor is clear from can best be accomplished following a selective neck dis
physical examination and a decision to perform a neck section. Preoperative determination of reconstruction
dissection has been made, either for elective treatment needs is critical, so a plan must be in place to account
based on clinical depth of invasion or therapeutic for for multiple eventualities.
palpable nodal disease, no radiographs are required.
Recurrent malignancies, particularly after radiation,
are often underestimated in size and scope. CT and MRI Special Equipment and
may offer additional information but the operative plan
Anesthetic Considerations
should include the ability to adjust to a wider resection
with appropriate reconstruction. Oral cavity malignan Preoperative antibiotics with both aerobic and anaero
cies, particularly second primary cancers associated bic coverage are given prior to incision. A timeout is
with field cancerization, are appropriately treated with performed to verify the appropriate patient, side, and
repeat operations. operation as well as to confirm the antibiotic has been
Failure following surgery and radiation is less apt to administered. A timeout also verifies to the operating
ultimately render the patient disease free, and a careful team the sequence of events such as:
weighing of the risk and benefits to the patient must n Which will be done first, the primary or the neck
occur, taking into account the pain and suffering from n Whether a tracheostomy will be performed and
local tumor growth versus the morbidity of extended when
reresections. Thus palliative resection may be a reason n What the plan for frozen sections will be
able option in some cases. n If radiographs need to be reviewed
If a clear indication for postoperative radiation Intubation via a nasotracheal approach provides the
therapy exists, such as extracapsular extension beyond best access to the entire oral cavity. It also allows for
the lymph node capsule or perineural invasion of tumor the use of self-retaining lip and cheek retractors to be
in the biopsy specimen, a dental evaluation is done to placed.
determine if nonrestorable dentition needs extraction. Topical vasoconstriction with 0.05% oxymetazoline
Extractions are best done at the same time as the opera is sprayed intranasally at least 5 minutes prior to intuba
tion particularly when multiple extractions are required. tion. The tube should be positioned so pressure is not
The patient with clinically positive nodes requires a exerted on the nasal ala (Figure 29-1).
therapeutic neck dissection. Elective neck dissection is A preformed nasotracheal tube is placed through the
appropriate when the depth of invasion is approxi contralateral nostril to the side of the lesion by anesthe
mately 3 mm or greater, or when the neck needs to be sia and is secured in position by placing a surgical towel
entered as part of the reconstruction effort. folded four times on the patient’s forehead and resting
the tube on the towel. Sometimes several towels are
required. The tube is secured to the towel with tape.
In select cases when depth of invasion is uncertain, The head is then wrapped with tape over the towel,
the primary tumor is resected and final pathology tube, and surgical hat, paying careful attention not to
features guide the recommendation for an interval apply tape to the patient’s skin. The eyes are lubricated
elective neck dissection. DWEisele and taped shut. The head is placed on a head rest so
that it is stable but can be repositioned during the case.
The nasotracheal tube is loosely placed in a holder so
My bias is that elective neck dissection (END) should that it does not become disconnected with head move
be offered all patients with oral cancer. The pathologic ment and such that it does not obstruct the surgeon’s
findings are the most important prognostic information hand movements.
available. Some patients are upstaged and essential Dexamethasone (Decadron) 4 to 10 mg is adminis
adjuvant therapy can be offered. Conversely, tered as an anti-emetic and for its potential to reduce
post traumatic edema in the tongue.
CHAPTER 29 Transoral Resections 271
If no communication is expected between the oral

cavity and the neck, such as with smaller anteriorly
located tumors, a limited setup using electrocautery, bite
blocks of various sizes, self-retaining lip and cheek
retractors, Minnesota retractors, a sweetheart tongue
retractor, hemostats, silk ties, long-toothed and smooth
forceps, Frazier tip or Yankauer suction, and a towel
clamp to hold the tongue, is appropriate.
The mouth and neck are both prepped with povidone-
iodine (Betadine) paint and draped with towels, then a
split sheet for the body and head and a half sheet over
the top. An additional drape can be placed over the neck
and removed after the oral portion is completed. The
surgeons and scrub personnel change gowns and gloves
after the oral portion is concluded if the neck will not
be entered as part of the oral resection.
Most posterior tongue cancer resections involve
communication between the floor of the mouth and
neck and thus separate setups are not needed and the
case is considered to be clean contaminated.
Headlight illumination serves best to illuminate the
field. Loupe magnification may provide better fine detail
of subtle phenotypic changes.
For smaller tumors I like to use a carbon dioxide laser

mounted on a handpiece, with a flexible waveguide, or
FIGURE 29-1. Nasal intubation and setup. via micromanipulator to perform oral resections. There
is less char, and no muscle contraction seen with
electrical current. Hemostasis is not as effective, but
with careful dissection and layered approach, larger
Muscle relaxation is important to minimize tongue vessels are identified and ligated or coagulated as
motion and maximize oral aperture. before they are transected. WBArmstrong
For larger tumors that require free flap reconstruction,

oral intubation is performed and tracheotomy is
I concur that the oral lesion should be removed prior
performed prior to performing oral resection or neck
to doing the neck dissection. This allows the
dissection. WBArmstrong
pathology team an opportunity to render an opinion
about the adequacy of the margins while the surgeons
are doing the neck dissection. JTJohnson
When securing the nasotracheal tube I ensure that the

tape is wrapped below the occiput to minimize the
likelihood of the wrap falling off. It is important to
supervise the positioning to ensure the wrap does not Operative Technique
pull against the ala. In addition, I insert a strip of
Xeroform gauze between the endotracheal tube and STEP 1. An incision is created using electrocautery on
upper lateral cartilages to decrease the tendency of the cutting mode and deepened through the mucosa to
the tube to pull superiorly. Finally, the patient is encompass the entire lesion with at least 1 to 1.5 cm of
prepped and draped with the nasal ala visible, and the phenotypically normal tissue.
area is inspected periodically throughout the
procedure to ensure there is no pressure on the nasal Non–Teflon-coated needle point cautery (Colorado tip)
ala. WBArmstrong works best for mucosal incisions but spatula-tipped
cautery serves best for the incisions in the tongue
Incision
Tumor
A
Leukoplakia
Leukoplakia
Tumor
FIGURE 29-2. A, Note the self-retaining retractor in

position. The figure shows the incisions for the wedge
resection. In this case the anterior portion is excised in a
longitudinal fashion and the posterior aspect in a wedge. B
B, Side view demonstrating the pyramidal shape.
musculature because it affords better coagulation.

In removing the sublingual gland, be careful to identify
Coagulating and cutting current is set on 25 watts.
and preserve the lingual nerve. Lingual anesthesia is
Additional margin should be attained in previously radi
very disturbing to many patients and may result in
ated patients and when the tumor dimension is less
inadvertent self-mutilation through chewing on the
palpable. Electrocautery using the coagulating current
numb tongue. JTJohnson
is used for hemostasis on the smaller vessels of the
tongue and can be used throughout the muscular
incisions. The depth of the resection requires a three-
dimensional understanding of the tumor, and again at
least a 1- to 1.5-cm margin should be achieved. As the
muscles and vessels are transected they will retract. This
We have used the plasma knife, which provides
has important implications from both a bleeding and
excellent hemostasis during dissection, with good
oncologic standpoint.
success for glossectomy. DWEisele
STEP 3. Vessels should be controlled prior to transac-

STEP 2. A wedge resection is best performed for local-
tion using a Debakey forceps, bipolar, or unipolar cautery
ized infiltrative tumors.
on the coagulating current depending on the size of the
Superficial tumors can be excised in a longitudinal vessel.
manner. The extension of the incision onto the floor
of mouth mucosa may expose the sublingual salivary Cautery alone works nicely for vessels less than 2 to
gland and a decision of whether this should be resected 3 mm. Avoid cauterization of the specimen because this
must be made based on local involvement of the gland will create falsely close pathologic margins. Margin
and expectation of function after resection. Error on shrinkage is substantial in the head and neck, especially
the side of removal if either is potentially relevant in the tongue where up to 40% to 50% shrinkage may
(Figure 29-2). occur.
First layer
of sutures
First layer
of sutures
FIGURE 29-3. A, The deep closure that

B reapproximates the intrinsic tongue musculature.
B, Side view.
Dissection typically moves from anterior to poste

We retract the tongue with multiple 2-0 silk sutures.
rior. Move slowly across the muscle to maintain hemo
Additional sutures are placed as the dissection
stasis. A bloodless field allows better appreciation for
proceeds. We make an initial cut through the tongue
the margin status.
mucosa circumferentially around the tumor with at
The intrinsic muscles of the tongue appear as a
least a 1- to 1.5-cm margin. The incision is then
complex interwoven pattern of fibers that connect to the
carried down into the tongue in a perpendicular
mucosal surface. They are chiefly involved with articula
fashion. The tumor is then removed with a 1.5-cm
tion and fine tongue movement. Because of their complex
deep margin. We prefer to obtain frozen section
interlacing anatomy tumor spread can follow multiple
margins from the margin of the surgical defect. These
paths. The majority of partial glossectomies involve the
can be obtained during the course of the dissection to
intrinsic musculature. Deeply invasive tumors and those
expedite their analysis. DWEisele
that involve the ventral tongue are more apt to require
resection of the extrinsic tongue muscles, as well.
Frequent palpation of the tongue and tumor is criti
cal to understanding where to make the line of incision.
The extrinsic tongue musculature is primarily involved
with protruding, retracting, and other major move I am an advocate of using electrocautery in performing
ments of the tongue, an important point to consider partial glossectomy. My experience is that the tongue
when closing the tongue. The resection tends to make a will begin to ooze 5 minutes after performing the
pyramidal specimen with the apex deepest in the intrin resection. This serves as an incentive to get the
sic tongue musculature. specimen out. Large vessels do need to be ligated.
The lingual artery should be controlled and ligated I am liberal with the use of suture ligature whenever
with 3-0 or 4-0 silk ties. there is a troublesome area, to prevent lingual
The specimen is marked with a suture and then sent hematoma postoperatively. The presence of a
to pathology for en face frozen sections. Closure can be hematoma may force an emergency tracheotomy,
started if the surgeon is confident of the margins (Figure something we would all like to avoid. JTJohnson
29-3).
Second layer
This is especially true of the extrinsic tongue muscu
of sutures lature such as the genioglossus and hyoglossus because
they are critical to protrusion.
A two- or three-layer closure is needed to provide
sufficient strength in the suture line. This shortens the
tongue somewhat but provides sufficient bulk to facili
tate swallowing. As long as the tongue can meet the
incisors, articulation will be satisfactory. This may
create a slight hump to the posterior or middle portion
of the tongue, but over time this will remodel to provide
excellent function.
FIGURE 29-4 Closure in both the horizontal and A ventral-to-dorsal closure has the potential to
perpendicular planes. lengthen the tongue and cause deviation of the tip away
from the side of resection, thus making it difficult for
the patient to completely keep the tongue in the mouth.
STEP 4 (Closure). Alternatively, the neck dissection can
be performed and closure completed after the neck
wound is closed.
The major goals of closure are to facilitate articulation Closure of the defect is performed based on the size
without undue lengthening of the tongue and mainte and location of the defect. Linear anterior-to-posterior
nance of swallowing ability. closure works well for most lateral defects. For select
Posterior lesions tend to interrupt swallowing func anterolateral defects, the anterior tongue remnant can
tion, whereas those anterior tend to diminish articula be rotated into the lateral defect. Provided the tongue
tion. Articulation is preserved by assessing the anterior remains untethered, patients retain good articulation
extent and the depth of resection. The anterior tip of despite a relatively shortened tongue. DWEisele
the tongue must be reconstructed and its mobility pre
served. One must avoid creating a bulbous tip, however.
Occasionally, additional resection may be required to Sometimes a combination of ventral-to-dorsal closure
reduce excess redundancy. anteriorly and anterior-to-posterior closure in the pos
If the depth is superficial a simple ventral-to-dorsal terior aspect is most appropriate, thus serving both
closure with alternating horizontal mattress and simple articulation and swallowing goals; 3-0 Vicryl is used to
sutures using resorbable suture material such as 3-0 close the mucosa as well.
Vicryl or Polysorb is appropriate (Figure 29-4). Horizontal mattress and simple sutures are used to
re-approximate the anterior horizontal mucosa incision
as shown in Figure 29-5. They are also used to close the
For superficial and moderately invasive T1 and T2
vertical incision.
lesions that do not involve the floor of the mouth, I
leave the wound open, encourage early oral intake,
and allow the wound to heal secondarily. Meticulous
I agree that most defects are best closed with a use of
oral hygiene is maintained, and the patient
a combination of the two approaches. The surgeon
aggressively maintains oral intake. This has produced
should recall that complete closure is not required.
excellent functional results. WBArmstrong
This is especially true of the posterior third of the oral
tongue. The raw surface will remucosalize nicely. One
Ventral dorsal closures lengthen the tongue. This goal of closure is hemostasis. Another goal is to
works well for small defects. JTJohnson ensure that two surfaces do not produce an adhesion
and interfere with function (such as between the
mandibular alveolus and the tongue). JTJohnson
If the depth of resection involves a moderate amount
of muscle in a wedge, usually 1 cm or more, an anterior-
to-posterior closure of the deep tongue musculature is A key point to stress is that the tongue is a complex
best, particularly in the posterior aspect of the oral organ composed of intricate interlacing muscles that is
tongue. impossible to completely reproduce. In general, function
is best saved, and unnecessary tongue should not be
Anterior-to-posterior closures tend to tether the resected. Restoration of function is best accomplished
tongue (and make it point toward the side of the by reapproximating extrinsic muscles in an anterior to
resection). JTJohnson posterior manner. Tongue mobility should be maxi
mized by not allowing it to become overly tethered to
Second layer
of sutures and
closure
Second layer
of sutures and
closure FIGURE 29-5. A, The anterior closure and the mobility
of the tongue. Note the towel clamp used for tongue
retraction and the position of the self-retaining cheek
retractors. Also see the bite block used to prop the
mouth open on the contralateral side. It is wedge
shaped and varies in size depending on the presence
B or absence of teeth and ability to open the mouth.
B, The completed closure.
the mandible. This may be accomplished by simple Most partial glossectomy cases do not require free-
closure as described previously. flap reconstruction (see Figure 29-5).
Healing by secondary intention results in contraction For T3 and T4 tumors that involve a substantial
and should be avoided when significant floor of the portion of the lateral tongue, a hemiglossectomy is indi
mouth mucosa has been resected. Secondary intention cated. If the invasive component of the lesion approaches
healing is excellent for thin defects of the tongue that to within 1.5 to 2 cm of the ipsilateral tip of the tongue,
do not reach onto the floor of mouth. the tip should not be saved. This will result in a bulbous,
A full- or split-thickness skin graft or allogenic graft nonfunctioning appendage that impairs rather than aug
material works well to provide additional tongue flexi ments articulation.
bility and mobility in those cases in which the incision An incision is created in the midtongue and deepened
extends onto the floor of the mouth. to find the septum linguae, a fascial plane that extends
A full-thickness skin graft prevents contraction of to the base of the tongue and is relatively avascular.
the tongue to the mandible. The graft is harvested from Branches of the hypoglossal nerve to the base of tongue
the neck and placed with a bolster sutured to the tongue. should be salvaged if oncologically possible. Anterior
A split-thickness graft contracts more but has a branches are obviously transected. Removal of the
higher rate of successful integration. entire oral hemi-tongue is thus accomplished.
The posterior incision is tapered laterally, and the
lingual artery is ligated posteriorly as described earlier.
I agree that a skin graft can afford good coverage If the tumor approaches the septum linguae, deeper
without hampering subsequent mobility. The challenge resection is required.
is to be sure of hemostasis and then to adequately Reconstruction is likely to be more complicated and
immobilize the graft so that healing can progress. the goal is to provide some bulk although the chief aim
Presence of a hematoma or constant shearing motion is to maintain flexibility of the remaining tongue. Radial
will cause failure of the graph. Most patients who forearm or lateral thigh free flaps are excellent selections
need a split thickness skin graft (STSG) require a if the floor of the mouth is removed, especially with a
tracheotomy. JTJohnson communication into the neck or when a substantial
portion of the mandible has been exposed.
detailed so the obturator can be fashioned to immedi

If significant floor of mouth involvement is present,
ately reconstruct the defect.
extrinsic tongue musculature resected, or free-flap
The majority of palate resections can be adequately
reconstruction performed, I generally perform
obturated with a prosthesis. Obturation can best be
tracheostomy because of expected prolonged
achieved when some dentition remains to help anchor
postoperative edema. WBArmstrong
the prosthesis. Larger defects may require free-flap
reconstruction.
Postoperative Considerations Special Equipment and

A tracheotomy may be required if excessive tongue
edema is anticipated. For anterior and lateral defects Preoperative antibiotics with both aerobic and anaero
this is usually not required. The patient can usually begin bic coverage are given prior to incision. A timeout is
a diet of liquids on postoperative day 1 and advanced performed to verify the appropriate patient, side, and
to soft as tolerated by day 2 or 3. This may need to be operation as well as to confirm the antibiotic has been
delayed a day or two if the resection involved the floor administered. This also serves to verify the sequence of
of the mouth and communicated with the neck. Some events to the operating team.
interruption in articulation is to be expected initially. The obturator must be available and soaking in
povidone-iodine solution for placement at the conclu
sion of the operation. Radiographs should be available
Early speech rehabilitation with a speech-language for review. Intubation via a nasotracheal approach pro
pathologist is recommended. DWEisele vides the best access to the entire oral cavity, palate, and
maxilla.
Tongue edema may wax for 2 to 3 days and then

begin to resolve depending on the depth and location of An oral tube may be placed if there is a
the resection. contraindication to a nasal tube, such as markedly
deviated nasal septum or the possibility of tumor
extending into the nasal cavity. ATRichards
Hard Palatectomy
The tube should be in the opposite naris to the resec
Tumors that arise in the mucosa of the hard palate are tion. For midline lesions or those that encompass the
most commonly found at the junction of the hard and majority of the palate, tracheotomy may be considered
soft palate. Benign and malignant minor salivary gland although it is generally not required. Usually the tube
tumors, squamous cell carcinomas, sarcomas, and mela can be protected from injury using careful technique.
nomas may all present in this region. The extent of
resection is dictated by the extent of the tumor and its
Operative Technique
histology.
Benign tumors can be excised with a small cuff of When a neck dissection and a radical palatectomy with
normal tissue around the tumor. Small benign lesions of extensive resection of the maxilla are anticipated, they
the hard palate with no radiographic evidence of bone can be performed prior to the palatectomy so the inter
change may be resected without bone resection. Malig nal maxillary artery can be identified and vessel loops
nant tumors require wider resection margins of 1 to placed. This provides additional control of arterial
2 cm including the bone margins. bleeding sometimes seen with maxillectomy.
Preoperative extent of disease is determined by physi Headlight illumination and loupe magnification aid
cal examination but strongly supplemented by CT or in the operation.
MRI scans. A coronal CT scan provides an excellent
view of the bone-tumor interface. Bone thickening may
be seen and should be taken as an indication for STEP 1 (Exposure). Self-retaining lip and cheek retrac-
resection. Bone destruction may also be demonstrated tors are placed to maximize exposure and protect the
and the tumor may extend into the maxillary sinus, nasal lip mucosa from inadvertent cautery burn.
cavity, pterygomaxillary space, or the nasopharynx.
The location of the osteotomies can be predicted An appropriately sized wedged-shaped bite block is
preoperatively and discussed with the dental oncologist inserted. If the patient is dentate, a small or medium
for construction of an appropriate dental obturator. adult size is usually sufficient. A large adult bite block
The number and location of dental extractions are works best for the edentulous patient.
Tumor
Incision
FIGURE 29-6. The bulge of the tumor with

minimal changes in the mucosa. The
proposed incision lines are drawn.
STEP 2 (Local anesthetic). Local infiltration using

0.25% bupivacaine (Marcaine) with epinephrine aids in For resections that will enter the nasal cavity, I insert
hemostasis. cottonoid pledgets with oxymetazoline (Afrin), or
epinephrine containing solution into the floor of the
Infiltration around the foramen of the greater palatine nasal cavity to provide mucosal hemostasis, and
artery lessens blood loss as well. protect the endotracheal tube and nasal tissues
The patient is prepped with povidone-iodine paint when the transoral resection enters the nasal
and draped with towels, a split sheet, and a half cavity. WBArmstrong
sheet.
The incisions are deepened through the mucosa,
soft tissue and periosteum, to the hard palate bone
STEP 3 (Incision). Any dental extractions that are neces- (Figure 29-7).
sary should be performed.
The location of an incision through a tooth socket STEP 4 (Hemostasis). Hemostasis is attained using the
requires extraction. The mucosal incisions are created coagulating current but is aided by the previously applied
using electrocautery on the cutting current (Figure local injection.
29-6).
Approximately 3- to 5-mm margins for benign The greater palatine artery can be controlled with
tumors is adequate. Margins of 1 to 1.5 cm should be cautery or ligation depending on the posterior extent of
used for malignant tumors. the resection line.
STEP 5 (Posterior incisions). Posterior incisions are

I prefer to identify the foramen with the injection deepened through the soft palate mucosa severing the
needle, and perform a sphenopalatine block on palatal attachments of the palatine muscles until the
the side of the tumor by inserting the needle nasopharynx is exposed.
approximately 1.5 cm into the greater palatine canal,
aspirate, then inject 1 to 2 mL of solution near the The lateral incision transects the medial and lateral
sphenopalatine ganglion. WBArmstrong pterygoids near their insertion into the lateral pterygoid
plate. The lateral wall of the maxilla is also exposed.
Lateral
pterygoid
plate
Lateral
pterygoid
plate
FIGURE 29-7. The resected specimen is seen.
Note the osteotomies and the incision through the
tooth socket.
STEP 6 (Osteotomies). Osteotomies are created using Bone margins are not readily obtainable but close
either a sagittal saw or osteotomes (see Figure 29-7). inspection of the specimen should give an idea for the
tumor proximity to the margin. If the specimen is
Copious irrigation is used. The last osteotomy is per damaged in removal and a margin is unclear, tissue from
formed by fracturing the pterygoid plate from the base the patient should be obtained for the frozen section
of the skull using the curved pterygoid chisel. margin and permanent margins in some cases. If a
significant amount of buccal flap is exposed, a split-
thickness skin graft is harvested and sewn into the
If the tumor crosses the midline, it is necessary to cut inferior and anterior mucosal margins of the defect
through the lower part of the nasal septum with a (Figure 29-8).
curved Mayo scissors. ATRichards
STEP 9 (Closure). Xeroform gauze is placed on the graft

if one is placed or directly onto the pterygoid muscles.
STEP 7 (Hemostasis). At this point significant bleeding
may occur, and the specimen should be removed as
Enough packing to fill the defect is used and the obtura
quickly as possible.
tor is then placed into position. If a significant portion
It is important to perform all muscular and mucosal of the soft palate is resected, a nasogastric tube is placed.
incisions prior to the osteotomies so that time is not
wasted when bony bleeding is difficult to control.
Hemostasis is accomplished with electrocautery and If nasogastric enteral feeding is required, a Dobhoff
packing the pterygoid fossa to stop pterygoid plexus silicone feeding tube can be passed. This is less
bleeding. The internal maxillary artery is ligated as traumatic and less rigid than a plastic nasogastric tube
needed. and is better tolerated by the patient. ATRichards
STEP 8 (Pathologic assessment). The specimen is Depending on the extent of the resection, oral intake
marked and sent to pathology for frozen section may begin immediately or when the defect is sufficiently
margins. obturated, which may take 5 to 7 days.
Posteroinferior
turbinate Surgicel
Buccal
fat pad
Endotracheal
tube
Palate Parotid
musculature duct
FIGURE 29-8. Note the cut edge of the

palate musculature in the medial and
posterior corner, the parotid duct on the
Obturator lateral aspect of the cheek, the exposed
buccal fat pad in the lateral midportion of
the defect, the packing of Surgicel in the
pterygoid fossa, the endotracheal tube in
the medial side of the defect, and the
posterior aspect of the inferior turbinate in
the middle of the defect. The obturator is
being inserted in the defect as well.
For edentulous patients or those with minimal

Lip Wedge Resection with Lip Shave
dentition to hold an obturator, I secure the obturator Carcinoma of the lower lip is associated with sun expo
by drilling a hole into the obturator and placing an sure and tobacco use. Two common clinical scenarios,
anchoring screw into remaining palate bone. At the an isolated T1 or T2 lip cancer and diffuse carcinoma
time of packing removal, the screw is removed. For in situ of the lower lip, will be considered together. Elec
difficult cases the maxillofacial prosthodontist will tive neck treatment is not usually indicated for lip car
adapt the obturator at this time to improve ability to cinoma; however, it should be considered when a free
retain the prosthesis. WBArmstrong flap is required or for large T2 lesions.
Postoperative Considerations It should also be considered if the patient has clinically

palpable or radiologically detected nodes. ATRichards
With an obturator in place, the patient can begin eating
soon after the operation on postoperative day 1 or 2.
Antibiotics typically can be discontinued at 24 hours. For resections requiring one third and possibly up to
The role of antibiotics until the packing is removed is half of the lip from commissure to commissure, a wedge
controversial. or shield resection is ideal. The nature of the tumor
dictates which is best. The patient is brought to the
operating room; preoperative antibiotics with both
I generally continue antibiotics until packing is
aerobic and anaerobic coverage are given prior to inci
removed to decrease odor from the packing.
sion. A timeout is performed to verify the appropriate
WBArmstrong
patient, side, and operation, as well as to confirm the
antibiotic has been administered. This also is done to
I usually leave the Xeroform packing in for 2 weeks so
verify to the operating team the sequence of events.
that more healing is allowed to take place. ATRichards
Radiographs are typically not needed, but if obtained
these can be reviewed.
For small lesions local anesthesia is suitable. This is
Prevention of toxic shock does not occur with anti accomplished with 0.25% bupivacaine with 1 : 200,000
biotic coverage. Obstruction of sinus drainage can epinephrine injected around the tumor. It is important
create a reservoir for bacteria to flourish, however. to mark the sites of incision prior to injection so
Incision
Leukoplakia
Tumor
FIGURE 29-9. The initial incision

for a lip shave and wedge.
distortion is not a factor. For large lesions or in patients The incision is placed along the vermilion border up
not suitable for local anesthesia, intubation via a naso to 1 cm before the invasive tumor. The depth of this
tracheal approach provides the best access to the entire resection is submucosal. Minor salivary glands will be
oral cavity. It also allows for maximum flexibility of the encountered and are resected unless they are deep.
lips without distortion. The posterior incision is dictated by clinical findings
and is approximately 4 to 6 mm beyond the visible
leukoplakia.
A nasal tube also allows better symmetry to be
The wedge resection is performed after both sides of
obtained during the closure of the defect. ATRichards
the lip mucosa have been excised. A full-thickness resec
tion of the lip with equal tissue on the mucosal and skin
STEP 1 (Preparation). The tube should be positioned so sides is performed.
undue pressure is not exerted on the nasal ala and so
the eyes are protected. Muscle relaxation is important
to minimize lip motion and maximize oral aperture.
Approximately 1-cm margins are obtained grossly For a wedge excision only, it is important to make
(Figure 29-9). both the mucosal and the skin incisions of equal
length. However, with a combined wedge and lip
shave, one can take less on the mucosal side while
When the tumor extends to beyond the lip proper with
maintaining an adequate margin around the tumor.
extensive deep muscular invasion, neck dissection is
This facilitates advancement of the mucosa to create
performed. WBArmstrong
the new lining of the lip. This results in a suture line
that is T shaped instead of cross shaped with less
chance of breakdown at the corners. ATRichards
Draping is performed so the nasal ala can be
inspected throughout the procedure to ensure there is
no pressure on the nasal ala from the endotracheal
tube. WBArmstrong The orbicularis oris is transected. The incision
reaches the mental crease in most lesions (Figure 29-10).
STEP 2 (Incision). If an excision of the lower lip mucosa For slightly larger lesions or smaller oral apertures, a
is planned, it should be done in conjunction with the shield design works well. Pay careful attention to both
wedge. sides of the resection to keep them equal.
advancing the tissue to release tension on the

vermilion closure, and placing a small split-thickness
skin graft in the sulcus. WBArmstrong
Postoperative Considerations
The patient is instructed to keep the incisions clean and
apply antibiotic ointment. A soft diet is preferred for 7
to 10 days. Nylon sutures are removed at 5 to 7 days
and the mucosal sutures can be trimmed after 7 to
10 days.
FIGURE 29-10. The resection specimen. Note the deeper

resection margin around the invasive tumor and the cut edges Marginal Mandibulectomy and
of the orbicularis oris. Resection of the Floor of the Mouth
STEP 3 (Themostasis). The labial artery is cauterized or
Neoplasms that involve the floor of mouth require
ligated.
certain special considerations. The proximity to and
necessity for removal of part or all of the mandible as
well as the need for removal of the sublingual gland and
STEP 4 (Closure). Closure is accomplished by first
the submandibular duct must all be taken into account
approximating the orbicularis oris into alignment using
in the preoperative planning. Assessment of the man
simple 3-0 Vicryl sutures (Figure 29-11).
dible is based on radiographic investigations, such as:
Consider the wound a wedge with the apex toward the n Panoramic x-ray
mental crease and the base as the outer lip margin. Start n Occlusal dental film
at the apex or depth of the wound and work toward n CT or MRI scans
the base. Sufficient muscle must be included in the These radiographic evaluations are meant to provide
closure suture to provide adequate strength. The additional information to what is ascertained on the
approximation must be equal with respect to the depth physical examination. It is critical to understand on
and the distance from the labial and skin surfaces. physical examination whether the tumor is completely
The vermilion border should be approximated if it mobile from the mandible, whether it is tethered, or
is still present. If it has been resected, careful approxi whether bone is actually exposed.
mation of the skin edges is performed using a 5-0 nylon Also critical in these assessments is whether the tumor
suture. The remaining skin is also approximated with is involving the dentition and gaining access to the man
the 5-0 nylon. dible via the tooth root. In this situation, composite
Mucosa is undermined as much as possible using resection is generally the most appropriate and effica
sharp dissecting scissors or a scalpel, usually to the cious because of potential involvement in the medullary
attached mucosa of the mandible. This allows maximum space. On the other hand, many floor of mouth cancers
advancement with the least amount of tension. involve the periosteum, but have minimal to no cortical
The perpendicular mucosal incision from the wedge invasion. These tumors are best treated with a marginal
resection is now closed with multiple simple sutures mandibulectomy, which achieves adequate oncologic
using 4-0 Vicryl. The mucosal advancement flap is margins and preserves the anatomic contour and integ
approximated to the skin to re-create the vermilion rity of the mandible.
border.
If the cancer is less than 1 cm from the alveolar ridge,

a marginal mandibulectomy provides an adequate
Vermilionectomy to remove actinically damaged skin oncologic margin. ATRichards
results in a significant defect. Undermining the
mucosa provides some tissue, but when there is
extensive resection of condemned mucosa, the lip Specific considerations regarding whether a marginal
rolls inward on closure. This can be moderated by mandibulectomy is appropriate include:
n Whether the patient has received prior irradiation
incising the mucosa of the gingivolabial sulcus,
n Whether the patient is dentate or edentulous
Deep
sutures
Final
FIGURE 29-11. A, Undermining closure
the labial mucosa for advancement
and placement of the suture to
reapproximate the orbicularis oris. For
larger resections multiple layers of
sutures are needed. B, Deep closure
B C
completed with vermilion border
reapproximated and the labial wedge
reapproximated. C, Closure of the
advancement flap.
n If edentulous, the height and thickness of the retractors are necessary. In addition, osteotomies can be
mandible performed using an oscillating saw, a Lindemann drill,
n Whether the tumor involves more than 180 degrees or narrow straight osteotomes. All should be available
of the mandible, even if no direct invasion is evident to the operating surgeon because each has specific indi
Secondary considerations include whether the lingual cations and can be used in various circumstances. The
gland and submandibular duct require removal. In most majority of the osteotomies should be performed using
situations, this will be the case and provides an adequate powered instrumentation; however, osteotomes can be
margin of removal. utilized in certain situations with good effect.
In addition, these can be areas where tumor infil
trates and so somewhat more aggressive margins are
advisable. Because most resections involving the floor For resection of larger tumors requiring pedicled flaps
of the mouth also incorporate unilateral or bilateral or free-flap reconstruction, oral intubation is performed
neck dissection, depending on depth of invasion and and converted to a tracheostomy before starting the
proximity to the midline, the submandibular glands surgical resection. WBArmstrong
often are removed, thus negating the need for sialodo
choplasty. Frequently, however, the contralateral sub
mandibular duct is involved in the resection margin,
Operative Technique
though not directly involved by tumor. It is important
to maintain function of this duct and a docoplasty may The patient is in the supine position.
be required. The mouth and neck are appropriately prepped and
draped, depending on whether a unilateral or bilateral
Special Equipment and neck dissection is planned.
If the decision has been made that the patient will
Anesthetic Considerations receive postoperative radiation therapy, then contra-
Floor of mouth resections with marginal mandibulec lateral elective neck need not be performed, and great
tomy are best performed under general anesthesia with care needs to be taken to preserve the function of the
nasal intubation. The usual transoral equipment and contralateral submandibular duct.
Deep
muscular
incision
Sublingual Genioglossus
glands muscles
(cut)
A Mucosal B
incision
FIGURE 29-12. A, Floor of mouth tumor extending across the midline and abutting the
mandible. B, Mucosal incisions and beginning of the deeper resection of the genioglossus
muscles.
A timeout is performed, verifying that appropriate In the case of the dentate mandible, the entire root
preoperative antibiotics have been delivered, which will of all teeth to be removed must be included in the mar
cover aerobic and anaerobic organisms. ginal mandibulectomy (Figure 29-13).
The head is in the neutral position.
STEP 3 (Osteotomy). The osteotomy is performed from

One can get better mouth opening by extending the buccal to lingual and from superior to inferior, preserv-
neck on a roll. ATRichards ing at least 11 mm of mandibular height.
Care should be taken to preserve the mental nerve and

STEP 1 (Preparation). Using headlamp illumination and inferior alveolar nerve, unless this would compromise
loupe magnification, appropriate self-retaining cheek the oncologic resection.
retractors are placed, the lesion is once again palpated
and inspected, and the degree of involvement of the
Avoid right angles on the osteotomies. I taper the cuts
tongue is ascertained. Once again it is confirmed that
to produce a boat-shaped excision. This is structurally
the tumor is involving at least the periosteum or very
stronger than performing right-angle osteotomies with
closely involving it, but without evidence of invasion of
the marginal mandibulectomy. This is especially
the dentition or frank invasion of the mandible.
important when the mandibular height is compromised.
WBArmstrong
STEP 2 (Incisions). Mucosal incisions are mapped out to

All mucosal incisions are made, and hemostasis
achieve at least a 1- to 1.5-cm mucosal margin (Figure
maintained, prior to any osteotomies.
29-12).
I prefer to do the bulk of the resection prior to the
Needle-point cautery works ideally for these in osteotomies until such time as the deep musculature
cisions. incisions. These can then be performed with the bone
A B
Inferior
alveolar
nerve
11 mm.
Mental
foramen
Suction
Osteotomy
FIGURE 29-13. A, Osteotomy of the mandible from buccal to lingual with irrigation and
suctioning. B, Site of osteotomy on mandible and relationship to the inferior alveolar nerve and
mental foramen.
out of the way, facilitating adequacy of assessment of The sublingual gland will be removed with the speci
margins. men, and ideally this dissection is started posteriorly
The interior mucosal incisions are carried down to and brought anteriorly.
the bone and through periosteum, again paying careful A capsule surrounding the sublingual gland can
attention to not injure the mental nerve. sometimes be appreciated; it is usually somewhat ill
At least 1.5 to 2 cm of bone should be excised to defined.
either side of the visible and palpable tumor. If full The dissection then proceeds on the buccal side of
dentition is present, it is often prudent to extract teeth the sublingual gland up to the incision of the posterior
to facilitate the osteotomy through the posterior and aspect of the osteotomy.
anterior portions of the marginal mandibulectomy. Care must be taken not to overdissect the gland and
This should be done just prior to osteotomy so that extend the dissection into the undersurface of the tumor
excess bleeding is not a nuisance during the mucosal because this can create a spurious positive margin.
dissections.
Palpate with the index finger deep to the lingual gland.
This gives a good assessment of the deeper extent of
the tumor for deep margins. ATRichards
STEP 4 (Posterior incisions). Once the anterior incisions
have been made, the posterior incisions can be made, Moving just lingually to the submandibular duct,
extending up onto the ventral tongue, taking care to one encounters the lingual nerve.
achieve hemostasis in the multiple veins within the floor The gland is elevated off the bed of the hyoglossus
of the mouth. muscle.
Lingual retraction, using a Minnesota retractor or a
If the lingual nerve is thought to be involved by or Sweetheart retractor, facilitates exposure, and if preser
closely approximated by tumor, resection is likely vation of the lingual nerve is desired, this can be
needed. accomplished.
Genial
tuberosity
Sublingual
gland
FIGURE 29-14. Defect showing portion of the
Mandible genioglossus muscles still intact. Also note specimen
Tumor with sublingual gland still attached.
Next, the dissection incorporates portions of the

cut is made. The cut is oblique so that on the labial
ventral tongue and genioglossus muscle. The extent to
surface it is shorter than on the lingual surface.
which this needs to be resected depends on the depth
Because the primary tumor is in the floor of the
and location of the malignancy.
mouth, this so-called lingual corticectomy gives an
Preserving some of the inferior attachments to the
adequate margin and at the same time preserves
genial tuberosity significantly improves postoperative
more mandible. ATRichards
tongue function, and so preservation should be sought,
unless this compromises the oncologic outcome.
The incision is then brought more anteriorly, and
here a decision on the contralateral submandibulary
duct needs to be made. The lateral osteotomies can also be performed with
Typically, a portion of the anterior submandibular the oscillating saw; however, a Lindemann drill bit
duct and its orifice is resected. This should therefore works nicely to perform these osteotomies. The Linde
carefully be dissected free, the duct tagged with a silk mann also can be used to do a more complicated oste
suture, and brought out and kept long so it can readily otomy when required. Again, care must be paid to the
be reimplanted at the closure, and then pulled aside. inferior alveolar nerve and mental nerve. Occasionally,
At this juncture, the osteotomies are performed. An straight osteotomes can be used; however, one must be
oscillating saw with a straight blade less than 1 cm very careful not to fracture the mandible, and I prefer
wide is used; the osteotomy is performed from the supe not to use these to any great extent.
rior to inferior direction as one moves from buccal to Once the osteotomies are completed, the specimen
lingual. can then be retracted and the conclusion of the resection
of the genioglossus muscle can be performed (Figure
29-14). The specimen should be marked for frozen
section. The entire sublingual gland and specimen can
I use an oscillating saw to make the posterior and then be removed.
anterior vertical cuts through the alveolar ridge. Then Reconstruction is performed. Smaller defects can be
using a sagittal saw, the anterior-to-posterior cortical closed with a skin graft. Larger defects are better suited
for the radial forearm free flap.
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in this chapter contain a great deal of real-world of cancer of the oral cavity and oropharynx. Otolaryngol
wisdom and pearls from very experienced Head Neck Surg 129:713-719, 2003.
surgeons related to the nuances of these surgeries Rothman K, Keller A: The effect of joint exposure to alcohol
that can make exposure, hemostasis, and and tobacco on risk of cancer of the mouth and pharynx.
controlled excision much more straightforward. J Chronic Dis 25:711-716, 1972.
There are really no significant disagreements Salgarelli AC, Sartorelli F, Cangiano A, Pagani R, Collini M:
related to any of the excisions but much Surgical treatment of lip cancer: our experience with 106
cases. J Oral Maxillofac Surg 67:840-845, 2009.
controversy and disagreement in terms of what
Shah JP, Lydiatt WM: Buccal mucosa, alveolus, retromolar
constitutes the best method of achieving the most
trigone, floor of the mouth, hard palate, and tongue tumors.
functional tongue reconstruction. The In Thawley SE, Panje WR, Batsakis JG, Lindberg RD,
disagreements likely underscore that there are editors: Comprehensive management of head and neck
significant factors that go beyond the technique of tumors, 2nd ed, vol. 1. Philadelphia, 1999, Saunders, pp
the surgery itself that ultimately determine the 686-687.
overall functional outcome. JICohen Silverman S Jr, Gorsky M, Lozada F: Oral leukoplakia and
malignant transformation: a follow-up study of 257 patients.
Cancer 53:563-568, 1984.
Suggested Readings Slaughter DP, Southwick HW, Smejkal W: “Field canceriza
tion” in oral stratified squamous epithelium: clinical impli
Bernhart BJ, Huryn JM, Disa J, Shah JP, Zlotolow IM: Hard cations of multicentric origin. Cancer 6:963-968, 1953.
palate resection, microvascular reconstruction, and pros Yamauchi M, Yotsuyanagi T, Ezoe K, Saito T, Yokoi K, Uru
thetic restoration: a 14-year retrospective analysis. Head shidate S: Estlander flap combined with an extended upper
Neck 25:671-680, 2003. lip flap technique for large defects of lower lip with oral
Blot WJ, McLaughlin JK, Winn DM, Austin DF, Greenberg commissure. J Plast Reconstr Aesthet Surg 62:997-1003,
RS, Preston-Martin S, et al: Smoking and drinking in rela 2009.
CHAPTER
Extended Approaches to the Oropharynx:
30 Mandibular Swing and Cheek Flap
Author William M. Lydiatt
Commentary by Bruce H. Campbell, David W. Eisele, and Jonas T. Johnson
Preoperative Considerations well as on physical examination. Examination under

anesthesia provides the best means of determining
for Both Approaches involvement.
Access to the oropharynx can be achieved transorally
using the cheek flap or via the more aggressive approach
using the mandibular swing. A careful weighing of Dental occlusal views and panoramic radiographs can
the risk-to-benefit ratio is necessary in deciding which be helpful in this assessment. DWEisele
approach should be used. The decision rests on achiev-
ing adequate exposure balanced with the morbidity
of each approach. Oncologically adequate resection Invasion of the mandible is a contraindication for
margins and safe access to vital structures (exposure) are mandibular swing. A mobile tumor is highly unlikely to
paramount. involve periosteum and can be safely resected using the
The cheek flap provides additional exposure over mandibular swing approach.
the oral route to perform a posterior marginal resection Patients with a history of previous irradiation do
of the mandible and can be converted to a segmental not have an absolute contraindication to mandibular
resection if intraoperative findings dictate. A mandibu- swing but the risk of osteoradionecrosis and failure
lar swing approach is ideally suited for cancers of the of mandibular union should be weighed against the
base of the tongue that extend onto the tonsillar fossa improved exposure achieved. Detection of tumor extent
that do not involve mandible. is also somewhat more difficult and may mitigate against
mandibular swing and in favor of composite resection
of the lateral mandible or an approach via a lateral
I agree that the chief consideration is exposure to
pharyngotomy.
achieve an appropriate resection with preservation
of vital structures and hemostasis. Under some
circumstances the surgeon must also be able to I think about exposure as I examine the patient in
execute a reconstruction. My bias is that some the office. It is essential to know the deep limits
patients can be satisfactorily resected using a and the posterior limits of the tumor. If these issues
transoral approach. Use of a cheek flap gives some cannot be answered in the office I usually plan for an
limited extra exposure; however, the mandible and open (mandibular splitting) procedure. Involvement of
dentition remain “in the way.” Therefore, in my hands the periosteum of the mandible can be treated with a
when transoral resection is not realistic, I usually go marginal resection of the bone. Invasion of the bone
directly to a mandibular splitting or mandibular requires segmental resection. When there is bone
resection procedure. JTJohnson invasion, I believe the minimal bone resected should
be the entire mental canal—the surgeon does not
want to do a fancy reconstruction only to find that the
The morbidity of each procedure must be weighed:
bone margin was involved. JTJohnson
facial incision, permanent numbness of the lower lip,
and temporary edema of the face that ensue with the
cheek flap versus risk of mandibulotomy with attendant The reconstruction method should also be accounted
failure of osteotomy to heal for mandibular swing. for in this decision-making process. The pectoralis
Preoperatively an assessment that can determine major myocutaneous pedicled flap is likely to be bulky
whether the tumor is mobile from the mandible is criti- and may not be as appropriate if a cheek flap approach
cal. This assessment should be done radiographically as is used.
287
The lateral thigh or radial forearm free flaps are well A tracheotomy allows for a safer airway in the
suited because they provide coverage of the denuded immediate postoperative period when edema of the
lingual aspect of the mandible and provide some bulk in reconstructive flap or the resected tongue can result in
reconstruction of the base of the tongue. If a mandibular airway obstruction. I place a No. 7.5 or 8.0 armor-
swing has been performed, the pectoralis major myocu- reinforced tube and bring it off on the contralateral side
taneous pedicled flap, lateral thigh, or rectus free flap is of the neck under the drapes. It is secured with 2-0 silk
well suited for the resection of the base of the tongue and sutures, one in proximity or attached to the trachea to
lateral faucial arch because they provide coverage of the provide stability and to prevent migration of the tube
denuded lingual aspect of the mandible and provide either into the mainstem bronchus or out the tracheo
some bulk in reconstruction of the base of the tongue. tomy site and the second attaching the tube to the chest
For more limited resections of the base of the tongue and skin to prevent extubation. This is performed in the
with more involvement of the lateral pharynx and tonsil- same sterile field and after prepping and draping but
lar fossa, radial forearm may be the best choice. prior to making the skin incisions.
Some oral pharyngeal defects do not require closure

or reconstruction. The best example is the tonsillar Another option is to initially place a cuffed
fossa, which heals well by secondary intention. A word tracheotomy tube and secure its flange to the neck
of caution here is appropriate, however. When doing with sutures. The respiratory circuit is attached to the
radical transoral tonsillar resection, the ascending tracheotomy inner cannula connector using a flexible
pharyngeal artery should be ligated—while doing the respiratory tube. This tube generally does not interfere
neck dissection—if the pharyngeal constrictor muscles with surgical exposure and obviates the need to
have been included in the resection. JTJohnson change the tracheal tube at the end of the case.
The nasogastric feeding tube is also placed at this
time. DWEisele
Special Equipment and Anesthetic
Considerations
The patient is brought to the operating room with pre- Technique for Mandibular Swing
operative antibiotics with both aerobic and anaerobic
coverage given prior to incision. A timeout is performed
STEP 1. The patient is placed in the supine position and
to verify the appropriate patient side and operation as
the eyes are lubricated, cushioned, and taped by the
well as to confirm the antibiotic has been administered.
anesthesiologist. The skin is marked with a marking pen.
The timeout also allows the surgeon to brief the oper
ating team on the sequence of events. Radiographs, It is critical to mark the midportion of the lip in a
specifically a computed tomography (CT) or magnetic manner without any distortion caused by taping of the
resonance imaging (MRI) scan demonstrating no man- endotracheal tube.
dibular involvement and if the patient is dentate, a
panoramic radiograph to demonstrate the anatomy of
the dental roots for appropriate placement of the osteo
Being able to easily mark the lip incision is another
tomy should be readily available.
advantage of nasal intubation. BHCampbell
I prefer a tracheotomy because it removes the
endotracheal tube from the field, thus providing
better exposure. Keeping the patient nasally intubated
postoperatively is another option in very selected cases. This may best be accomplished prior to intubation
but if it is performed after intubation the tube should
We request nasal intubation on essentially every be completely free of any adherence to the lip so that
patient, even those who will almost certainly require a the midline can be discerned.
tracheotomy. Having the endotracheal tube out of the
way allows for simpler assessment of the tumor.
We find it beneficial to use a marking pen to mark the
Sometimes, tracheotomy is not needed. When it is, it
midline of the lower lip and chin while the patient is
is performed during a break in the operation, for
still awake. This optimizes proper placement of the
example, when waiting for frozen section results. If
midline lower lip and chin incision. DWEisele
tracheotomy is not needed, we often give a dose of
intravenous (IV) steroids (if not contraindicated) well
before the end of the case to decrease postoperative
edema. BHCampbell The line is drawn between the vermilion border and
the mental crease. A triangular wedge is drawn as
CHAPTER 30 Extended Approaches to the Oropharynx: Mandibular Swing and Cheek Flap 289
Following a natural skin crease provides better post-

operative cosmesis, less edema of the upper flap, and a
lower risk of vascular insufficiency.
Local anesthetic may be infiltrated into the lip and
chin sections of the incision.
I prefer a pure vertical straight line through the chin to

avoid a U-shaped contracture of the mentum. In
Incision transitioning from the midline vertical to the neck
incision, I believe it makes sense to make a 90-degree
angle to avoid contracture due to a curved—less than
90 degree—relationship between the two incisions.
In addition, I strongly advocate for keeping the
incision used to expose the neck separate from the
tracheotomy. If the two are inadvertently connected,
they must be closed to prevent contamination of the
neck with respiratory secretions—no amount of
FIGURE 30-1. Outline of the incision and beginning of the antibiotic will prevent the ensuing infection. JTJohnson
incision using electrocautery.
We prefer a midline incision from the lip to the

illustrated in Figure 30-1 to break up the solid line and submental crease. If placed properly in the midline,
diminish contracture. this incision heals inconspicuously. DWEisele
We make a “stairstep” incision at the vermilion border, STEP 2. Prepping and draping are next accomplished.
rather than a triangular wedge in the lower lip.
BHCampbell The patient is prepped with povidone-iodine (Betadine)
paint across the shoulders and both sides of the neck
including the face over the nose and just below the eyes.
The mentum is then circumnavigated back to the The field is then draped with towels that are secured
midline of the neck in the submental crease. with staples to the skin to prevent movement of the
towels. A split sheet is then placed over the entire area
exposing the operative site. A half sheet is draped over
The incision should go widely around the chin and the upper face.
follow the entire natural curve of the mentum. If the
half-circle is too small, the scar will be very
obvious. BHCampbell STEP 3 (Incision). An incision is created beginning at the
vermilion border and extending down to the submental
crease.
The incision is then sloped down to blend into and
then follow a natural skin tension line sweeping up The incision is performed using a No. 15 blade knife.
toward the mastoid tip. The incision is then deepened using electrocautery. The
surgeon holds one side of the lip while the assistant
holds the other, pinching the labial artery (see Figure
We tend to create the horizontal incision in a skin
30-1).
crease about three fingerbreadths below the mandible.
The incision is taken back to a point just behind the
greater auricular nerve and not carried up to the Pinching the lip tightly during the incision really
mastoid tip. The more vertical portions of the incision helps! BHCampbell
(both anterior and posterior) are the most likely to
become hypertrophic and noticeable. BHCampbell
The artery is appropriately cauterized or tied depend-
ing on the caliber of the vessel.
The incision needs to be low enough to provide The orbicularis oris is incised and the surgeon must
access to levels IV and V but should be sloped gently work both intraorally and extraorally, incising mucosa
enough to avoid a U-shaped incision. under direct vision.
The incision is then deepened through the platysma

We like to make as much of the mucosal incision as
muscle using electrocautery. The flap is elevated in the
possible at this point, making it less likely that we will
subplatysmal plane.
inadvertently sacrifice too much normal mucosa later
I prefer to identify the marginal mandibular nerve as
when the field is partially obscured with blood.
it overlies the submandibular gland and then follow it
BHCampbell
anteriorly, thus preserving innervation.
This portion of the dissection is done with bipolar

The incision is made in the labial gingival sulcus
cautery rather than monopolar cautery in order to
leaving approximately 8 to 10 mm of unattached
preserve the integrity of the marginal branch.
mucosa for later reattachment. The incision is carried
BHCampbell
laterally to the point of osteotomy.
STEP 4 (Planning the osteotomy). The site of osteotomy The inferior border of the mandible is the superior
is predetermined based on the panoramic x-ray and is extent of this elevation to lessen the risk of devascular-
made just anterior to the mental foramen. ization of the mandible (Figure 30-2).
The proposed line of osteotomy is outlined with
electrocautery directly on the bone or with a marking
Although the site of the osteotomy is identified at this pen.
point in the procedure, the osteotomy is not made
until more soft tissue preparation is completed and the
bone plate is prepared. BHCampbell
A sterile pencil works great for marking bone.
BHCampbell
In the dentate patient, this is typically between the

ipsilateral-lateral incisor and the bicuspid.
Extraction is typically not necessary; however, if the STEP 5 (Placing the plates). A 2.0 locking compression
distance between the roots is very close, then the lateral plate with three holes on either side of the incision is
incisor is best extracted to avoid injury to the bicuspid bent to the contour of the mandible and placed just
root. below the mental foramen.
The placement of the osteotomy depends to some
degree on the location of the tumor.
We use a 2.0 compression plate with two holes on
A tumor more anteriorly located may require an
each side. All holes are drilled in compression
osteotomy farther toward the symphysis.
mode. DWEisele
Most can be made just anterior to the mental
foramen.
In the edentulous mandible the osteotomy is typi-
cally a straight vertical incision, whereas in the dentate We do not use a compression plate. This is a personal
patient, a stairstep osteotomy works nicely for creating preference. BHCampbell
an interlocking bony fragment.
Using a compression plate ensures that the posterior

We make a paramedian vertical osteotomy in all screws do not enter the inferior alveolar canal and
patients. In dentate patients a central incisor is damage the inferior alveolar nerve. Constant low-flow
extracted and the osteotomy made through the center irrigation from a bulb syringe is maintained during the
of the tooth socket. DWEisele entire drilling process. The hole is irrigated, allowing
dissipation of heat and bone dust. The hole should be
drilled quickly to avoid enlarging the hole.
The incisions are then deepened through the muscu- Both cortices should be engaged, the drill bit size is
lature until bone is reached. The incision in the neck can 1.5 mm for a 2.0 plate, and should be long enough to
be performed either with a No. 15 blade knife or elec- just be palpable 1 to 2 mm beyond the inner cortex of
trocautery on the cutting mode. the mandible.
If cautery is used, sufficient perpendicular tension The appropriate screw length is determined using the
must be applied so that the skin is not cauterized depth guide and is typically a 10- or 12-mm screw
excessively. length.
Mandible
Mental nerve
Incision
FIGURE 30-2. Holes are predrilled

and the incision is designed in a
stairstep fashion.
All drill holes are performed and screws placed, If the lateral incisor and bicuspid are in very close
making sure that they are tightened adequately but not proximity, I prefer to extract the lateral incisor and
excessively. If a screw feels loose, an emergency screw make the osteotomy through the midportion of the
slightly larger should be used. socket. A malleable retractor or a No. 9 dental elevator
is placed through the mylohyoid muscle on the lingual
surface of the mandible to ensure the blade does not cut
STEP 6 (Removing the plates and screw). The screws too deeply after it transects the inner cortex.
are then backed out and marked so that the exact screw The bone edge is then cauterized. There may be some
is associated with each hole in the plate. bleeding from the symphyseal portion as well. Bone wax
is usually not required.
The plate is marked signifying anterior and posterior
ends and screws are then numbered from anterior to
posterior and kept on the sterile back table for later I agree. Bone wax in the osteotomy site is a foreign
reapproximation of the mandible or placed in a caddy. body. BHCampbell
If 2.0 plates are used, an additional plate along the
superior mandibulotomy is helpful on larger mandibles.
A bone hook is then used to retract the mandible
laterally as the mylohyoid is transected.
This plate uses monocortical screws. BHCampbell
A large Weitlaner retractor works great for stabilizing
the bone segments, as well. BHCampbell
STEP 7 (Creating the osteotomy). The osteotomy is per-
formed with a sagittal saw.
Again, copious irrigation is utilized and the previ- The mylohyoid, digastrics, and mucosa are transected
ously defined incision line is followed. carefully as the swing is accomplished. By keeping the
Care should be taken and the Panorex consulted in field dry, the surgeon can avoid unnecessary injury to
the dentate patient to ensure that injury to the roots the lingual and the hypoglossal nerves. BHCampbell
does not occur.
Tumor
Digastric m.
Mylohyoid m.
Lingual nerve
FIGURE 30-3. Floor of mouth
incision to access the tumor.
I prefer to leave a 5- to 7-mm cuff of mylohyoid Depending on the location of the tumor, this incision
attached to the mylohyoid ridge for later reattachment. is carried posteriorly to within approximately 1.5 to
2 cm of the visible and palpable malignancy.
For a lesion that involves the anterior tonsillar pillar,
STEP 8 (Placement of mucosal incisions). The mucosal the mucosal incision should then extend up onto the
incision is now made from the point of osteotomy lin- ascending ramus and may or may not involve the retro-
gually approximately 8 to 10 mm perpendicular to the molar trigone, depending again on the exact location of
inner cortex of the mandible just lateral to the subman- the tumor. See Chapter 32 for a complete discussion of
dibular duct. lesions of the base of tongue, tonsil, or soft palate.
The incision then runs parallel to the mandible, As a general rule, think of the mandible as being part
leaving a cuff of mucosa of approximately 8 mm for of the lateral flap of tissue that is being elevated off of
later reconstruction (Figure 30-3). the tumor. By carrying the incision through the floor of
the mouth, up the pharyngeal wall, and over the top
of the tumor, the mass is freed away from the structures
of the carotid sheath. This makes mobilization of the
tumor much simpler and safer. BHCampbell
When the tumor involves the periosteum, marginal
resection of the mandible can be considered. This can
be combined with the mandibular split; however, the A Sweetheart retractor is used to provide exposure
potential for nonunion is increased. Plating the entire by moving the tongue out of the way.
mandible helps protect against future pathologic
fracture. Unfortunately this requires extensive We use 2-0 silk sutures liberally to retract the
periosteal elevation. Mandibular split should never be tongue. DWEisele
accomplished with marginal resection if the patient
has had prior radiation therapy. In most cases it is
preferable to choose between marginal mandibular By moving from the contralateral side toward the
resection and mandibular splitting approach and not tumor a better appreciation of the posterior palatal
combine the two. JTJohnson margins and the lateral pharyngeal margins can be
accomplished.
The hypoglossal nerve is preserved particularly for

Be careful to not traumatize the uvula because it may
its anterior branches. The posterior branches to the base
be useful for soft palate augmentation in select
of tongue will likely need transection and sometimes the
cases. DWEisele
entire nerve for more anteriorly located tumors.
An Allis clamp is placed on the uvula and the assis-

tant retracts toward the tumor and uses a Yankauer STEP 10 (Posterior incisions). The medial pterygoids
suction for smoke, saliva, and blood evacuation. The insert into the posterior aspect of the mandible and are
surgeon uses electrocautery and a Cushing forceps to transected either as part of the resection specimen or
provide counterretraction. to provide access.
Because the tumor is likely to be within a centimeter

STEP 9 (Preserving the lingual nerve). After the mucosal of the periosteum of the mandible, I make my incision
incision is made and prior to transecting the mylohyoid, with electrocautery directly onto the bone of the lingual
the lingual nerve is identified and preserved. cortex and up onto the alveolar ridge. A No. 9 dental
elevator can then be used to ensure that the periosteum
The nerve is kept medial to the dissection but the easily elevates and that there is nothing to indicate
nerve does cross from medial to lateral and a decision tumor involvement.
whether to preserve or resect the nerve must be made.
If the nerve can safely be preserved oncologically, this This is a key step in the assessment of mandibular
is ideal. However, it also provides somewhat of an cortex invasion by tumor. DWEisele
obstacle, and a vein retractor or nerve hook may be
necessary to keep the nerve out of the operative field for
Continue the posterior dissection through the medial
smaller lesions.
pterygoids, mindful of the location of tumor and previ-
ous mucosal incisions that extend onto the palate.
Many times, the lingual nerve is the only remaining
structure bridging the gap between the mandible and Extensive resection of the pterygoid muscles results in
the tongue. BHCampbell postoperative scarring and contracture with resultant
trismus. These patients benefit from full-thickness
Most T3 or T4 lesions in this area that involve the reconstruction but all have limited motion. JTJohnson
anterior tonsillar pillar and base of tongue are in such
close proximity to the nerve that preservation may be This dissection is carried posteriorly until it is felt
unwise. If the nerve is to be sacrificed I use the cutting the exposure is not adequate to make the posterior
mode with a quick transection of the nerve posteriorly mucosal incisions.
and anteriorly. If they can be easily visualized, they can be made at
this time. However, I prefer to remove the base of tongue
portion prior to making these final incisions across the
If the nerve must be sacrificed, we send a section
lateral pharyngeal wall because it is more readily done
of it to pathology. Having large nerves demonstrate
under direct vision with the bulk of the tumor and base
perineural spread is an important prognostic
of the tongue being retracted outside the mouth.
factor. BHCampbell
These dissections are difficult. It is always wise to

The sublingual gland is elevated out of the bed of
work from “easiest to hardest” and “known to
the floor of the mouth and taken anteriorly to resect the
unknown.” BHCampbell
majority of the sublingual gland.
The glossectomy is next performed using vision and

Because of its appearance and texture, the sublingual
palpation as the guide as described in Chapter 33.
gland can look like cancer. A frozen section can be
At least 1 to 1.5 cm of normal tissue is used as the
helpful. BHCampbell
margin.
Using the cutting mode, the mucosal incision is taken
There may be an attachment anteriorly that can be back posteriorly to the circumvallate papillae. The glos-
transected. It is then kept as part of the specimen as we sectomy is then performed using primarily the coagulat-
move from anterior to posterior; again preserving the ing current; the complex interlacing intrinsic tongue
lingual nerve if oncologically feasible or resecting it if musculature ultimately gives way to the more longitu-
needed. dinally oriented extrinsic tongue muscles.
We have found the plasma knife to be particularly When approaching the hyoid for oropharynx tumors,
useful in performing the glossectomy. DWEisele we try to dissect both the hypoglossal and superior
laryngeal nerves prior to making the pharyngeal
mucosal cuts. BHCampbell
These are all taken as part of specimen.
The lingual artery requires identification and ligation
with 3-0 silk suture. Finally, the posterior pharyngeal margins can be per-
A towel clamp or a 2-0 silk suture works nicely for formed. The resection may extend up to the fossa of
retraction of the tongue, which the assistant holds while Rosenmuller and may also include a portion of the torus
the surgeon works the specimen. tubarius if necessary.
I prefer to use my fingers as the primary retractor If this is not oncologically necessary, care should be
once I have transected approximately half of the base taken not to damage the eustachian tube orifice to lessen
of the tongue. This allows me to continually feel the the risk and longevity of postoperative serous otitis
extent of the tumor. media.
This is an excellent point. A dry field, excellent STEP 11 (Obtaining frozen sections). The specimen
visualization, and constant palpation are absolutely should then be marked with sutures to determine ante-
critical. BHCampbell rior tongue margin and superior pharyngeal margin.
Keeping track of the margins on this large and very

This is an important method to ensure an adequate complicated specimen is difficult but essential—
margin of resection around invasive tumors. DWEisele another strategy is to take “new margins” from the
patient after the main specimen has been removed.
These are carefully labeled and sent to the pathologist
I also use Cushing forceps or a 2-0 silk suture to for frozen section. Any tumor observed at all calls for
provide retraction and counterretraction. further tissue removal. JTJohnson
A wedge resection is performed.
The apex of the wedge is typically at the location or
just posterior to the circumvallate papillae just to The pathologist ideally will come to the room or one
midline or across midline by transecting the extrinsic member of the surgical team takes the specimen to
tongue musculature and the medial pterygoids. pathology for orientation because this is a complex
The specimen can then be drawn underneath the specimen and miscommunication can result in errone-
retracted body of the mandible, exposing the base of ous frozen section information.
tongue and vallecula.
The lingual tonsil tissue can sometimes be more
difficult to discern normal from abnormal; therefore This step is important to ensure clinicopathologic
palpation is frequently used. correlation especially if the specimen orientation
requires explanation, the tumor margins have been
disrupted, or the specimen has not been removed
en bloc. DWEisele
The base of the tongue presents the surgeon with
some challenging moments when it comes to
separating tumor from normal tissue. I find that input STEP 12 (Reconstruction). The wound is then carefully
from the pathologist and the use of frozen section is inspected to ensure hemostasis. The neck dissection
essential. JTJohnson can be performed while awaiting the results of the frozen
section and the defect can be evaluated and measured
to confirm that the reconstructive option planned pre-
operatively is the appropriate one.
The incision can extend into the vallecular space and
ideally will leave some of the base of tongue muscula- We prefer to perform the neck dissection prior to
ture at that level. resection of the primary tumor. This can provide
The hyoid bone may be exposed for larger, more improved access to the primary tumor and enhanced
invasive tumors, although this is not necessary for most inferior tumor clearance. DWEisele
T3 or smaller tumors.
The mylohyoid is closed in the case of the radial

In cases that combine a mandibulotomy and neck
forearm or left open in case of the pectoralis flap.
dissection, we usually perform the neck dissection
Mucosa is closed with interrupted 3-0 Polysorb.
first. This allows us to identify and protect the vessels
The mandible is reapproximated using the previ-
and nerves prior to the mandibulotomy and improves
ously applied plates. The orbicularis oris must be closed
visibility for difficult parapharyngeal dissections.
very carefully. I prefer a series of simple sutures reap-
BHCampbell
proximating the muscle first, then closing the vermilion
border to ensure it is even. This is done with interrupted
5-0 Prolene.
The base of tongue should be reapproximated. The mucosa of the lip can then be reapproximated
Because a wedge resection has been performed the apex with interrupted 3-0 Polysorb. The mentum and lateral
of the wedge is closed together with deep 3-0 horizontal flap are then reapproximated using deep interrupted 3-0
mattress Polysorb. Polysorb.
Typically two well-placed sutures bring approxi- Skin is closed down to the mental crease with 5-0
mately 30% to 50% of the tongue back, forming a Prolene. Suction drains are placed in the neck and pec-
sufficiently muscular base of tongue for swallowing. toralis site. The neck is closed by reapproximating the
However, the ipsilateral 40% to 60% of the defect platysma with interrupted 3-0 Polysorb and closing
requires additional bulk and the pectoralis flap works skin with a 4-0 subcuticular absorbable monofilament
nicely. suture.
As mentioned, microvascular reconstruction is also an The lip should be closed with fine suture. I routinely
excellent option. BHCampbell close skin with staples. JTJohnson
If the resection is limited to the tongue base, most Technique for Cheek Flap
defects can be closed primarily by “shortening the If a cheek flap is to be performed, the approach is
tongue.” The exception is a patient who has been similar to that of the mandibular swing. The incisions
previously irradiated. JTJohnson are the same as outlined previously.
Several mucosal sutures can be applied to the base

In some instances the incision need only be carried
of the tongue as well closing off the apex. Again the
around the mentum and the flap extended only to the
apex of the wedge and the pectoralis flap skin are then
mental foramen. This allows improved access to the
sewn directly to the base of the tongue. Tension from
posterior horizontal ramus of the mandible and part
the muscle and gravity over time work to pull the muscle
of the oropharynx without sacrificing lower lip
inferiorly.
sensation. BHCampbell
This of course is the chief disadvantage of the

pedicled flaps. Gravity pulls them down and tends to As in the mandibulotomy approach, the orbicularis
result in wound separation. A free flap is lighter but oris is incised, and the surgeon must work both intra-
requires more time and expertise and has some orally and extraorally, incising mucosa under direct
different donor site issues. JTJohnson vision.
The incision is made in the labial gingival sulcus,
leaving approximately 8 to 10 mm of unattached
mucosa for later reattachment. This incision is carried
Anchor sutures into the maxillary tuberosity help all the way to a point lateral to the retromolar trigone.
suspend the flap; however, this is the most tenuous The dissection is down to but not through the peri-
aspect of the blood supply, and necrosis here is not osteum. Sacrifice of the mental nerve is necessary in this
infrequent because it is primarily a random pattern. approach, and the patient must be cautioned about
The vessels from the radial forearm flap can be numbness of the lower lip (Figure 30-4). The resection
threaded underneath the mandible just posterior to the is then performed as per Chapter 29 and the previous
most posterior attachment of the mylohyoid muscle. discussion.
Tumor
FIGURE 30-4. Flap elevation with

nerve sacrifice.
My bias is that the cheek flap is best used when

Postoperative Considerations
marginal resection of the mandible is required because The patient is fed via a nasogastric (NG) tube. The
of involvement of the periosteum. JTJohnson tracheostomy tube is changed to a cuffless tube at
approximately day 4 or 5 depending on edema in the
posterior pharynx. I make a determination as to the
ability of the patient to swallow.
The need for a cheek flap is infrequent with enhanced If it looks like the swallowing function is severely
cheek retraction by assistants. Other options include impaired and the mouth is full of saliva or there is a
combined transoral-transcervical approaches that high likelihood of adjuvant chemotherapy or radiation
obviate the need to split the lip. DWEisele therapy, I prefer to place a gastrostomy tube early in the
hospital stay so that the patient and his or her caregivers
can become accustomed to its presence and learn to
deliver tube feeding and medication.
Closure of this flap requires careful reapproximation
of the gingival and buccal mucosal incisions. Start pos-
teriorly and move anteriorly, making sure neither side
I think we should try to predict the expected functional
is advanced more than the other by frequently bringing
disability. A percutaneous endoscopic gastrostomy
the flap together at the lip. Next the orbicularis oris is
(PEG) can be easily introduced during the initial
approximated using sutures of 3-0 Vicryl, making sure
surgery if delayed oral feeding is to be expected
the depths are similar on both sides.
based on prior disability or extent of soft tissue
The vermilion border can next be approximated
resection. JTJohnson
with a 5-0 nylon or Prolene suture. This verifies that the
flap is brought back in appropriate proportions. The
platysma is closed also with 3-0 Vicryl. Finally, labial Swallowing rehabilitation can still be performed
mucosa of the lip split and skin of the lip and neck can with a gastrostomy tube but nutrition will not be
be closed. compromised.
We wait to initiate swallowing therapy until after the broad acceptance until the advent of mandibular
tracheotomy tube has been removed and the plating technology in the 1980s (primarily designed
tracheotomy wound has healed in order to optimize for trauma but adapted to this situation) allowed
swallowing mechanics. DWEisele for better stabilization of the mandible after
osteotomy and therefore more predictable healing.
This is especially important if postoperative
Early ambulation is strenuously encouraged to radiation is planned as is most often the case with
decrease the risk of pulmonary and thromboembolic tumors of a size that require this approach in the
complications. These patients are at higher risk for aspi- first place.
ration and I place them on either H2 blockers or proton Nevertheless, the success or failure of these
pump inhibitors. Decannulation is performed as soon approaches to expose the tumor adequately for
as possible if the cuffless tracheotomy tube can be safely excision and to heal with a minimum of functional
plugged and the patient adequately oxygenated. The deficit still depends on attention to detail—both
tracheotomy site is closed with benzoin, Steri-strips, and in terms of appropriate patient selection and
gauze sponges. the technical aspects of the resection. These
details are nicely outlined by the author and
commentators. JICohen
My practice is to deflate the cuff on the tracheotomy

tube when I think the patient is likely to be able to
protect his or her own airway. Fits of coughing are Suggested Readings
always a sign of aspiration and indicate need for
Bolzoni A, Cappiello J, Piazza C, Peretti G, Maroldi R, Farina
continuation of the cuffed tracheotomy tube. If the D, Nicolai P: Diagnostic accuracy of magnetic resonance
patient can control his own secretions without imaging in the assessment of mandibular involvement in
aspiration, I downsize the tracheotomy tube to a oral-oropharyngeal squamous cell carcinoma: a prospective
smaller uncuffed tube and plug it overnight. If the study. Arch Otolaryngol Head Neck Surg 130:837, 2004.
plugged tube is tolerated overnight, it indicates to me Cantù G, Bimbi G, Colombo S, Compan A, Gilardi R,
that the tracheostomy is no longer needed and can Pompilio M, et al: Lip-splitting in transmandibular resec-
safely be removed. JTJohnson tions: is it really necessary? Oral Oncol 42:619-624, 2006.
(AJCC) Cancer Staging Manual, 7th ed. New York, 2010,
Springer.
Complications include an oral or pharyngocutane- McGregor IA, MacDonald DG: Routes of entry of squamous
ous fistula, flap loss, either partial in the pectoralis cell carcinoma to the mandible. Head Neck Surg 10:294,
major situation or total in the free flap, pneumonia, 1988.
deep venous thrombosis, and wound infection, hema- McGregor IA, MacDonald DG: Patterns of spread of squa-
mous cell carcinoma within the mandible. Head Neck
toma, or seroma.
11:457, 1989.
NCCN Treatment Guidelines, 2010. Available at www.
NCCN.org.
Rao LP, Das SR, Mathews A, Naik BR, Chacko E, Pandey M:
EDITORIAL COMMENT: The concept of
Mandibular invasion in oral squamous cell carcinoma:
mandibular osteotomy for exposure of oral cavity investigation by clinical examination and orthopantomo-
and oropharyngeal lesions has been around for a gram. Int J Oral Maxillofac Surg 33:454, 2004.
long time—it is an approach that allows even the Shaha AR: Mandibulotomy and mandibulectomy in difficult
relatively inexperienced operator a degree of tumors of the base of the tongue and oropharynx. Semin
exposure that is unparalleled by other mandible- Surg Oncol 7:25-30, 1991.
sparing approaches. However, delayed or Spiro RH, Gerold FP, Shah JP, Sessions RB, Strong EW: Man-
nonunion of the osteotomy had held back its dibulotomy approach to oropharyngeal tumors. Am J Surg
150:466-469, 1985.
CHAPTER
Transoral Robotic Surgery
31 Author Neil D. Gross
Commentary by F. Christopher Holsinger, Jeffery Scott Magnuson, and Catherine F. Sinclair
Overview indications related to the primary tumor. JSMagnuson/

Transoral robotic surgery (TORS) is U.S. Food and CFSinclair
Drug Administration (FDA) approved for the treatment
of benign and malignant tumors of the oral cavity and
oropharynx. The procedure is broadly defined; however, Indications: The Oncologic Rationale
it is usually applied to tumors involving the palatine and for TORS Is Strongest for
or lingual tonsils. For the purposes of this chapter I
describe in detail the procedure for transoral robotic-
Small-Volume Disease
assisted radical tonsillectomy/partial pharyngectomy, Indications for applying TORS to the treatment of head
which is the most common application. Tips for base of and neck cancers vary greatly and are beyond scope of
tongue procedures are also included. this discussion. That said, I think that TORS is best
suited for early-stage oropharynx squamous cell carci-
nomas (T1-2, N0) with the goal of avoiding radiation
Patient Selection: Staging Endoscopy therapy. I also treat advanced-stage patients with low-
volume disease (T1-3, N1-2b) with the goal of avoiding
Is Unnecessary in Most Cases adjuvant chemotherapy with planned postoperative
A thorough knowledge of the anatomy and appropriate radiation.
robotic training is requisite to successful TORS. Ade-
quate exposure is also paramount. In considering
patients for TORS I am careful to consider potential TORS-assisted resection of oropharyngeal tumors
deleterious patient factors (e.g., obstructive dentition, decreases the need for postoperative radiotherapy
trismus, kyphosis) and tumor characteristics (e.g., large and, in those requiring radiotherapy, significantly
size, extent beyond midline). For these reasons some lowers the dose of radiation required. It also allows a
experienced TORS surgeons recommend routine staging substantial proportion of patients to avoid adjuvant
endoscopy. I have found this unnecessary in most cases. chemotherapy (Alexander et al, 2011, unpublished
data). Compared with open surgical procedures,
TORS-assisted resection of oropharyngeal
Staging endoscopy may be valuable in a minority of malignancies significantly reduces hospital stay and
selected patients in whom there are concerns about decreases long-term tracheostomy and gastrostomy
accessibility or for assessing tumors that may require tube dependence (Dean et al, 2010). JSMagnuson/
free flap reconstruction. JSMagnuson/CFSinclair CFSinclair
Likewise, some surgeons prefer to stage the neck I have found it unnecessary to perform a tracheot-
dissection several weeks following TORS. I have found omy using these indications for TORS. The clinical
it safe to perform a selective neck dissection at the same judgment regarding prophylactic tracheotomy should
time as TORS. be no different for TORS than those for conventional
surgical approaches. Therefore a tracheotomy should be
We routinely perform neck dissections 2 to 3 weeks considered for large-volume cancers treated with TORS.
before or after TORS-assisted resection of the primary
tumor to prevent salivary fistula occurrence (Iseli et al, I agree. For tonsillar carcinoma, tracheotomy is rarely
2009). For N0 disease, selective neck dissections needed. However, for robotic head and neck surgical
(levels 2 to 4) are performed as per standard procedures for the tongue base, I have found that
298
CHAPTER 31 Transoral Robotic Surgery 299
a shoulder roll although adequate exposure is possible

without one. The patient’s arms do not need to be
tucked for TORS but may need to be tucked depending
or
lat
on the method used for suspension laryngoscopy or for
nti
a neck dissection. Sterile draping is not required for
Ve
Anesthesiologist
TORS.
We exclusively use nasal intubation with a nasal RAE

tube through the nasal passsage on the contralateral
side to the tumor. For laser cases we wrap the tube
with saline-soaked cottonoid pledgets. We do not use
a shoulder roll but do extend the neck. Drapes are
Patient cart necessary when laser is used for dissection.
JSMagnuson/CFSinclair
STEP 2. Perform suspension laryngoscopy using the

Feyh-Kastenbauer laryngeal retractor.
I start the procedure with direct laryngoscopy and

Scrub esophagoscopy unless a staging endoscopy was already
Assistant nurse performed. I then secure a large silk suture to the ante-
rior tongue to be used for retraction. The tongue suture
Console Surgeon
is important for manipulation of the tongue during sus-
pension laryngoscopy in order to maximize exposure.
The Feyh-Kastenbauer (FK) laryngeal retractor (Gyrus
AMI, Southborough, MA) is required for base of tongue
procedures (Figure 31-2). More standard retractors
FIGURE 31-1. Proper positioning for transoral robotic surgery (e.g., Crow-Davis, Dingman) can be used for tonsil pro-
(TORS). cedures. However, I use the FK retractor for nearly every
case because it allows superior visualization at the infe-
rior extent of disease, which often includes the glosso-
tracheotomy plays more of a role, especially after tonsillar fold and lateral base of tongue.
patients with previous radiation therapy and for
patients whose procedure and “suspension” time lasts Then I rest the selected oral/oropharyngeal retractor of
longer than 1.5 hours. FCHolsinger choice onto a Goettingen endoscope holder (Karl
Storz 8575), which eliminates the need for resting the
endoscope on the patient’s chest, or worse, using a
We do not perform prophylactic tracheotomy for Mayo stand, which may create a likely source of
TORS-assisted operations. Rarely a patient may need collision with robotic arms or reduce range of motion.
to remain intubated for 24 hours postoperatively; FCHolsinger
however, a perioperative dose of steroid prior to
commencement of the procedure can significantly
decrease any anticipated pharyngeal edema.
JSMagnuson/CFSinclair Robot Setup
STEP 3. Move the patient cart to the bedside and maneu-

ver the robotic arms into a V formation (Figure 31-3).
Patient Setup
Careful positioning of the robot is important to maxi-
mize instrument degree of freedom and minimize robotic
STEP 1. Reverse the operating table and turn it 180
arm collisions. The bed must be lowered to accommo-
degrees to allow the support “legs” of the robotic patient
date the robotic arms over the suspension apparatus.
cart to fit under the bed (Figure 31-1).
The da Vinci S or Si Surgical System (Intuitive Surgical,
Proper patient positioning is critical for TORS. I prefer Inc., Sunnyvale, CA) patient cart with robotic arms is
a nasal intubation except in cases involving the soft positioned as shown in Figure 31-1. TORS uses only
palate or posterior pharyngeal wall. I also routinely use three of the four interactive robotic arms: one camera
Camera
Range of
motion Pivot
points
FIGURE 31-2. The Feyh-Kastenbauer (FK) laryngeal retractor. FIGURE 31-3. Positioning the robotic arms.
(central), two working instruments (lateral). I use a STEP 4. Position the surgical assistant at the head of
0-degree camera for tonsil cases and a 30-degree camera the bed.
facing up for base of tongue cases. I start with monopo-
A properly trained surgical assistant in addition to the
lar cautery in the working arm ipsilateral to the tumor
scrub nurse is important for TORS. The assistant must
and a Maryland dissecting forceps (Intuitive Surgical,
have endoscopic skills because he or she will be working
Inc., Sunnyvale, CA) in the working arm contralateral
off a screen rather than direct visualization. Further, the
to the tumor.
assistant must be familiar enough with the robot to help
troubleshoot potential device malfunction or robotic
arm interference. I have my assistant equipped with
I agree. It is important to have the instrument for suction Bovie, laryngeal suction, and an Autosuture
traction/countertraction on the side contralateral to the Endo Clip III (US Surgical, Norwalk, CT) 5-mm vascu-
tumor; thus I place the energy source for hemostasis lar clip appliers. The primary role of the assistant is to
and tissue cutting onto the robotic arm, ipsilateral to suction smoke and blood. The assistant is also critical
the tumor. This arrangement recapitulates the intuitive for clipping vessels, retracting and applying external
environment of open surgery, but in an endoscopic hyoid pressure intermittently as directed by the primary
environment. FCHolsinger surgeon.
The robotic patient cart is brought in to the bed at an The assistant should hold a suction device in one
angle of 15 to 30 degrees after the bed is rotated 180 hand and some form of tissue retraction device in the
degrees. A 30-degree up-facing camera is also useful contralateral hand to facilitate tissue retraction during
for supraglottic operations. JSMagnuson/CFSinclair the dissection. JSMagnuson/CFSinclair
Monitor
Thumb loop
Middle finger loop
Control
panel Tumor
Clutch
Camera
pedal Bovie
FIGURE 31-4. The robotic surgeon’s console.
The role of the patient-side assistant is critical for a

smooth robotic resection. I have the scrub nurse FIGURE 31-5. Initial mucosal cut.
create a small table, covered with a green sheet,
containing bipolar electrocautery, curved Yankauer
and mini-Yankauer tonsillar suction catheters, Hurd
retractor, and a tonsil tenaculum. Rather than 5-mm
Dissection
clip appliers, I prefer the 22-cm Karl Storz “Steiner”
clip forceps, 8665L or R, which uses the Ethicon STEP 6. Make the initial mucosal cut starting at the
LT100 Ligaclip Extra vascular clips. I use these for palate or superior pole of the tonsil (Figure 31-5).
transoral laser microsurgery and find them more
The mucosal cut is extended from superior to inferior
suited the microsurgical anatomy of the lateral
along the lateral aspect of the anterior tonsillar pillar
oropharynx. FCHolsinger
and pterygomandibular raphe. As with an “open” pro-
cedure, I aim for a 1-cm margin of normal-appearing
mucosa.
STEP 5. Adjust the robotic surgeon’s console for comfort,
and confirm settings (Figure 31-4).
After making these initial mucosal incisions superiorly,
I routinely confirm that the camera selection on console
whenever possible I prefer to make the inferior
matches the camera installed on the robotic patient cart.
releasing incision as soon as the tumor resection
The camera is focused. The camera and robotic arms
permits. This prevents the pooling of blood and
are then maneuvered to check for responsiveness and
secretions in the inferior aspect of the wound,
adequate degrees of freedom. In general, the dissection
obscuring visualization. FCHolsinger
is straightforward if the exposure and robotic arm posi-
tioning are good. Conversely, the procedure can be made
exceedingly difficult or unsafe if the setup is improper.
STEP 7. Dissect through the submucosal muscle layers;
I spend at least an equal amount of time with positioning
palatoglossus and palatopharyngeus muscles superiorly
and setup as I do with the actual dissection.
and superior constrictor muscle anterolaterally (Figure
31-6).
For the Si robotic system, camera confirmation is
automatic. The S robotic system requires that camera Adequate traction and countertraction are important
configuration be confirmed prior to procedure for dissecting the muscle layers. A red rubber catheter
commencement. JSMagnuson/CFSinclair in the nose is helpful to retract the soft palate for tonsil
cancer cases. I have also found intermittent lateral
Palatopharyngeus m.
Palatoglossus m.
Superior constrictor m.
FIGURE 31-6. Dissect through the submucosal muscle layers.
retraction by the surgical assistant using a Hurd tonsil

Thorough preoperative review of the computed
dissector/pillar retractor to be beneficial. At this point
tomography (CT) scan can help identify a more
of the dissection I often use the Maryland dissector
medially placed carotid system. JSMagnuson/
to bluntly push the specimen rather than grasp the
CFSinclair
mucosal edges to avoid tearing the mucosa and muscle
overlying the tumor. For base of tongue TORS, the
submucosal muscle layer is the genioglossus muscle and
I usually identify the medial pterygoid muscle first,
superior longitudinal muscle of the tongue. In these
because this muscle defines a natural lateral landmark,
cases, external hyoid pressure by the assistant is key for
before proceeding more deeply into the
exposure and tissue tension.
parapharyngeal space. According to Huet and
Laccourreye, this maneuver also permits the surgeon
to assess whether the tumor invades microscopically
STEP 8. Use blunt dissection to traverse the buccopha-
into the mandible, which is a contraindication to
ryngeal fascia and enter the poststyloid parapharyngeal
transoral resection. FCHolsinger
space laterally.
The parapharyngeal space is identified by the presence

STEP 9. Apply vascular clips to numerous branches of
of parapharyngeal fat (Figure 31-7). The medial ptery-
the external carotid system that traverse the parapha-
goid muscle may be visualized first and found immedi-
ryngeal space to enter the constrictor muscles (Figure
ately cephalad to the parapharyngeal fat. It is usually
31-8).
possible to visualize carotid pulsations at this point deep
and lateral to the parapharyngeal fat. Further dissection The tonsillar branch of the lesser palatine artery and
laterally should be avoided to minimize exposure of the vein is usually encountered first superiorly and can be
carotid artery. variable in size. It may be possible to simply cauterize
External
carotid a.
Parapharyngeal
fat
Medial
pterygoid m.
FIGURE 31-7. Identification of the

poststyloid parapharyngeal space.
Facial a.
(tonsillar
branch)
Ascending
palatine a.
Ascending
pharyngeal a.
FIGURE 31-8. Apply vascular

clips.
Glossopharyngeus m.
Styloglossus m.
Glossopharyngeal
nerve
Stylopharyngeus
m.
FIGURE 31-9. Divide deep pharyngeal muscles as needed.
these vessels. However, I routinely place vascular clips STEP 11. Complete inferior mucosal cuts.
on any vessel over 1 mm in size in order to minimize
The dissection may include the glossotonsillar fold and
the risk of postoperative bleeding. I leave two clips on
base of tongue depending on the extent of disease. Assis-
the patient side of the specimen. The tonsillar branches
tant retraction and or external hyoid pressure may be
of the ascending pharyngeal and ascending palatine
necessary at this point to fully visualize the tumor.
arterieries can be visualized more inferiorly and are
Rarely adjustment or repositioning of the laryngoscope
handled similarly. Vascular clips should be applied liber-
with possible removal and replacement of the robotic
ally to ensure long-term hemostasis.
arms may be needed to ensure adequate exposure for
surgical margins.
I concur. Hemostasis with small vascular clip is

STEP 12. Rolling the specimen from lateral to medial,
paramount here, not just in the immediate
divide the pharyngeal constrictor muscle, styloglossus
postoperative period. I have found that using these
and glossopharyngeus muscles from superior to inferior
clips reduces the incidence and volume of bleeding on
(Figure 31-9).
postoperative days 7 to 9, when the healing mucosal
eschar generally sloughs. FCHolsinger
A branch of the glossopharyngeal nerve can be identi-
fied between the muscle layers. I have found it possible
to preserve the nerve in many cases. Occasionally a
STEP 10. Continue dissection from superior to inferior
tonsillar branch of the dorsal lingual artery can be
using cautery to divide the remaining superior pharyn-
encountered as well, further highlighting the vascular
geal constrictor muscle.
complexity and variability of the area.
At this level I prefer to leave the buccopharyngeal fascia
intact laterally when possible. I am particularly vigilant
for the carotid artery in this area because it can be found STEP 13. The final mucosal cuts are then completed
more medial at the inferior limits of the dissection. The medially along the posterior pharyngeal wall.
tonsillar branch of the facial artery is traversed at the
inferior portion of the dissection. I apply vascular clips An en bloc resection is feasible in most cases. However,
to this vessel routinely as described earlier. bulky tumors that traverse the glossotonsillar fold may
be better extirpated in two pieces. Regardless, I prefer

We seldom use nasogastric tubes for tonsillar tumors
to complete all mucosal cuts before mobilizing the speci-
but routinely use them for base of tongue resections.
men in order to ensure adequate radial margins.
For posterior pharyngeal wall tumors, the nasogastric
tube should be inserted under direct laryngoscopic
We routinely remove the specimen en bloc and have visualization to prevent formation of a false passage.
not found it helpful to divide the tumor. JSMagnuson/ Postoperatively, patients are commenced on a clear
CFSinclair fluid diet as tolerated, and if a nasogastric tube is
present, this is generally removed at 5 to 7 days
postoperatively. Gastrostomy tubes are occasionally
STEP 14. The specimen is dissected off of the preverte- placed for recurrent tumors and supraglottic tumors.
bral fascia again from lateral to medial and the constric- JSMagnuson/CFSinclair
tor muscles are divided along the medial attachment.
The specimen can then be removed. It is important to

maintain orientation of the specimen to allow accurate Suggested Readings
pathologic assessment. I inspect the specimen carefully Alexander NS, Sullivan BP, Rosenthal EL, et al: Treatment
to check for the closest margins. Frozen section sam- differences between TORS and primary chemoradiotherapy
pling can be helpful, particularly for larger tumors. I for T1 and T2 squamous cell carcinoma of the oropharynx.
prefer to send separate margins for permanent section In press.
analyses. Boudreaux BA, Rosenthal EL, Magnuson JS, et al: Robot-
assisted surgery for upper aerodigestive tract neoplasms.
Arch Otolaryngol Head Neck Surg 135:397-401, 2009.
Dean NR, Rosenthal EL, Carroll WR, et al: Robotic-assisted
Frozen sections are useful; however, while the frozen surgery for primary or recurrent oropharyngeal carcinoma.
sections are being analyzed, we routinely take Arch Otolaryngol Head Neck Surg 136:380-384, 2010.
additional margins that can then be sent for Holsinger FC, McWhorter AJ, Menard M, et al: Transoral
permanent section analyses if the frozen sections are lateral oropharyngectomy for squamous cell carcinoma of
negative. JSMagnuson/CFSinclair the tonsillar region. Arch Otolaryngol Head Neck Surg
131:583-591, 2005.
Huet PC: L’électro-coagulation dans le épithéliomas de
l’amygdale-palatine. Ann Otolaryngol Chir Cervicofac 68:
STEP 15. The wound is inspected for hemostasis before 433-442, 1951.
removing the robotic instruments and taking the patient Iseli TA, Kulbersh BD, Iseli CE, et al: Functional outcomes
out of suspension laryngoscopy. after transoral robotic surgery for head and neck cancer.
Otol Head Neck Surg 141:166-171, 2009.
Bleeding after TORS can be fatal. Therefore I am
Moore EJ, Olsen KD, Kasperbauer JL: Transoral robotic
extremely cautious to ensure hemostasis before termi- surgery for oropharyngeal squamous cell carcinoma: a pro-
nating the procedure. I inspect the wound with a head- spective study of feasibility and functional outcomes. Laryn-
light after the robotic arms are removed and apply goscope 119:2156-2164, 2009.
suction cautery and additional surgical clips liberally. I Weinstein GS, O’Malley BW Jr, Snyder W, et al: Transoral
routinely place a nasogastric feeding tube at the conclu- robotic surgery: radical tonsillectomy. Arch Otolaryngol
sion of the procedure. Head Neck Surg 133:1220-1226, 2007.
SECTION B Operations on the Mandible and Maxilla
CHAPTER
Composite Resection with
32 Segmental Mandibulectomy
Author William M. Lydiatt
Commentary by Terry A. Day, John A. Ridge, and Richard J. Wong
Preoperative Considerations If the patient has not been treated with radiation, the
The fundamental decision as to whether to do a com mandible is seldom invaded unless disease reaches
posite resection or a mandibulotomy for an approach an open tooth socket. When teeth are present, both
to the posterior pharynx is whether the mandible must mandibular height and the teeth themselves limit
be resected segmentally. If there is evidence of man invasion of the jawbone. When the jaw has been
dibular invasion or more than 180 degrees of the man radiated, the tumor is far more likely to transgress the
dible is surrounded by tumor, segmental resection is periosteum and to invade the mandible without having
necessary. to reach tooth sockets. JARidge
The evaluation requires an assessment of the extent

Segmental mandibulectomy is clearly indicated if there of lesion by physical examination and palpation, in
is evidence of medullary space invasion, cortical spection, and radiographic evaluation. Computed
breach, or inferior alveolar nerve invasion. Marginal tomography (CT) scan is reasonably sensitive to cortical
mandibulectomy might be appropriate in selected invasion.
cases of minimal cortical erosion. RJWong
I prefer CT scanning. The imaging used to construct

the stereolithographic model, which I use for
If the tumor is adjacent but appears not to be invad reconstruction, demonstrates bone invasion well.
ing the mandible, a marginal mandibular resection may JARidge
be feasible. However, the surgeon must be confident
that nothing more than a marginal mandibulectomy is
required if a parasymphyseal mandibulotomy is con Magnetic resonance imaging (MRI) can also show
templated as the method of approach. limited cortical invasion and may serve as an alternative
to CT scan. The more posteriorly located the tumor
the more difficult it is to demonstrate on plain radio
graphs. Anterior bony invasion is best demonstrated by
Segmental mandibulectomy may also be indicated if anteroposterior (AP) dental films but these are not prac
marginal mandibulectomy is not feasible due to loss tical for more posterior involvement. Bone scans are
of bone height in the edentulous patient and the insensitive to detecting anything but gross invasion or
associated risk of fracture. RJWong metastatic involvement of the mandible and are not
warranted.
307
coverage given prior to incision. A timeout is performed

Indeed, they are useless. JARidge
to verify the appropriate patient side and operation as
well as to confirm the antibiotic has been administered.
The timeout also allows the surgeon to brief the operat
Preoperative dental evaluation with Panorex, occlusal
ing team on the sequence of events. An examination
evaluation, interdental occlusal planning, and
under anesthesia to verify the extent of tumor is impor
intraoperative splints may be indicated to enhance
tant. Oral intubation with conversion to a tracheotomy
postoperative occlusion and masticatory
provides the safest airway, which will not create an
efficiency. TADay
obstacle when performing the removal of tumor.
The degree of resection is dictated by the extension

of the malignancy. From this approach, posterior oral
I usually conduct the procedure with nasotracheal
cavity and oral tongue tumors and extensive lateral and
intubation and convert to a tracheotomy only after the
base of tongue, buccal, tonsil, and soft palate cancers
resection has been completed. The endotracheal (ET)
can all be resected. The key distinction is the need for
tube seldom represents an impediment to resection.
resection of the mandible. Reconstructive considerations
I run the circuit cephalad, where the circuit is well
are the length of bone resected and the amount of soft
clear of the entire field, and to not cross the chest or
tissue that need to be replaced.
shoulder. JARidge
Also consider the type of tissue to be replaced: skin,

tongue, floor of mouth. TADay
For lateral defects with minimal soft tissue involve
ment, nasal intubation may be considered to avoid
Fibula and osteocutaneous radial forearm flaps tracheotomy.
provide excellent soft tissue. The fibula provides an
excellent length of bone of heavier stock and is suited
for longer and more anterior defects.
I generally consider tracheotomy for even a lateral
segmental mandibulectomy, due to soft-tissue edema
Our plastic surgeons at Memorial Sloan-Kettering and loss of structural support that might cause
Cancer Center rarely use osteocutaneous radial transient postoperative airway obstruction. RJWong
forearm flaps, favoring the stronger bone of the fibular
free flap. Although scapula and iliac crest are
alternative options in selected cases, the fibula is the
most commonly chosen donor site for free tissue In my experience, a tracheotomy proves necessary in
reconstruction. RJWong only about one third of patients undergoing mandible
resection. However, this is contingent not only on the
location and extent of resection, but also the duration
The scapula provides significant soft tissue and the of the procedure and blood loss, which contributes to
best mandibular height of bone but does not span large postoperative edema. JARidge
distances.
I very seldom use a radial osteocutaneous flap, and Performing the mandibulotomy and resection of the
use the scapula primarily in settings in which the primary prior to the neck dissection improves efficiency.
vessels to the lower extremity are inadequate. JARidge It also allows the reconstructive team to plan their
approach while a neck dissection is being performed,
and frozen section margins can be attained while the
Obturation using a palatal appliance may be neces neck dissection is proceeding, thereby minimizing down
sary if soft palate resection is contemplated. time during the operation.
There are two exceptions to this preference. If tumor
extends into level I, this dissection should be performed
Special Equipment and with the ablation of tumor. Second, with extensive
tumors involving the external carotid artery system, a
Anesthetic Considerations neck dissection may need to be done first for control of
The patient is brought to the operating room with pre the carotid vasculature prior to resection of the primary
operative antibiotics with both aerobic and anaerobic malignancy.
CHAPTER 32 Composite Resection with Segmental Mandibulectomy 309
I almost invariably perform the neck dissection first, A transverse incision affords better appearance in the
which allows me to evaluate the quality of the vessels long run, but damage to the contralateral mental nerve
that will be used for free-tissue transfer. The must be avoided, and adequate exposure of the
examination under anesthesia (EUA) (mentioned primary tumor should not be sacrificed in the pursuit
earlier) is sufficient for planning the reconstruction. of cosmetic result. JARidge
Occasionally I define margins and send specimens for
frozen section at the EUA. JARidge
Incisions can then be injected with 0.25% bupiva
caine hydrochloride (Marcaine) with epinephrine to
Operative Steps facilitate hemostasis and for preemptive analgesia.
STEP 1. The table is rotated 180 degrees, with the anes-

I never do this. Postoperative incision pain is not an
thesia circuit positioned and secured out of the operat-
issue after flap elevation in what are usually long
ing field.
procedures, and attention to depth of incision
Compression stockings, a warming blanket, and Foley eliminates the need for epinephrine injection. JARidge
catheter are placed.
STEP 3. In the supine position, the patient is prepped

and draped in a sterile fashion using towels to outline
It is almost impossible to prevent anesthesiologists
the area of operation.
from placing an arterial line in these patients. Those
with an upper extremity donor site often benefit from
This should include the ipsilateral neck, contralateral
placement of a central venous catheter. I use the
neck, and trachea, below the clavicle if a free flap is
subclavian vein contralateral to the tumor. JARidge
contemplated for reconstruction and below the costal
margin if a pectoralis major myocutaneous flap is con
templated. The drape should expose the mastoid tip and
STEP 2. The skin incision is mapped out using natural
earlobe as well as the tragus, and above the nose includ
skin creases extending from the mastoid tip across the
ing the mouth. An intraoral prep is also performed and
neck and across the midline, continuing in a natural skin
is included in the field.
crease toward the contralateral mastoid tip.
The length of this incision depends on whether a con

tralateral neck dissection is performed and how far STEP 4. If a tracheotomy is to be performed, it can be
anterior the mandible needs to be exposed. The farther done now through a small vertical incision with a No. 7.5
the anterior extent of the mandibulectomy, the farther or 8.0 reinforced endotracheal tube (Figure 32-1).
the incision needs to be in the contralateral neck to
allow enough relaxation of the soft tissues for adequate This is secured with a 2-0 silk suture at the trachea and
exposure. again to the skin on the contralateral subclavicular skin
so that the balloon is just below the tracheotomy inci
Although uncommonly needed, the extension of the
sion to prevent mainstem intubation. The endotracheal
neck incision up to a midline lower lip-splitting incision
tube is then placed under the drapes and given to the
can give excellent access and exposure for very large
anesthesiologist.
tumors. RJWong
STEP 5. Using headlamp illumination and loupe magni-

The incision can be extended into a modified Blair fication, the oral cavity and oral pharynx are inspected
incision if needed. This allows slightly more superior and palpated to confirm the extent of the malignancy
exposure. Anteriorly, if a contralateral neck dissection and confirm that the tumor does involve the lingual
is not performed, the incision can be drawn such that aspect of the mandible.
the incision points toward the mentum or slightly across
the midline. This allows for easier elevation of the cheek
flap and exposure; however, cosmetically it is inferior, For base of tongue carcinomas, direct laryngoscopy
and webbing of this incision is relatively common. This might be appropriate to assess relationships between
may be somewhat mitigated by a Z-plasty incorporated the tumor and the supraglottic larynx and lateral
within the incision, but this incision is generally neither pharyngeal wall. RJWong
needed nor advantageous.
Incision
Possible
FIGURE 32-1. Proposed site of incision
extension
incision with extension into a modified
Blair incision. Tracheotomy has been
performed.
I perform the EUA before monitoring lines are I ligate and divide the facial artery as distally as
placed. Rarely, a significant change in plan follows possible, away from the external carotid, to provide
the EUA, affecting positioning and the need for a maximum length for its potential use in the
tracheotomy. JARidge microvascular arterial anastomosis. If there is no
adjacent adenopathy, the proximal facial artery can be
dissected out from the submandibular gland to
provide greater length. RJWong
The estimated locations for the osteotomy should
also be made at this time, confirming preoperative
assessment. This approach allows resection of malig
nancies that involve the mandible, floor of mouth, oral
and base of tongue, tonsil, buccal mucosa, and soft Unless there is bulky disease in level I, I regularly
palate. preserve the facial artery and vein. I preserve
the external jugular vein, and I only cautiously
interrupt any neck vein if free tissue transfer is
STEP 6. Skin is incised and deepened through the
planned. JARidge
platysma.
STEP 7. A subplatysmal flap is elevated across the entire

length of dissection and is taken to the mandible. Level I can be dissected if there is no direct extension
of tumor into the submandibular space. If the cancer
The marginal mandibular branch of the facial nerve extends into this space, it is best kept with the specimen.
must be identified and preserved and elevated with the The remainder of the neck can be done after the speci
flap. The facial artery and facial veins are ligated, expos men is out and while awaiting margins. This provides
ing the periosteum of the undersurface of the mandible. the needed dimensions for the reconstructive surgeon
These vessels may be preserved for microvascular anas and provides efficient use of time while awaiting the
tomosis in some cases. frozen section margin report.
Facial a.
Masseter m.
(retracted)
FIGURE 32-2. Exposure of the

mandible with isolation and
preservation of adequate length of
the facial artery. A level I neck
dissection may be included in the
resection of the primary tumor.
I typically create the tracheotomy and place a feeding An “appendiceal Richardson” is nice for this. JARidge
tube (if needed) while awaiting the pathologist’s
report. JARidge
The elevation of the masseter muscle provides eleva
tion of the entire parotid gland. The posterior margin
STEP 8. The periosteum is incised and the dissection is of the ascending ramus must be done with care. Forceful
carried up over the lower portion of the mandible using retraction or abundant use of electrocautery should be
a No. 9 dental elevator and electrocautery. avoided in this area to avoid injury to the facial nerve
either from excessive retraction or from electrical injury.
Approximately 3 cm of mandible should be exposed The nerve need not be exposed unless substantial dis
anterior to the site of the mandibulotomy. The mental section into the parotid is required due to nodal meta
nerve and artery may be incised because the nerve will stasis or if a modified Blair incision is used.
be transected with the mandibulotomy.
I agree with this important point about the facial nerve
proximity. RJWong
STEP 9. Posteriorly, the masseter muscle is elevated off
its attachment to the lateral mandible (Figure 32-2).
STEP 10. The coronoid process is dissected by removing
This is best accomplished using electrocautery alternat
the insertion of the temporalis muscle as circumferen-
ing between cutting and coagulating current supple
tially as possible.
mented with the use of a No. 9 dental elevator. If the
tumor is confined to the lingual surface of the mandible Care should be taken not to extend the cautery off the
and does not extend superiorly into the lateral pterygoid bone because bleeding can be troublesome in this
musculature substantially, this dissection can be carried location.
up to the mandibular notch and the entire coronoid
process exposed. This dissection is somewhat more dif
ficult because of the lack of direct exposure, but a right- Once the coronoid has been dissected fully, the
angle retractor or an army-navy retractor works well to exposure may be enhanced by “hooking” the bone
expose the coronoid with the direction of the vectors of with a Green retractor, and pulling caudally. JARidge
retraction lateral and superior.
STEP 11. Mouth retraction is provided with a bite block The more posterior condyle and ascending ramus
or molt retractor on the contralateral side; if the lesion that is preserved, the easier the reconstruction will be.
is more posteriorly located, self-retaining cheek retrac- However, complete resection of all tumor is of para
tors work nicely. mount importance and should not be compromised to
facilitate reconstruction. This should be clear from pal
pation and review of the preoperative imaging. In cases
One can also consider a Denhart retractor here. TADay
of recurrence or in postirradiated patients, defining
tumor margins in this area is more difficult and wider
If the lesion approaches the anterior commissure or the margins should be the rule. If the tumor does cross over
upper or lower labial mucosa, double-pronged skin the mandible and extend into the buccal cavity, these
retractors maximize exposure until these incisions are intraoral incisions should be made prior to the elevation
made. of the flap from the mandible.
In this setting, a lip-splitting incision facilitates

STEP 12. Intraoral incisions are created through the
exposure and may permit a more sound oncologic
expected site of mandibulotomy.
resection as noted earlier. Complete resection of the
tumor (with adequate margin) should enjoy the highest
If the area of mandibulotomy is teeth bearing, the
priority. JARidge
appropriate tooth can be extracted and the incision
taken through the extraction site or made between exist
ing teeth. Incisions are performed using 1.5-cm margins around
phenotypically normal tissue, with a non–Teflon-coated
needle-point cautery. Spatula-tip cautery serves best for
If an osteotomy is made between existing teeth, care
incisions once through the mucosa. Coagulating and
should be taken to avoid exposure of the tooth roots
cutting current is set on 25 watts, with cutting current
during the osteotomy. RJWong
on low (Figure 32-3).
Do not take the mucosa of the vestibule too close to One can also consider using the laser as a cutting
the gum where the mandible will be preserved. instrument. TADay
Leaving a “cuff” of mucosa facilitates closure.
JARidge
When I have completed the neck dissection, I switch

Depending on the location of the tumor and whether from a blade to a protected needle-tip cautery and
a portion of the buccal mucosa must be resected, the use it for complete resection of the primary
incision can be completed under direct vision. A promi tumor. JARidge
nent branch of the buccal artery will likely be encoun
tered and should be ligated with suture or HemaClips.
If the tumor is extending into the medial pterygoid The depth of resection in the buccal area is deter
musculature and posterior pharynx, the osteotomy must mined by the histology of the peripheral tumor; dysplas
include the entire ascending ramus, sparing the condyle tic or superficially invasive tumors can be resected with
and condylar neck and as much of the posterior superior margins that extend to but generally do not remove the
ramus as oncologically feasible. buccinator muscle. If there is any sense of invasion
through the basement membrane, the depth should
Preserving more of the posterior superior ramus and
include portions or all of the buccinator muscle. For
condyle facilitates the reconstruction a great deal.
more invasive tumors, a determination of skin resection
TADay
is made by palpating both the intraoral and skin sur
faces to achieve 1 to 1.5 cm of palpably normal soft
tissue.
If, however, no bone reconstruction is being planned If the skin is freely mobile and the tumor does not
for a lateral segmental mandibulectomy, I would not abut the dermis, skin is not resected. If there is any
attempt to preserve any portion of the superior question, however, skin should be resected ideally in an
mandibular ramus. This is because the unopposed elliptical manner to allow primary closure.
pterygoid muscle action on this mandibular remnant
leads to its displacement and protrusion
postoperatively. RJWong STEP 13. The lateral incisions should now be connected
between the oral cavity and the neck and a right-angle
Intraoral incision
Tumor
FIGURE 32-3. Proposed sites of

incisions seen through the mouth
with retractors in position.
retractor used to elevate the remaining buccal mucosa, accomplished with additional plating. This plate must
which is still attached to the upper skin and facial flap. be in a location that does not interfere with the screw
This provides the initial view of the oral cavity through placement necessary for plating of the graft. This plate
the neck. can be placed with two screws in each side just prior to
osteotomies. If the plate is kept superiorly, this causes
At this point, though, there is limited exposure because less interference with subsequent dissections. Ideally, the
of the remaining attachments of the anterior buccal definitive reconstruction plate using a 2.4 locking plate
gingival sulcus. If necessary, a relaxing incision along is fashioned to appropriate position and shape and cut
the labial gingival sulcus will facilitate exposure. Care to fit the defect. This plate is then removed while oste
should be taken to leave an adequate cuff of mucosa for otomies are performed. It is kept on the back table
later closure. exactly in the position it was placed, with the screws in
the same holes for later use with the bone flap or in a
caddy (Figure 32-4).
STEP 14. If bony reconstruction is planned, it is impor-
tant to try to maintain the same dental and mandibular
relationships. This can be accomplished one of two
ways.
In conjunction with the reconstructive team, we use a
If the patient is dentate, the patient can be placed in
previously fashioned plate (which is designed using a
internal maxillary fixation using screws on the contra
stereolithographic model). The plate is used as a guide
lateral side. This provides occlusion of dentition;
for construction of the osteotomies and to drill bone
however, it does not fix the condyle and remaining
appropriately. This approach is frustrated only when
ramus. Ideally, a long reconstructive plate is fixed such
tumor bulk precludes positioning the reconstruction
that the plate maintains the relationship between the
plate. Malocclusion is uncommon. JARidge
severed posterior and anterior mandibular fragments.
Two options are viable.
One is to place a temporary plate to keep the frag
STEP 15. The anterior mandibulotomy should now be
ment positions and occlusion stable. This is sometimes
performed, which greatly enhances exposure.
needed when the tumor extends laterally distorting the
contour of the lateral aspect of the mandible. This is The anterior mandibulotomy is marked by once again
then removed after the reconstruction bony fixation is verifying that approximately 2 cm of normal-appearing
STEP 16. The appropriate posterior osteotomy is now

performed.
Incision
For more anteriorly located tumors a vertical sagittal
osteotomy can be performed between the facial notch
and the mandibular notch. For any lesion that extends
posteriorly to involve the coronoid, the entire ramus
Plate should be resected, preserving the appropriate amount
of condyle if oncologically sound, as discussed earlier.
The condylar head should only be removed from the
glenoid fossa for oncologic reasons. Keeping this in situ
allows for better vascularization of the condylar neck
and bone graft.
It also limits annoying bleeding. JARidge

Incision
After osteotomies are performed the mandible and

tumor can be retracted inferiorly to provide a direct
visualization of the resection bed (Figure 32-5).
STEP 17. The floor of mouth incisions are performed.

FIGURE 32-4. Reconstruction plate conformed to the
mandible, then removed.
The mylohyoid muscle is transected. The anterior bellies
of the digastric may be detached from the mandible in
more anteriorly located tumors. Care should be taken
bone based on the preoperative and intraoperative to preserve branches of the hypoglossal nerve unless a
assessment is present. A 2-cm bony margin should be substantial amount of anterior oral tongue requires
attained because frozen sections are not as helpful or resection. Ipsilateral neck dissections ensure that sub
as practical. mandibular gland obstruction will not be a problem if
the midline is not crossed.
The duct is transected and sublingual tissue can be
removed as well. The lingual nerve will likely require
The anterior arch of the mandible is more difficult to
resection unless the tumor does not extend into the deep
reconstruct. For a smaller anterior carcinoma with
muscles of the tongue or deeply into the posterior
limited bone invasion, it may be reasonable to take a
glossopharyngeal fold.
smaller bone margin if the lesion seems contained and
if this enables you to preserve a portion of the anterior
mandibular arch and avoid an extra osteotomy in the
bone flap, for example. RJWong The nerve is in jeopardy at the ascending ramus of the
mandible as well. JARidge
The rare involved bone margin may be heralded by STEP 18. Using palpation a 1- to 1.5-cm margin of soft
intraoperative “touch preps” of marrow at the proximal pliable tongue should be resected.
and distal bone cuts. JARidge
For anterior lesions the tongue can be resected in a
V fashion, preserving some of the lateral aspects of
the tongue for later reconstruction of a tip. Without
When using the sagittal saw and continuous irriga adequate muscular bulk of the intrinsic tongue mus
tion, a vertical osteotomy is made through both cortices. culature, however, sparing of superficial mucosa is not
The inferior alveolar artery is cauterized. Bone wax may warranted and amputation of the tongue tip is more
be used on the posterior mandible osteotomy if bleeding likely required. As the dissection proceeds through
persists because this will be the higher pressure bleeding, the tongue into the extrinsic tongue musculature, the
but cautery alone should suffice for the anterior geniohyoid and the genioglossus are also transected. A
mandible. 3-0 Polysorb suture can be placed in these for later
Torus
tubarius
Nasopharynx
Oropharynx
Lingual nerve
(cut)
Tongue
(cut)
Mylohyoid m.
FIGURE 32-5. Final defect seen through

the neck. Note the cut edge of the
tongue with the epiglottis visible, the cut
edges of the palate, and the posterior
pharynx.
reattachment to the graft. This will provide anterior The palatine muscles, palatoglossus and palato
projection of the tongue and is important for both swal pharyngeus are next resected and, again, care is taken
lowing function and improved articulation. to maintain an adequate margin. Hemostasis is obtained
using electrocautery. Typically uvular arteries are
encountered that can be cauterized. The tendon of the
STEP 19. For lesions involving the posterior tongue, levator veli palatini is typically resected. The mucosa on
tonsil, and soft palate, such as Figure 32-3, incisions the back side of the soft palate is then transected using
are made under direct vision through the floor of the electrocautery on the cutting mode.
mouth.
The uvula is grasped with an Allis clamp and retracted STEP 20. The incision can then be connected to the
toward the surgeon, 1- to 1.5-cm mucosal margins, posterior buccal incision over the ascending ramus or
attained and using the cutting mode of the electrocau extending up onto the posterior hard palate.
tery, the mucosa is incised and deepened through the
subcutaneous tissue.
Anatomic considerations in palate resection include STEP 21. The maxillary tuberosity may require resection
the fact that the uvula is primarily lymphatic, with a depending on the extension of the tumor superiorly.
small amount of muscle called the musculus uvulae. The
posterior aspect of the soft palate has little active mus
cular contraction, and the majority of the palatal mus STEP 22. Hard palate incisions are also created using
culature is in the middle and anterior aspects. Although the oscillating saw.
the amount of resection is dictated by the size and
location of the malignancy, the uvula should not be
spared because it will make subsequent obturation more STEP 23. Medial pterygoid muscle is transected next
difficult. because it runs from the lateral plate of the pterygoid
The aponeurosis extends from its attachment into process to the medial aspect of the mandible. This is the
the hard palate to near the posterior aspect of the soft critical connection that once freed, allows much more
palate. mobility of the specimen and much clearer exposure.
Every patient (and tumor) is different, but there are I use 3-0 braided polyglactin (Vicryl) sutures for
common threads in management. In essentially all closure, and 4-0 absorbable monofilament to close
such cases, there is a “critical connection” that allows the skin. TADay
enhanced mobility of the specimen and far better
exposure. Typically this results from releasing mucosa
and muscle posteriorly, taking care not to engender
hemorrhage that may be difficult to control with the Postoperative Considerations
specimen in place. JARidge
Feeding is accomplished with a feeding tube for the first
6 or 7 days. This may need to be extended if significant
dysphagia persists.
STEP 24. The base of tongue can now be resected if
necessary.
This is common after a significant anterior
mandibulectomy or pharyngeal resection. I also use a
STEP 25. The specimen is then marked and oriented for gastrostomy tube if postoperative radiation is
the pathologist and frozen section margins are attained. anticipated, though I move patients to a near-normal
diet in advance of radiation (if possible). JARidge
Frozen section margins should be obtained either from
the mucosa of the specimen or if any doubt exists as
to the validity of this representation, tissue from the
The tracheotomy tube should be changed to a cuff
patient side of the resection. Bone margins are more
less tube around day 4 to facilitate articulation and
difficult but can be obtained from the periosteum or by
swallowing. Decannulation should be accomplished
touch preparations of the marrow. Deep soft-tissue
depending on tongue edema, by days 5 to 7. Ambula
margins may be obtained as well and should include
tion as early as feasible is critical to decreasing the
key nerves such as the alveolar or lingual and deep
incidence of deep vein thrombosis.
muscle margins. TADay
EDITORIAL COMMENT: Whereas composite

STEP 26. Neck dissections can now be performed while
resection with mandibulectomy (“the commando
the frozen sections are being done (see Chapter 24).
operation”) was once the most routine approach
The defect size can be estimated including both soft to tumors in this area, an increased understanding
tissue for the skin paddle and the bony length allowing of pathways and mechanisms of mandibular
the reconstructive surgeons to harvest the appropriate invasion by tumor and improved reconstructive
regional or free flap if they have not already done so. techniques for the associated soft-tissue defects
By working simultaneously with the head-and-neck has made its application more limited. However,
ablative surgeon significant operative efficiency is it still has a major role to play in surgical
achieved, lessening the risk of complication through management of advanced oral cavity and
extended anesthetic exposure. oropharyngeal malignancy. Once again the detail
provided here in terms of patient selection and the
I typically define the extent of resection (in nuances of achieving the necessary exposure for
consultation with the reconstruction team) before adequate selection are key to the operation’s
beginning the ablative procedure. Harvesting a fibula success. JICohen
or anterior thigh flap is straightforward with a “two-
team” approach during the tumor resection. However,
we work serially if the donor site is the forearm (to Suggested Readings
limit crowding) or the scapula (due to changes in
patient position). JARidge Bolzoni A, Cappiello J, Piazza C, Peretti G, Maroldi R, Farina
D, et al: Diagnostic accuracy of magnetic resonance imaging
in the assessment of mandibular involvement in oral-
oropharyngeal squamous cell carcinoma: a prospective
STEP 27. One or two suction drains are placed in
study. Arch Otolaryngol Head Neck Surg 130:837-843,
the neck.
2004.
(AJCC) Cancer Staging Manual, 7th ed. New York, 2010,
STEP 28. Closure is accomplished with 3-0 Polysorb Springer.
sutures reapproximating the platysma. Skin is closed Hidalgo DA: Fibula free flap: a new method of mandible
with absorbable 4-0 Caprosyn or 5-0 fast-absorbing gut. reconstruction. Plast Reconstr Surg 84:71-79, 1989.
McGregor IA, MacDonald DG: Routes of entry of squamous NCCN Treatment Guidelines, 2010. Available at www.
cell carcinoma to the mandible. Head Neck Surg 10:294, NCCN.org.
1988. Rao LP, Das SR, Mathews A, Naik BR, Chacko E, Pandey M:
McGregor IA, MacDonald DG: Patterns of spread of squa Mandibular invasion in oral squamous cell carcinoma:
mous cell carcinoma within the mandible. Head Neck investigation by clinical examination and orthopantomo
11:457, 1989. gram. Int J Oral Maxillofac Surg 33:454, 2004.
Militsakh ON, Wallace DI, Kriet JD, Girod DA, Olvera MS, Rogers SN, Devine J, Lowe D, Shokar P, Brown JS, Vaugman
Tsue TT: Use of the 2.0-mm locking reconstruction plate in ED: Longitudinal health-related quality of life after man
primary oromandibular reconstruction after composite dibular resection for oral cancer: a comparison between rim
resection. Otolaryngol Head Neck Surg 131:660-665, 2004. and segment. Head Neck 26:54-62, 2004.
CHAPTER
Transhyoid and Lateral Pharyngotomy
33 Authors William M. Lydiatt and Daniel D. Lydiatt
Commentary by Bruce H. Campbell and Bruce J. Davidson
Transhyoid Pharyngotomy STEP 4. The vallecular space is entered using a curved

metal instrument such as a Yankauer suction placed in
Indications the vallecular space.
The indications for transhyoid pharyngotomy are very
This is most easily accomplished by carefully dividing
few: T1 and T2 tumors of the posterior inferior pharyn-
all of the muscles down to the mucosa of the pharynx.
geal wall that cannot be accessed via transoral, lateral
The tip of the metal Yankauer suction is removed
pharyngeal, or endoscopic routes, and the very occa-
and the instrument is passed transorally into the
sional small low-grade or benign tumor of the lateral
vallecula. The tip is easily seen through the mucosa.
tongue base.
The mucosa is incised and the tips of a small hemostat
A tumor of the posterior wall can be resected under
are placed in the suction. As the suction is withdrawn,
direct vision. Invasive tumors of the tongue base are
the hemostat follows it into the pharynx. The hemostat
contraindicated with this approach because the tumor
is then used to guide the incisions, separating the
may be entered with the approach. Direct invasion
mucosa of the epiglottis from the tongue base as
of the prevertebral fascia is a contraindication to
deeply in the vallecula as possible. BHCampbell
resection.
Anesthesia Considerations STEP 5. Using electrocautery, transect the mucosa of

the base of tongue over the retractor.
Tracheotomy provides an unhindered view of the pos-
terior pharynx and protects postoperatively against As the incision is widened, care must be taken to
significant tongue edema resulting in airway embarrass- avoid the lingual artery and hypoglossal nerves because
ment. Preoperative antibiotics are given for aerobic and they lie on the lateral aspects of the tongue base. The
anaerobic coverage. A timeout is performed and appro- superior laryngeal nerves should be protected as well.
priate computed tomography (CT) or magnetic reso-
nance imaging (MRI) scans should be available for
review of extension of disease. STEP 6. Deaver retractors (large curved metal retrac-
tors) placed to retract the tongue superiorly and the
larynx inferiorly provide good access to the posterior
Operative Technique
wall (Figure 33-2).
STEP 1. A cervical neck incision is created in a Appendiceal retractors are also very effective.
natural skin crease extending from the posterior BHCampbell
sternocleidomastoid (SCM) muscle to the contralateral
posterior SCM. Additional exposure can be obtained by dividing the
hyoid or even resecting the middle third.
Smaller tumors can be allowed to heal by secondary
STEP 2. Subplatysmal flaps are elevated superiorly and intent.
inferiorly. The lateral edges should be imbricated to the con-
strictor muscles to avoid leakage into the neck.
Larger defects may require a skin graft or radial
STEP 3. The suprahyoid musculature is separated from forearm free flap depending on the size of the defect.
the hyoid bone paying special attention to preservation Patients with American Society of Anesthesiology
of both lingual arteries and hypoglossal nerves (Figure (ASA) classification 3 or higher are not good candidates
33-1). for a radial forearm due to the high risk of aspiration.
318
CHAPTER 33 Transhyoid and Lateral Pharyngotomy 319
Hypoglossal
nerve
Lingual
artery
FIGURE 33-1. The curvilinear

incision, with subplatysmal flaps
elevated and beginning of
separation of the suprahyoid
musculature. Special care should
be exercised to avoid injury to
the hypoglossal and superior
laryngeal nerves.
Tumor
Incision
FIGURE 33-2. The use of Deaver retractors and the

entry into the vallecular space using the Yankauer
suction.
Hypoglossal
nerve
Lingual
artery
FIGURE 33-3. Closure of the defect.
STEP 7. Closure of the pharyngotomy is accomplished

by 0 Polysorb or Vicryl sutures placed deeply into the Access to the lateral oropharynx is difficult using this
tongue and around the hyoid bone. approach. Unless a transoral release of the upper and
lateral margins of the resection can be accomplished,
Again special care here is essential because the hypo- this approach should be avoided in these tumors. A
glossal nerve and the lingual artery can be ligated result- mandibulotomy is more likely to be required in lateral
ing in severe complications (Figure 33-3). oropharyngeal tumors. BJDavidson
If the hyoid is divided, it can be wired back together
or merely secured with a figure-eight suture.
Mucosa does not need to be closed. n Very selective resections of small base of tongue
cancers
n Can be used in conjunction with neck dissection
Postoperative Care
The patient should be kept nothing per mouth (NPO)
Anesthesia Considerations
for approximately 5 to 7 days depending on the pha-
ryngeal resection and reconstruction. The patient should Tracheotomy is usually necessary to provide a good
be able to be decannulated in the first 4 to 7 postopera- view of the posterior pharynx and protect the airway
tive days. postoperatively. Preoperative antibiotics with aerobic
and anaerobic coverage are administered. Appropriate
films should be available.
Lateral Pharyngotomy Operative Technique

Indications
STEP 1. Skin incision is usually dictated by the neck
This approach to the oropharynx is rarely used. Indica-
dissection.
tions are as follows:
n Smaller tumors of the oropharynx If unilateral, a low apron flap gives nice exposure to the
n Hypopharynx with partial pharyngectomy neck and pharynx (Figure 33-4).
Incision
FIGURE 33-4. A low apron incision not in

continuity with the tracheotomy incision.
The incision is carried through the skin and platysma STEP 3. Step osteotomy with bone plate preadapted and
muscle and a subplatysmal skin flap is dissected to screw holes predrilled to preserve dental occlusion if
expose the structures of the neck to be dissected. needed.
The hypoglossal nerve is preserved if not involved

with tumor and preservation does not compromise
STEP 2. Neck dissection is completed. exposure.
A lateral pharyngotomy approach is used to resect the It is also important to attempt to preserve the superior
primary site. laryngeal nerve, as well. It helps to dissect the
hypoglossal nerve as far distally as possible into the
tongue musculature. Similarly, the superior laryngeal
Prior to the pharyngotomy, release the digastric nerve is dissected to the entrance into the larynx. Both
tendon and resect the ipsilateral hyoid bone, transect nerves are mobilized. BHCampbell
the ansi hypoglossi, then dissect free the hypoglossal
so the exposure is maximized. Resection of the upper
STEP 4. Digastric and stylohyoid muscles are typically
thyroid cartilage may also be helpful, but the superior
resected.
laryngeal nerve will then need to be managed as
well. BJDavidson The pharyngotomy incision depends on the tumor loca-
tion and is made to establish the lateral margin of tumor
resection by palpation and via a small incision to visual-
Mandibulotomy may or may not be used to enhance ize (Figure 33-5).
exposure to the lateral or posterior pharynx.
After mobilization of the nerves, the pharyngeal
One of the benefits of lateral pharyngotomy is the lack constrictor is divided. This allows a direct view of the
of a bone cut and its potential complications. When pharyngeal mucosa. The mucosal incisions are made
necessary, however, the mandibulotomy gives much on top of an instrument (such as a Yankauer suction)
broader exposure. BJDavidson while keeping the nerves in view. BHCampbell
Hypoglossal
nerve
Tumor
Incision
FIGURE 33-5. The pharyngotomy incision

and the primary tumor. The hypoglossal
nerve is seen preserved and a mandibular
osteotomy has been performed. The
osteotomy is held open with bone hooks,
and a Deaver retractor helps to expose the
primary tumor.
STEP 5. A Yankauer can be used to palpate similar as in The pharyngotomy is closed with two-layer closure
a laryngectomy. similar to a laryngectomy.
This is the key step, and the use of direct visualization I prefer 3-0 Vicryl in an interrupted Connell suture
and palpation of the tumor through the neck and with as the first layer with a second layer of the muscle and
the use of an instrument such as the Yankauer suction submucosa also with a 3-0 Vicryl in either a simple or
are important for incision placement. running stitch (Figure 33-6).
The remainder of resection is performed under direct The osteotomy is reconstructed with the predrilled
visualization achieving at least 1.5-cm margins visually bone plate. Drains are placed and the skin closed in a
and by palpation. two-layer fashion.
As with all head and neck cancers, margin distance Postoperative Care
depends on the type of cancer, prior treatment, and
Oral feedings by fifth to seventh postoperative day.
location. BHCampbell
Decannulation by postoperative days 5 to 7.
Frozen section margins are essential because submu-

cosal spread of disease beyond that which is palpable is
common in this region. EDITORIAL COMMENT: As is clear from the text
Reconstruction is performed after establishment of and commentary, these approaches have limited
negative margins, typically with a radial forearm free application and should be reserved for smaller
flap. tumors in very specific locations with very-well-
defined margins in all three dimensions, otherwise
Smaller defects can be closed primarily. Removing the the exposure will be inadequate for oncologic
lateral part of the hyoid bone can make closure resection. When questions arise, the mandibular
simpler. The closure can be reinforced using the “swing” approach represents a better approach
sternomastoid muscle. BHCampbell because of its versatility and the ability to extend
Graft sutured
into place
FIGURE 33-6. Closure of the defect

with a free flap.
Suggested Readings
the operation (including extensions to one or both
of these approaches) as needed for safe resection. Civantos F, Wenig BL: Transhyoid resection of tongue base
With reasonable assurance of predictable and tonsil tumors. Otolaryngol Head Neck Surg 111:59-62,
mandibular healing through plating technology, the 1994.
concern about mandibular osteotomy that Edge SB, Compton CC: American Joint Committee on Cancer
(AJCC) Cancer Staging Manual, 7th ed, New York, 2010,
previously drove surgeons to seek out these
Springer.
alternate approaches is no longer a significant
Hollinshead WH: Anatomy for surgeons, vol. 1. The head and
consideration. neck, Philadelphia, 1982, Harper and Row, pp 411-441.
However, for very specific situations, Laccourreye O, Seccia V, Ménard M, Garcia D, Vacher C,
pharyngotomies still have application, and the Holsinger FC: Extended lateral pharyngotomy for selected
details provided here can ensure a very limited squamous cell carcinomas of the lateral tongue base. Ann
morbidity in terms of the operation itself, although Otol Rhinol Laryngol 118:428-434, 2009.
the swallowing issues that accompany significant NCCN Treatment Guidelines, 2010. Available at www.
resection of the pharyngeal wall must be NCCN.org.
discussed with the patient. JICohen O’Malley BW Jr, Weinstein GS, Snyder W, Hockstein NG:
Transoral robotic surgery (TORS) for base of tongue neo-
plasms. Laryngoscope 116:1465-1472, 2006.
Stern SJ: Anatomy of the lateral pharyngotomy approach.
Head Neck 14:153-156, 1992.
SECTION A Laryngectomy
CHAPTER
Exam Under Anesthesia for the Patient
34 with Cancer: Direct Laryngopharyngoscopy
and Mucosal Tatouage
Authors F. Christopher Holsinger and Ollivier Laccourreye
Commentary by Eduardo Méndez and Marc Remacle
step in a three-part assessment of head and neck cancer

Preoperative Considerations from the first impression gained by clinical examination
Direct laryngopharyngoscopy (DLP) is the gold stan- in the office (with or without indirect fiberoptic endos-
dard assessment for staging the head-and-neck cancer copy in the office) and subsequent high-resolution
patient, especially for patients with tumors arising in the imaging using computed tomography (CT) or magnetic
oropharynx, larynx, and hypopharynx. resonance imaging (MRI) techniques.
I agree, considering that most oral cavity cancers can With the widespread availability of fiberoptic
usually be well visualized in the clinic. In particular, endoscopes, Garcia’s mirror is less and less used.
tumors arising from or extending to the More recent technologies, such as stroboscopy and
glossopharyngeal fold could be hard to visualize under narrow band imaging (NBI), are also available in many
anesthesia. An exception to this is in situations in departments or offices. MRemacle
which there is significant trismus or pain, which would
limit direct visualization of the oral cavity. EMéndez In most cases the actual mechanics of performing
DLP are less challenging than the interpretation of find-
The objective of the procedure is to discover and to ings. Thus a precise knowledge of both the mucosal
document the primary tumor’s location and associated topography and the underlying bony, cartilaginous, and
tumoral extension. During DLP, regardless of tumor muscular anatomy of each region of the head and neck
location, the clinician must perform both a fixed mor- is essential for accurate tumor staging. Because underly-
phologic tumor mapping as well as a dynamic assessing musculature and associated mucosal folds must be
ment of the region invaded by the tumor. Therefore seen as a highway or obstruction for cancer spread, a
palpation and exploration of the laryngopharynx are detailed knowledge of the points of muscular insertion
essential to successfully performing this procedure. and origin must be considered during DLP. Modern
imaging further supplements the clinician’s appreciation
Palpation of the larynx can only be instrumental. of subtle and otherwise occult examination findings. In
MRemacle summary, DLP is the third dimension of a three-part
examination: clinical examination, CT/MRI, and then
direct examination of the region in the operating room.
I often performed bimanual palpation with one hand
along the neck around the submandibular triangles
Fluorine-18 fluorodeoxyglucose positron emission
(with the thumb on one side and the index and middle
tomography (FDG PET) is efficient for restaging
finger one the other) and the other inside the mouth.
disease in patients with structural abnormalities after
This allows for full assessment of tumor fixation against
definitive treatment of head and neck cancer. For
the mandible and/or laryngeal framework. EMéndez
patients with oral cavity cancer with dental artifacts
on the conventional imaging, PET/CT could provide
DLP should never be seen as a perfunctory obliga- useful clinical information about the primary tumors,
tion of the otolaryngologist–head-and-neck surgeon, particularly in cases with advanced tumors (see Baek
nor merely an exercise to provide tissue for the multi- et al, 2008). MRemacle
disciplinary team. Rather, DLP is the final and decisive
327
328 UNIT IV Laryngopharyngeal Operations
Special Equipment and Anesthetic For some difficult cases, intubation is performed
Considerations under fiberoptic guidance: the fiberscope is passed in
the tube and introduced transnasally into the larynx.
Successful and careful tumor staging by DLP requires
The tube is then inserted into the larynx, using the
close collaboration among the operating surgeon, the
fiberscope as a guidewire. In case of obstructive
anesthesia team, and nursing personnel. The eyes are
tumor, having a tracheotomy set ready is
protected and a suitable dental guard is used.
advisable. MRemacle
In preparation for this procedure, the team must
understand the purpose for the procedure: to perform Technique
tumor mapping? to establish a diagnosis? to assess
STEP 1. Direct laryngopharyngoscopy is performed with
for transoral endoscopic resectability?
a suitable endoscope and a comprehensive assessment
Before the start of procedure it is important to
of the mucosa of the laryngopharynx is made.
communicate about loose teeth or other airway issues
with the entire operative team, including nursing and The technical aspects of direct laryngopharyngoscopy
anesthesia. have been presented earlier. Here we emphasize the
It is also important to discuss issues that would unique objectives of direct laryngopharyngoscopy for
affect exposure, such as trismus or history of cervical the cancer patient, ranging from simply obtaining a
trauma or surgery, that would limit or prevent neck tissue diagnosis to anticipating a plan for later surgical
extension. The tumor location will also dictate a priori resection.
the different scopes that will be needed. EMéndez
When the patient’s airway allows, endoscopy under STEP 2. Biopsy of suspicious lesions or known tumor.
apnea prior to intubation provides the optimal assess-
ment for tumor staging. However, the surgeon must
communicate directly with the operative team to ensure
The Biopsy
the feasibility of the procedure and to ensure that proper Of course the primary objective of DLP is to obtain tissue
equipment is ready and available during the procedure. for diagnosis and/or research. The head-and-neck sur-
If endoscopy prior to intubation is performed, no biopsy geon’s approach should vary with the disease. For
is usually performed. Rigid endoscopes, video tower, instance, in patients with premalignant, equivocal, or
defogging solution, and a slotted laryngoscope are intermediate disease, the depth of the biopsy must be at
required. We routinely apply a 4% solution of lidocaine first superficial and then if guided by frozen section
to prevent inadvertent laryngospasm. adjusted or repeated at a greater but more judicious depth.
I do not routinely perform endoscopy under apnea I agree. In this day and age, obtaining a tissue
prior to intubation—only in selected cases. In most diagnosis must not necessarily be the primary
instances, a smaller endotracheal tube, such as one objective of the procedure. With the rise in transoral
with an inner diameter ≤6.5 mm, does not significantly endoscopic head and neck surgery, an equally
obstruct DLP. This is particularly important when there important objective of the procedure can be to
is a question as to the ability to maintain an airway determine the primary tumor’s location and associated
under apnea due to tumor size or location, and when tumoral extension for proper staging and to determine
it would be therefore unsafe to lose the patient’s transoral resectability. EMéndez
ability to maintain an airway (via deep sedation or
paralysis) prior to intubation. EMéndez However, when the tumor is larger and more exten-
sive, such a superficial approach is not needed. When
performing a biopsy, it is of the utmost importance to
Endoscopy or microsurgery under apnea is prohibited take an adequately deep biopsy. Take large biopsies with
in some institutions or countries. Any accident or large cupped forceps to minimize the need for a repeated
complications due to a procedure under apnea could procedure or intraoperative delays. Of course these gen-
be considered a fault in my country (Belgium). erous deep biopsies should be performed while also
MRemacle avoiding the purely necrotic aspects of the tumor. We
prefer to use large up-biting cupped forceps directed to
Finally, the surgeon must discuss the plan for intuba- the leading edge of tumor. Frozen section is not always
tion at the conclusion of endoscopy with apnea. The necessary but is sometimes crucial to ensure adequacy
endotracheal tube size and the use of a stylette should of the biopsy or when the pathology is uncertain: for
be reviewed so that these items are available immedi- instance in verrucous carcinomas, tumors of the tongue
ately after the surgeon’s examination is complete. base that might be of salivary gland origin.
CHAPTER 34 Exam Under Anesthesia for the Patient with Cancer 329
relationships of the head and neck are altered. First, the

Frozen section is also useful when an early cancer is
passage of even a soft flexible plastic ET and its balloon
suspected and when the patient allows us to perform
may create mild mucosal trauma that precludes assess-
the endoscopic surgery directly after the frozen
ment of glottic laryngeal tumors and premalignant
section was performed and the diagnosis of squamous
disease. Intubation and subsequent fixation of the tube
cell carcinoma was confirmed. MRemacle
with tape also distort the laryngopharyngeal anatomy.
For this reason we advocate performing endoscopy
For most patients such an approach will suffice. under apnea for patients with laryngeal tumors, using
However, for patients with a metastatic carcinoma to 0-, 30-, and 70-degree rigid endoscopes. With this
the neck with an unknown primary, directed biopsies of image projected onto a video tower, subtle details of
the oropharynx, nasopharynx, supraglottic larynx, and tumor spread and associated anatomic abnormalities
hypopharynx are indicated. Often these tumors can be can be seen and documented with photography or
found when combining (where possible) digital inspec- video. For tumors of the anterior and posterior com
tion and palpation and DLP. Tumors often bleed after missures, laryngeal ventricle, and epilarynx, such an
palpation, which alerts the surgeon to the precise loca- approach is essential for precise tumor staging. For all
tion of the tumors. For unknown primary tumors we tumors of the head and neck, the opportunity to view
find that careful inspection of the tonsil and glossopha- this microscopic anatomy at high resolution not only
ryngeal sulcus, vallecula, and lingual aspect of the epi- allows for the precise discrimination of disease extent
glottis is always important. If biopsies here are negative, but also provides an opportunity to teach trainees and
tonsillectomy must be performed. nursing colleagues. For tumors of the hypopharynx,
mapping can be done after intubation.
In the case of an unknown primary tumor, palpation
and magnified visualization of base of tongue and If analysis of the tumor is needed without an ET, and it
Waldeyer’s ring may be crucial. Consider deeper is not deemed that deep sedation or paralysis prior to
biopsies of the base of the tongue, particularly intubation is safe, another method to consider is to
ipsilaterally. Observe for friability, cobblestoning/ suspend the larynx and, under visualization, remove
papillomatous tonsillar tissue, and so on, because the ET to perform rigid endoscopic examination with
these could all be clues of a tumor-harboring the 0-, 30- and/or 70-degree rigid endoscopes.
mucosa. EMéndez An ET can then be reinserted under direct
visualization through or around the suspending
endoscope to proceed with the more proximal
Haughey has advocated wide mucosal “carpet
aspects of the procedure. EMéndez
biopsy” via transoral laser microsurgery, especially
when an oropharyngeal tumor is suspected due to cystic
level II-II metastasis. For tumors of the laryngeal ven- After endoscopy with apnea, a gentle intubation
tricle, resection of the false cord to fully expose the should be performed. Depending on the clinical scenario
lesion is sometimes required. and logistics of the operating room, this means that
sometimes the otolaryngologist should intubate.
STEP 3. Tumor mapping. After intubation we proceed with an examination by
palpation of all mucosal surfaces of the oral cavity and
If a primary tumor’s location is well known prior to oropharynx. We map the surface extent of the lesion,
DLP, the surgeon’s next objective is precise tumor sometimes using toluidine blue, which can be used from
mapping. In general, we perform a comprehensive the soft palate to oral tongue, and even in the endolar-
survey, moving from “far” to “near” the tumor, ideally. ynx where premalignant changes and invasive tumor
Great care must be taken so as not to elicit bleeding, can sometimes be difficult to discern.
which can diminish understanding the pattern of tumoral
spread.
From what I know toluidine blue is rarely used
because this technique is very time-consuming.
It is important to pay particular attention to anatomy MRemacle
difficult to inspect via flexible endoscopy or physical
examination, such as the glossopharyngeal sulcus,
For tumors of the oral cavity, usually a DLP is brief
vallecula, ventricle, pyriform sinuses, and the
because much of this examination can be performed in
postcricoid region. EMéndez
the clinic. However, digital inspection and bimanual
palpation can provide important information for these
When an endotracheal tube (ET) is placed patients. For the floor of mouth, the tumor’s relation-
through the laryngopharynx, fundamental anatomic ship to the mylohyoid muscle insertion should be noted.
For the tonsil, the surgeon must palpate and deter-

mine whether the gland is mobile. Is the tonsil fixed to
the underlying constrictor? To the medial pterygoid?
Such findings suggest unresectability via transoral endo-
scopic approaches.
This is particularly relevant when trismus is noted

preoperatively in the clinic. EMéndez
We also document carefully the relationship of the

tumor to the anterior and posterior tonsillar pillars.
Palatoglossus m. Does the tumor arise from within the fossa itself? Does
(insertion variable) the tumor arise from the anterior pillar and soft palate?
Finally, the relationship of the tonsillar tumor to the
surrounding oral cavity and oropharynx should be
documented as well. We describe whether the gland
expands the anterior or posterior tonsillar pillars
(Figure 34-2) or spreads submucosally to the soft palate
or posterior oropharyngeal wall, nasopharynx, poste-
rior floor of mouth, retromolar trigone, and buccal
mucosa.
For tumors of the soft palate the relationship of
the tumor to the midline and hard palate should be
carefully noted. Does the tumor expand through the full
thickness of the palate? Is there nasopharyngeal
extension?
FIGURE 34-1. Folds of the oropharynx. Though uncommon, tumors of the posterior oropha-
ryngeal wall are still sometimes seen. When evaluating
such a lesion, whether a primary tumor or from tumoral
extension from a palatal or tonsillar neoplasm, the
surgeon should also assess the posterior oropharynx. It
If level I adenopathy is encountered, this is often an is important here to ascertain whether the tumor is fixed
ideal moment to assess for mandibular fixation as to the prevertebral fascia, ligamenta flava, and/or the
well. EMéndez musculature of the longus coli or longus capitis.
In the endolarynx, the examination must extend to
much more than simply an assessment of the vocal cord.
For tumors of the tongue base, we estimate where A wide-aperture scope is preferred here as throughout
the tumor is confined to a single side and assess whether the examination. The Hollinger laryngoscope is ade-
the tumor might cross the midline. If so, is more than quate for patients with difficult exposure and for the
two thirds of the entire tongue-base involved? Docu- anterior commissure, but should not be used as the
menting these findings at the time of DLP helps the surgeon’s routine endoscope.
surgeon later to develop a precise operative plan, if For the vocal cords we prefer to document intra
surgery is chosen for treatment. operative findings with a drawing of any tumor, to
The experienced head-and-neck surgeon will know document the tumor’s extension, synthesizing intra
that there is significant variation in the anatomy of this operative findings with signs appreciated on clinic-based
region from patient to patient. Superficial mucosal folds examination and then revised after DLP. Internal disten-
are defined by the prominence of underlying muscula- tion and external compression are key maneuvers to
ture and/or insertion points. For instance, some patients evaluate the ventricle and false cords. The arytenoids
have well-defined anterior tonsillar pillars formed by a should be palpated and the subglottis should be exam-
prominent underlying palatoglossus muscle belly. For ined carefully with 30- and 70-degree endoscopy. Much
these patients there may be a clear boundary from of the examination is directed by the tumor. For instance,
spread outside the tonsillar fossa to the posterior floor for a patient with a transglottic tumor, when there is a
of mouth (Figure 34-1). For other patients with less tumor with subglottic spread, the superior border of
well-defined musculature, tumors may spread more cricoid cartilage should be examined, both anteriorly
easily from oropharynx to oral cavity. and posteriorly.
Palatopharyngeus m.
Palatoglossus m.
Pterygomaxillary
ligament
FIGURE 34-2. Underlying musculature defines

mucosal folds in the oropharynx.
region represents a watershed area where the orophar-

When determining candidacy for endoscopic resection
ynx, supraglottic larynx, and hypopharynx merge.
of a supraglottic tumor in a patient noted to have
The oropharynx and the larynx and hypopharynx
vocal cord impairment on flexible laryngoscopy, it is
are therefore separated by a unique region, paired and
critical to palpate the involved arytenoid to
symmetric, the lateral epilarynx or lateral “margin.” Of
differentiate between pseudofixation versus true
utmost interest is the analysis of the folds that the
fixation. This is because a bulky supraglottic tumor
surgeon sees when performing clinical examination or
could cause vocal cord immobility without
performing endoscopic resection of tumors. Three folds
cricoarytenoid joint invasion. EMéndez
are also termed pharyngoepiglottic, aryepiglottic, and
glossoepiglottic (depicted in Figure 34-3), and they
For tumors of the supraglottic larynx, the surgeon might be individualized. We call the perimeter created
should describe the relationship of the tumor the ven- by these three structures the “three-fold region” (see
tricle and glottis, as well as its relationship to the hyoid. Holsinger et al, 2006; 2008).
If infrahyoid, is there anterior spread across the midline? There are two other folds that provide landmarks
Does the tumor extend into the paraglottic space, during tumor mapping and DLP. The first is located on
bulging the aryepiglottic fold? Is there extension to the average 1 cm below the three-fold region and crosses
medial wall of the pyriform sinus? the anterior wall of the pyriform sinus. Called Hyrtl’s
Although not included in the nomenclature of the fold in the old European anatomic literature, it underlies
American Joint Committee on Cancer (AJCC), the epi- the crossing of the major branch of the superior laryn-
larynx (see Laccourreye 1983, Lefebvre 1995) is a tran- geal nerve that innervates the mucosa of the hypophar-
sition zone with the oropharynx anteriorly (vallecula ynx and allows for precise localization of the bolus
and tongue base), the supraglottic larynx internally, the during swallowing (see Figure 34-3). The second fold,
retrocricoid and retroarytenoid posteriorly, and the Betz fold, is located at the apex of the pyriform sinus
pyriform sinus laterally (Figure 34-3). The epilarynx is and delineates the junction with the esophageal inlet.
further divided into anterior epilarynx (the suprahyoid Betz fold is created by the superior border of the crico-
epiglottis), lateral epilarynx (aryepiglottic folds), and pharyngeus as it crosses the pyriform sinus to attach to
posterior epilarynx (arytenoids). On the upper and the cricoid. These folds are important anatomic land-
lateral borders of the epilarynx, there is another impor- marks in describing different subsites within the pyri-
tant landmark that is helpful when describing the form sinus and the transition from hypopharynx to
spread of laryngopharyngeal carcinomas. The three-fold cervical esophagus.
Three-fold
region
Hyrtl’s
fold
Betz
fold
Esophagus
FIGURE 34-3. The “three-fold region” that the surgeon sees when performing clinical
examination or performing endoscopic resection of tumors.
Finally, in addition to describing the tumor of inter- Finally, for very small tumors, do not hesitate to
est that led to the DLP, the surgeon must tirelessly simply resect the tumor, especially when the resection
examine each fold of mucosa and area of the upper would not impair function. During DLP, the surgeon
aerodigestive tract for signs of a second primary tumor. should take every precaution to avoid bleeding espe-
A premalignant lesion may also be found. When cially in patients with larger tumors in which postopera-
leukoplakia is encountered, a simple biopsy should not tive airway obstruction might be a concern.
be done. Rather, a wide-field excisional biopsy with an
epithelial mucosal resection should be done. In the In this regard, laser-assisted tumor debulking can be
larynx, hydrodissection prevents damage to the liga- performed when the endoscopy is completed (see
ment and facilitates functional voice preservation. Paleri 2005). MRemacle
It is important to be very clear about this intraoperative STEP 4 (Mucosal tatouage): We advocate mucosal tat-
decision, preoperatively. This should be discussed in ouage at the time of direct laryngopharyngoscopy in
detail when obtaining informed consent for the several clinical scenarios.
procedure because when invasive carcinoma is found,
other treatment modalities might be equally effective. A precise outline of the tumor and its border can be
For this reason, I find it useful to separate diagnostic helpful to the surgeon if the patient is to be considered
procedures from treatment when this issue is of for an organ-preservation strategy (surgical or not) or
particular concern because it allows for the diagnostic when the borders of the tumor are ill-defined or difficult
dilemma to clear and a more detailed conversation to see on clinical examination. Once done, the extent of
regarding the different treatment options to ensue. tatouage helps the surgeon estimate the functional effect
EMéndez of any potential resection and therefore to choose
between treatment options. Mucosal tatouage may help
Tumor of the
palatine tonsil
A B Gross C Gross
residual residual
tumor tumor
Microscopic
residual
tumor
FIGURE 34-4. Differential response of a tonsillar carcinoma to chemotherapy. A, Complete

response, gross and microscopic. B, Partial response. C, Microscopic residual disease as a
satellite lesion to the grossly apparent residual tumor.
to estimate margins at recurrence or provide prognostic primary specialists for this disease, we often manage
information about the extent of disease and/or resect- patients after chemotherapy or chemoradiation. By
ability. If a transcervical conservation surgery is planned, having a precise tumor map of the tumor’s initial bound-
mucosal tatouage helps the surgeon accurately identify aries, the surgeon can at least sample or possibly resect
where to enter the pharynx or larynx in a safe region, all of the tumor’s initial extent because unfortunately
far from the tumor. tumors do not always respond symmetrically or coher-
We use India ink and a Bruning’s laryngeal injection ently (Figure 34-4).
needle, but any type of needle will do. In general, a
larger-diameter needle (such as that used for intracordal
injection) is optimal. The needle should be used to intro-
Postoperative Management
duce and permanently tattoo the mucosa, and where Most if not all patients are managed as outpatients.
necessary the underlying musculature. However, the Thus the most important aspect of postoperative care
surgeon should not inject the dye, only tattoo. is following up on pathology results and discussing
Although the technique may be straightforward, the intraoperative findings with the multidisciplinary
there are still two different approaches. The surgeon tumor planning conference. This detailed assessment is
could tattoo immediately adjacent to the tumor or mark an essential element that the head-and-neck surgeon
the appropriate surgical margin (1 to 2 cm) around the brings to the multidisciplinary conference. Precise
primary tumor. Our preference is to perform tatouage tumor mapping as well as high-resolution photograph-
so as to delineate the margins of resection as if the ing can help decide if functional organ-preservation
complete resection is to be done immediately. surgery might be possible. Perhaps more important, this
In the oropharynx and hypopharynx, we typically same information can be provided to the patient and
perform tatouage with the appropriate surgical margin. his or her family to explain why a particular treatment
However, the complex three-dimensional anatomy of is chosen.
the larynx may preclude such an approach. Here we ink
the appropriate “spaces,” not just a standard surgical
margin in millimeters or centimeters. Suggested Readings
We think mucosal tatouage is an important part of Baek CH, Chung MK, Son YI, et al: Tumor volume assessment
the surgeon’s role in multidisciplinary care. As the by 18F-FDG PET/CT in patients with oral cavity cancer
with dental artifacts on CT or MR images. J Nucl Med Karni RJ, Rich JT, Haughey BH: Transoral laser microsurgery:
9:1422-1428, 2008. a new approach for occult primaries of the head and neck.
Holsinger FC, Kies MS, Weinstock YE, et al. Videos in clinical Laryngoscope 2011 (In Press).
medicine. Examination of the larynx and pharynx. N Engl Laccourreye H, Brasnu DF, Beutter P: Carcinoma of the laryn-
J Med 358:e2, 2008. geal margin. Head Neck Surg 5:500-507, 1983.
Holsinger FC, Motamed M, Garcia D, et al: Resection of Lefebvre JL, Buisset E, Coche-Dequeant B, et al: Epilarynx:
selected invasive squamous cell carcinoma of the pyriform pharynx or larynx? Head Neck 17:377-381, 1995.
sinus by means of the lateral pharyngotomy approach: the Paleri V, Stafford FW, Sammut MS: Laser debulking in malig-
partial lateral pharyngectomy. Head Neck 28:705-711, nant upper airway obstruction. Head Neck 4:296-301,
2006. 2005.
CHAPTER
Horizontal Supraglottic Laryngectomy
35 Authors Giuseppe Spriano, Paolo Ruscito, and Raul Pellini
Commentary by Rosario Marchese-Ragona and Aniel Sewnaik
Horizontal supraglottic laryngectomy (HSL) is a partial q Impaired pulmonary function

resection of the portion of larynx placed above the q Note: The ability to tolerate physical exercise is
glottis, including the epiglottis, ventricular folds, supe- generally accepted as the most reliable parameter
rior part of Morgagni ventricles, and corresponding to be evaluated for a patient’s general ability to
supraglottic spaces. It can be extended, depending on tolerate an HSL. If the patient can climb two
the tumor extension, anteriorly to the oropharynx (val- flights of stairs without becoming “winded,”
leculas or base of the tongue), laterally to the hypophar- the patient probably will tolerate a partial
ynx (pyriform sinus), posteriorly to the arytenoids, and laryngectomy.
inferiorly to the vocal cords. In these cases the proce- q Impaired cough reflex
dure is called extended horizontal supraglottic laryngec- q Prior cerebrovascular events
tomy (EHSL). They are generally performed together q Previous thoracic surgery
with bilateral neck dissections. Two important final considerations:
The rationale for supraglottic horizontal laryngec-
tomy is that a tumor, arising in the supraglottic portion n
Both the patient and family must be highly
of the larynx, originating from the 3- and 4-degree motivated and demonstrate the ability to
visceral arches (buccopharyngeal origin), tends be an understand, as well as the willingness to follow
“ascending tumor,” growing toward the pharynx. This instructions postoperatively, especially with
attitude has been explained embryologically, consider- regard to the rehabilitation of swallowing.
ing the barrier of the glottic plane, coming from the n The possibility for a conversion to a total
6-degree visceral arch of tracheopulmonary origin, laryngectomy is always discussed
tending toward inferior extension. The high incidence (preoperatively).
of lymphatic spread related to supraglottic tumors must ASewnaik
be taken into account and relates to the general indica-
tion for bilateral neck dissections for both therapeutic
and diagnostic purposes.
Preoperative Imaging
HSL is an indicated procedure for the following We recommend high-resolution computed tomography
supraglottic tumors: (CT) scan of the larynx and a baseline CT scan of the
n Clinically staged as T1, T2, and selected T3 (only for chest.
preepiglottic space involvement), with normal cord
mobility.
n Limited to one or more of the following sites: STEP 1. The patient is placed in a supine position with
q Epiglottis a horizontally oriented shoulder roll. The patient’s neck
q Ventricular folds should be extended to perform laryngectomy and the
q Tumors may have preepiglottic space invasion head rotated away from the operative side during bilat-
Contraindications to HSL: eral neck dissection. The table can be kept straight, with
n Significant thyroid cartilage destruction the anesthesia machine placed on the left side of the
n Anterior commissure involvement patient, to allow positioning of two assistants, one on
n Impaired vocal cord mobility the opposite side and the other at the head of the table.
n Bilateral arytenoid infiltration
n Pyriform apex or postcricoid mucosa involvement Prophylactic antibiotics are necessary to cover aerodi-
n Some areas of controversy include: gestive tract flora. Antibiotics are continued until at
q Advanced age least 72 hours following the surgery.
335
Prophylactic antibiotics: All our patients receive

postoperative prophylactic antibiotic therapy for at
least 8 days. The most frequently used antibiotics
were ampicillin sodium plus sulbactam sodium (1.5 g
intravenously [IV] three times daily), associated with
metronidazole phosphate (500 mg IV three times
daily). RMarchese-Ragona
Anesthesia: For patients with airway compromise, a

tracheotomy under local anesthesia is performed prior
to induction of general anesthesia for the remainder of
the procedure.
Horizontal
As with any partial laryngectomy, a careful endoscopy supraglottic
under general anesthesia is performed to determine laryngectomy
incision
precise staging and suitability of the tumor for
Modified radical
conservative laryngeal resection. ASewnaik neck dissection
incision
We perform fiberoptic nasotracheal intubation (FNI) in Tracheotomy

potentially difficult airways under local anesthesia
(procaine-soaked cotton swabs in the nose). During
the procedure we can remove secretions and provide
topical anesthesia (lidocaine 2%) in the larynx and FIGURE 35-1. Incisions for horizontal supraglottic
laryngectomy with and without neck dissection and
trachea via the suction channel of the
tracheostomy are depicted.
endoscope. RMarchese-Ragona
STEP 2. The incision is marked for both horizontal supra-

A cuffed tracheostomy tube is positioned (No. 8 or
glottic laryngectomy with (or without) neck dissection as
7 for men, No. 6 for women) and connected to the
well as tracheotomy (Figure 35-1).
anesthesia machine.
STEP 3. Tracheotomy (see Chapter 6).
Tracheotomy is performed without tracheal flap
A 3-cm skin incision is performed below the thyroid
between the second and third tracheal ring. The
gland isthmus, at the level of the second and third
tracheal edges are sutured to the superior and
tracheal ring, isolated from the laryngectomy skin
inferior skin flaps with interrupted nylon suture.
incision.
RMarchese-Ragona
The tracheotomy is performed with an inferiorly
based U-shaped tracheal flap that is sutured to the infe-
rior tracheotomy site skin flap with interrupted nylon
STEP 4. An apron incision is made extending from each
sutures to protect the anterior superior mediastinum
mastoid tip, along the posterior border of the sterno-
from air insufflation complications. The inferior U-
cleidomastoid muscle, along a horizontal crease, cepha-
shaped tracheal flap is preferred because it guarantees
lad and not connecting with the tracheotomy incision.
the mobility of the laryngotracheal complex during the
pexy, reducing the risk of tracheal ring damage at the The maintenance of two separate surgical fields,
level of the sutures and facilitating the swallowing reha- the tracheotomy and the laryngectomy and neck dissec-
bilitation. Finally the tracheal flap covers the mediasti- tion, reduces the risk of drainage tube failure. It reduces
nal space and protects mediastinal vessels during cannula risk of contamination by aerodigestive flora from the
introduction. tracheal opening into the superior clean-contaminated
wound and facilitates easier recovery of laryngeal
We perform a tracheotomy with a vertical incision in motility during swallowing, after tracheotomy tube
the midline; on both sides of the incision, sutures are decannulation.
placed to open the trachea in case of emergency (if Some surgeons use a single incision. In these
the cannula comes out). ASewnaik instances, the tracheostoma should be prepared in a
circumferential interrupted closure to allow wound
CHAPTER 35 Horizontal Supraglottic Laryngectomy 337
suction drainage. If neck incisions are allowed to com-

municate with the tracheotomy, air can track between
the trachea and neck dissection wounds creating a host
of problems and delays. Additionally, a secondary pro-
cedure for stoma closure is sometimes required follow-
ing decannulation.
The shape and width of the cervical skin flap does Mylohyoid m.
Ant. belly of
not depend on the laryngectomy but on the preferred Stylohyoid m. digastric m.
incision to provide access for the planned elective/ Post. belly of
therapeutic levels II to IV neck dissection. This incision digastric m. Hyoid bone
is based on surgeon experience and preference and may
be as standard as a bilateral apron flap incision to one Sternocleido-
mastoid m.
that approximates a cervical at the level of the cricothy- (cut)
roid membrane. The procedure for selective levels II
Int. jugular v.
through IV dissection is described in Chapter 20. Sternohyoid m.
Common
carotid a.
We usually perform the typical U-shaped bimastoid Sternothyroid m.
apron flap comprising the tracheostomy incision, and
a subplatysmal flap is raised to about 1 cm above the
hyoid bone. Only in very rare instances, when a neck
dissection is not planned, a smaller incision is Omohyoid m.
considered and the lateral arm of the incision can be
placed about midway between the lower neck and
mastoid tip, and the tracheotomy is performed in a
separate incision. RMarchese-Ragona
STEP 5. The incision is continued through the subcuta-

neous fat and the platysma muscle. The external jugular FIGURE 35-2. The sternohyoid muscle flap is incised
approximately 1 cm from the inferior hyoid margin, providing
vein and greater auricular nerve are deep to the level of
a healthy muscular flap as well as soft tissue along the inferior
skin flap elevation and can be spared in almost all cir-
edge of the hyoid bone to promote wound healing during the
cumstances. The skin flap is elevated in the immediate planned pexy/impaction process.
subplatysmal level with electrocautery.
The skin flaps are elevated to the level of the hyoid bone Larynx Is Skeletonized
and digastric muscles. Laterally, the flaps are elevated to
the posterior border of the sternocleidomastoid muscle,
STEP 8. The hyoid bone and the infrahyoid strap muscles
identifying and preserving the external jugular vein and
are isolated using electrocautery.
great auricular nerves. Inferiorly the flap is elevated to
provide wide exposure for both the central and lateral In instances of tumors limited to the supraglottic
necks exposing the posterior border of the sternocleido- larynx without preepiglottic space invasion, a sternohy-
mastoid muscles, clavicles, and sternal notch. oid muscle flap is harvested, incising the muscle about
1 cm below the hyoid bone. Then this muscle flap is
gently dissected using cutting electrocautery and rotated
STEP 6. The flaps are sutured back with moistened downward to expose the laryngotracheal complex
sponges to provide self-maintained visualization of the (Figure 35-2).
surgical field. In cases with preepiglottic space involvement, the
strap muscles should be resected en block with the lar-
yngectomy specimen.
The raised U-shaped flap is sutured to the sterile The inferior border of the hyoid bone is skeletonized
drapes to facilitate visualization of the surgical field. with the use of electrocautery, sectioning the thyrohyoid
RMarchese-Ragona membrane and ligaments. Paying strict attention to
the inferior border of the hyoid bone is critical to not
damaging either of the hypoglossal nerves or lingual
STEP 7. Bilateral neck dissections are performed as arteries.
described in Chapter 20 and once completed, the laryn- Some authors prefer to remove the hyoid bone in all
gectomy may proceed. cases, so as to achieve a wider excision of preepiglottic
space. If the tumor invasion is not extensive, we prefer

to spare the hyoid bone in order to avoid the risk injury
of the lingual artery and hypoglossal nerve, and in order
to achieve a better and stable matching of the pexy
between the sectioned thyroid cartilage and hyoid bone.
STEP 9. Laterally the superior laryngeal vascular pedi-

cles are isolated and divided bilaterally, after the identi-
fication of the superior laryngeal nerves (which must be Strap muscle
remnant
carefully preserved) that are located in a deeper plane
than superior laryngeal vessels.
The superior cornu of thyroid cartilage is exposed and

excised bilaterally and the superior laryngeal vascular
Thyroid cartilage
pedicles are ligated. RMarchese-Ragona
Perichondral flap
STEP 10. The external perichondrium of the thyroid car- Thyroid gland
tilage is incised along the superior and lateral border of
the edge with use of a scalpel and gently dissected
downward to harvest a perichondral flap that is kept
attached to the inferior third of thyroid cartilage and
reflected (Figure 35-3).
STEP 11. Laterally, along the thyroid cartilage’s poste-

rior insertion, the superior constrictor muscle is
sectioned bilaterally along its lateral thyroid cartilage
attachment with electrocautery and the pyriform sinuses FIGURE 35-3. The thyroid cartilage perichondral flap is
elevated bluntly from the inner perichondrium of the shown elevated and reflected inferiorly providing exposed
thyroid cartilage (Figure 35-4). thyroid cartilage framework.
The surgeon should rotate the thyroid cartilage in the

nondominant hand so that the lateral thyroid border
“tents” the superior constrictor of the pharynx.
The larynx is rotated toward the opposite side with The thyroid cartilage incision line may differ in relation
a single hook, and the superior constrictor muscle to the tumor extent and the hyoid bone preservation.
is sectioned bilaterally with electrocautery. The thyroid cartilage may be cut horizontally (removing
RMarchese-Ragona both superior cornu), or in different fashions (V- or
L-shaped incisions), relating to the site and extent of the
tumor about halfway between the thyroid notch and its
Supraglottic Laryngectomy inferior edge (Figure 35-5).
Historically, curved line or V incisions were generally
STEP 12. The thyroid cartilage is incised about halfway used when supraglottic laryngectomy was performed
between the thyroid notch and its inferior edge, estimat- for tumors of the suprahyoid epiglottis as well as when
ing the location of the anterior commissure between the hyoid bone excision was included and a thyroglos-
3.5 and 6 mm in men and between 3 and 5 mm in sopexy was performed. It is much more common today
women. The chondrotomy can be achieved by means that the hyoid bone is preserved and therefore a hori-
of oscillating saw, scalpel, or scissors, depending on zontal linear thyroid cartilage incision is preferred to
thyroid cartilage ossification, but I prefer the former achieve a better match of the laryngeal and pharyngeal
except in young individuals. remnants for thyrohyoidpexy.
We perform the chondrotomy with sharp scissors, and

a small-diameter rotating saw is sometimes used We prefer a horizontal linear thyroid cartilage incision.
anteriorly in the midline. RMarchese-Ragona RMarchese-Ragona
Thyrohyoid
membrane
Constrictor mm.
(cut) Thyroid
cartilage
Sup. thyroid a.
Constrictor mm.
Thyroid
cartilage
FIGURE 35-5. An example of horizontally designed thyroid

cartilage excision.
FIGURE 35-4. The superior constrictor of the pharynx is until the mucosa of valleculae is evident. The
exposed and incised, thus allowing access to the pyriform pharyngotomy is initiated at the vallecular site most
sinus mucosa to be preserved. distant from the primary tumor at the level of the
resected cornu of thyroid cartilage.
RMarchese-Ragona
STEP 13. Pharyngotomy is carried out at the level of the
vallecula in cases of tumors of the infrahyoid supraglot-
tic larynx. STEP 14. The surgeon steps to the head of the table, and
a clamp is placed on the epiglottis and it is elevated and
The pharyngotomy is performed with cutting cautery rotated outward to provide adequate visualization of the
on the tip of a Yankauer suction placed in the vallecula laryngeal lumen and tumor extent (Figure 35-6).
and displacing the overlying soft tissues.
We do this differently: we open the pharynx from the After the pharyngotomy, a good headlamp helps the
surgical area without a suction through the mouth. surgeon to visualize the inner laryngeal lumen. During
ASewnaik this step the infusion of myorelaxant drugs improves
the visualization of inner larynx. RMarchese-Ragona
The pharyngotomy is initiated at the vallecular site

estimated by presurgical endoscopy to be most distant STEP 15. With a curved sharp scissors, the laryngec-
from the primary tumor. tomy continues under direct visualization, along the
aryepiglottic folds up to the anterior insertion to the
The whole preepiglottic space must be resected. After arytenoids, which are preserved when not involved by
the inferior border of the hyoid bone is skeletonized tumor.
with the use of electrocautery, through the thyrohyoid
membrane, the larynx is pulled downward and the
hyoepiglottic ligament is carefully followed and We usually perform this step with needle-tip
separated from the tongue base, using sharp scissors, electrocautery. RMarchese-Ragona
STEP 18. Hemostasis is performed usually by means of

bipolar coagulation along the mucosal edge of the laryn-
gopharyngeal stump, with special attention to the base
of the tongue.
STEP 19. A feeding tube is placed under direct

visualization.
Tumor
Epiglottis
The nasogastric tube is usually placed before the
laryngectomy, just after the intubation or the
tracheostomy. RMarchese-Ragona
Vestibular Aryepiglottic fold

fold Reconstruction
Vocal fold
STEP 20. The external perichondral flap, which has been
harvested and preserved, is rotated inward to cover the
Cuneiform thyroid cartilage’s cut edge and fixed with 4-0 absorb-
tubercle Constrictor mm.
(cut)
able sutures to the inner glottic larynx (usually to the
Corniculate
tubercle internal perichondrium).
In this way it is possible to protect the cartilage and to

interpose a soft-tissue layer between the chondral edge
of the laryngeal stump and the osseous border (hyoid
bone) of the oropharyngeal one.
Some authors use this chondral flap to cover the
FIGURE 35-6. The vallecular pharyngotomy has been
thyrohyoidpexy, externally suturing it to the suprahyoid
completed and the epiglottis is used for traction and
muscles, to get a better isolation of the laryngeal lumen
visualization of the laryngeal incisions.
from the neck space, preventing or reducing eventual
neck emphysema.
Usually the surgeon vertically cuts the aryepiglottic STEP 21. The pexy is now begun, reapproximating the
folds. Then, the surgeon rotates the scissors 90 degrees, base of the tongue and the glottic aspect of the larynx.
cutting horizontally along the floor of the ventricles, In this phase the removal of the shoulder roll and the
reaching the area of the insertion of petiole of the epi- following reduction of the neck extension facilitate the
glottis. The supraglottic laryngectomy is now completed matching of the two stumps.
(Figure 35-7).
The entire removal of the supraglottic larynx must
be achieved while maintaining the in vivo relationship STEP 22. Laryngeal reconstruction is achieved through
between the external skeleton of the supraglottic larynx thyrohyoidpexy by the positioning of interrupted 2-0
and its soft tissues to avoid risk of recurrence. Vicryl sutures with atraumatic needles, reapproximation
the oropharyngeal stump to the laryngopharyngeal one.
Three to five interrupted sutures are generally required.
STEP 16. The specimen is carefully examined by the
surgeon, who “opens” the larynx, fracturing its cartilagi- During the impaction an assistant keeps the patient’s
nous framework as one would open a book. Now the head flexed in order to reduce tension. The sutures are
surgeon determines the adequacy of the excised margins tied synchronously on the two opposite sides, beginning
and the relationship of the tumor to the surrounding from the lateral ones and ending with the median stitch,
resected mucosa. in order to avoid cartilage fracture.
The sutures are passed through or around the resid-
ual thyroid cartilage, avoiding the true vocal cords. The
STEP 17. Intraoperative frozen sections of mucosal sutures are then passed through the suprahyoid muscles,
margins, taken from the residual larynx, complete the beneath the retained hyoid bone and base of tongue
ablative portion of the procedure. musculature (Figure 35-8).
Epiglottis
Tumor
Specimen
B
Aryepiglottic fold (cut)
Int. laryngeal n.
Vocal fold
Constrictor mm.
(cut)
A
FIGURE 35-7. The surgeon’s view from the head of the table of the horizontal supraglottic
laryngectomy surgical bed and excised specimen.
STEP 24. The prelaryngeal muscle flap is rotated to

The median suture is performed between the hyoid
cover the pexy and sutured with 3-0 Vicryl mattress
and the lower edge of thyroid cartilage. The lateral
sutures to the suprahyoid muscles.
sutures are performed between the hyoid and edges
of thyroid cartilage (small holes in thyroid may help
needle passage). RMarchese-Ragona
Extended Horizontal Supraglottic
If the hyoid bone has been removed, deep muscle
Laryngectomy
suture placement is suggested in the tongue base. Horizontal supraglottic laryngectomy can be extended
The sutures are positioned at a distance of about to either other laryngeal sub-sites or structures, either
1.5 cm from each other, beginning from the central one, to the oropharynx, or to the hypopharynx. In these
corresponding at the commissural vertical line (Figure cases the procedures are called EHSL, and the denomi-
35-9). Pharyngeal suture placement is not necessary. nation is comprehensive of the site or structure the
laryngectomy must be extended to include.
In case of upward extension of the tumor to the val-
The cut surfaces of the soft tissues of the lower leculae or to the base of the tongue, HSL extended to
side of the arytenoids and the previous aryepiglottic the base of the tongue or to the oropharynx is required.
folds are covered with mucosa mobilized from the In case of lateral extension of the tumor to the pyriform
preserved adjacent pyriform sinuses to create new sinus, HSL extended to the pyriform sinus or other
pyriform sinuses. RMarchese-Ragona hypopharyngeal sites is necessary. In these instances, the
denomination of partial laryngopharyngectomy may be
correctly used, referring generally to the kind and site
STEP 23. The perichondral flap is positioned and sutured, of resection.
in those cases in which it is not used to cover the car- If the tumor goes downward involving, the laryngeal
tilaginous cut line. ventricle, HSL will be extended to the vocal cord of that
or less, then en bloc resection is achieved by EHSL to

the base of the tongue. The procedure consists of HSL
and partial tongue base resection. The en bloc excision
requires the complete removal of the hyoid bone.
Contraindications to extended HSL and tongue base
resection include massive involvement of the base of the
tongue by the tumor, reaching the foramen cecum or the
circumvallate papillae, or in its spread to the lateral
Hyoid bone oropharyngeal wall.
The initial phases of the procedure are the same as
HSL, up to laryngectomy. In this case the laryngectomy
begins with a pharyngotomy along the inferior and
lateral pharyngeal wall on the less involved side of the
malignancy (in contrast to the HSL in which the phar-
Perichondral flap yngotomy is performed in the vallecula, and therefore
contraindicated in these circumstances due to the pres-
ence of tumor). The laryngectomy may be carried out
under direct visual and palpation control at the level of
the base of the tongue.
It is critical to preserve at least one hypoglossal nerve
and lingual artery to maintain tongue function as well
as viability. The hyoid bone must be comprehensively
excised.
The thyroid cartilage cut may be curved, sparing part
of supraglottic thyroid cartilage at the level of less
involved side by the tumor.
The pexy is achieved using 1-cm spaced 2-0 Vicryl
sutures passing through the suprahyoid muscles of the
FIGURE 35-8. Starting laterally, the first of the pexy sutures residual tongue and the impacting thyroid cartilage
is demonstrated, which will affect the remnant laryngeal laryngopharyngeal organ by the same method as
framework with the retained hyoid bone and surrounding soft described in this chapter under HSL reconstruction.
tissues.

Extended to the Pyriform Sinus
homolateral side, in order to achieve the en bloc
excision of the ventricle and its surrounding structures. This technique is indicated in tumors that have
This procedure was called three-quarter laryngectomy extended laterally to involve the medial and anterior
by Ogura (1965), but many other denominations have wall of the pyriform sinus. Contraindications include
been used: five-sixth laryngectomy, vertical subtotal the following:
laryngectomy, extended horizontal resection, subtotal n Lateral pyriform sinus wall invasion.
laryngectomy, extended hemilaryngectomy. n Apex of pyriform sinus involvement (because the
Finally, in case of limited mucosal infiltration of the tumor is below the ventricle plane).
arytenoid mucosa for tumors spreading posteriorly, The procedure, as first described by Ogura, allows
without cricoarytenoid junction involvement, HSL will the en bloc removal of laryngopharyngeal tumors
be extended to include the arytenoid. through HSL extended to part of the pharynx.
It is important to note that in all cases of partial The procedure is the same as HSL as previously
pharyngolaryngectomies, the mucosal free margins of described in this text until the laryngectomy phase.
the pharyngeal edge must be at least 1 cm and therefore Laryngectomy phase remains the same through to the
wider than the endolaryngeal margins. This is necessary thyroid chondrotomy. Pharyngotomy is carried out at
to avoid microscopic residual disease due to submucosal the level of the vallecula, on the contralateral side of
lymphatic extension in pharyngeal sites of disease. the pharyngeal extension. The epiglottis is pulled
outward to expose the laryngeal lumen and tumor.
The excision continues, under direct visual control,
along the aryepiglottic fold contralateral to the tumor
Extended to the Base of the Tongue
at the anterior edge of arytenoid (with the scissors at
If the tumor involves the vallecula or the base of the 90 degrees and the surgeon standing at the head of
tongue with extension into the tongue base of 1.5 cm the table). The scissors is then rotated with the blade
Hyoid bone
Hyoid bone
Perichondral flap
overlying thyroid Perichondral flap
cartilage remnant overlying thyroid
cartilage remnant
B
A
FIGURE 35-9. The pexy sutures are all placed and then closed in an interrupted fashion with
the perichrondral flap inset to cover the incised thyroid cartilage.
parallel to the ventricular fold and follows the ventricles to the hypopharynx, either at level of the pyriform
from the healthy side to the affected one. sinus, or the postcricoid area, without involving the
Finally the specimen remains connected to the neck cricoarytenoid junction.
only through the tumor-involved aryepiglottic fold, The procedure is the same as HSL with the follow-
which is resected at the end of the procedure, preserving ing modification of the laryngectomy portion of the
the arytenoid and excising at least 1 cm of mucosal-free procedure.
margin of the pharynx. The incision of the contralateral side of the involved
Before closure, the shoulder roll is again removed. arytenoid is performed initially, then working from the
The pexy sutures are placed contralaterally first, then less involved side to the greater involved side, the HSL
moving toward the side of hypopharyngeal extension. is pursued.
The pexy is not tied until the excised pharyngeal site is Once to the involved arytenoid (the laryngectomy
close (see the following). Interrupted 3-0 atraumatic specimen is now tethered primarily by the involved ary-
Vicryl sutures are used to close the pharyngeal defect. tenoid), the scissors is again turned at 90 degrees to the
The pexy is carried out as described in HSL. vocalis process and the true vocal cord cut immediately
anterior to the process. The resection follows the ary-
epiglottic fold, then the cricoarytenoid joint, and the
posterior arytenoid resection. The scissors is placed on
Extended to the Arytenoid
the upper edge of the cricoid cartilage. In this way, the
The HSL may be extended posteriorly to one arytenoid surgery surrounds and removes the arytenoid.
if the tumor extends mucosally to the arytenoid The true vocal cord, disconnected from the vocal
without fixation (or cricoarytenoid joint involvement process of the arytenoid, is preserved and sutured with
radiographically). The mucosal extension must be absorbable stitches to the cricoid edge in a paramedian
limited to the laryngeal lumen, without any extension position, to avoid its retraction.
The residual mucosa of the hypopharyngeal side of wall suction in order to avoid compressive dressing
the arytenoid is sutured to cover the cartilage edge of placement.
the cricoid with 4-0 absorbable sutures. The pexy is The skin is closed in layers including platysma, sub-
performed as previously described for HSL. cutaneous, and subcuticular or cutaneous closure of
choice.
Extended to One Vocal Cord
(Three-Quarter Laryngectomy) Postoperative Care and Rehabilitation
When a supraglottic tumor spreads inferiorly to involve The draining tubes are maintained until drainage is
significantly one ventricle or one true vocal cord, it is serosanguineous only and less than 30 mL over 24
possible to remove en bloc the supraglottic larynx, the hours. Compressive neck dressing may be indicated
ventricle, and the true vocal cord. The procedure is when subcutaneous emphysema is observed in the first
essentially a fusion of an HSL and a hemilaryngectomy. postoperative days, due to air passing from the trache-
Indications when tumors extend into: otomy site, laryngeal lumen, or pexy site. Continuous
n The ventricle. wall suction may alleviate the need for compressive
n The vocal cord. dressing placement.
n The arytenoid and the posterior third of the vocal The tracheotomy tube cuff remains inflated for the
cord. first 2 postoperative days, then it is removed and a new
n The infrahyoid epiglottis and extended inferiorly and noncuffed tracheotomy tube is positioned, to avoid
laterally toward the anterior third of the true vocal damage to the tracheal wall by cuff pressure.
cord. Speech-language pathology is consulted for both
To reconstruct the larynx and preserve the functions speech and swallowing rehabilitation in all patients.
of swallowing, breathing, and speaking, it is necessary Initially all patients undergoing supraglottic laryngec-
to preserve one aryepiglottic fold, one arytenoid, one tomy aspirate, independent of the extent of resection
side of the thyroid cartilage, and the cricoid ring. and type of closure obtained. Modified barium swallow
The laryngectomy procedure resembles the HSL. On studies will facilitate interventions to reduce or alleviate
the side of the planned cord extended resection, the aspiration potential.
inferior border of the thyroid cartilage is skeletonized Broad-spectrum prophylactic antibiotics are admin-
with electrocautery. On the opposite side, the thyroid istered for the first 10 postoperative days, until wound
cartilage cuts are made as previously described in HSL. healing is achieved and swallowing rehabilitation is
In the midline, the thyroid cartilage incision is con- close to being completed. In cases of infection, the anti-
nected vertically at the anterior commissure to the infe- biotics are adjusted based on culture and sensitivity
rior cricothyroid membrane incision of the planned results and maintained for 10 days or until infection
excised cord. Soft-tissue excision may include the vocal resolution, whichever is greater.
cord as well as the arytenoid cartilage. The cricoid car- Stitches are removed between the seventh and tenth
tilage must be preserved to reconstruct a neolarynx. postoperative days, in case of primary treatment, and
From a reconstructive standpoint, in order to achieve later (between the tenth and fifteenth postoperative
a complete reapproximation of the laryngeal and pha- days) in case of salvage surgery after radiation or che-
ryngeal stumps through pexy, when a complete glottic motherapy or radiation therapy.
excision is performed, a muscle-perichondral flap, The tracheotomy tube is decannulated when the
formed by the thyrohyoid muscle, is rotated inward to edema is reduced enough to restore normal breathing
interpose a soft-tissue layer between the irregular chon- through the glottic aperture. This usually occurs during
dral edge of thyroid cartilage (inferiorly) and the hyoid the first or second postoperative week. I generally down-
bone, superiorly on the side of the excised cord. size the tracheotomy tube and plug during the first 3 to
Pexy is achieved by separate nonabsorbable sutures 5 postoperative days and decannulate following 48
connecting the hyoid bone, on one side, to the thyroid hours of successful tracheotomy tube plugging.
cartilage and, on the other one, to the cricoid ring, with The nasogastric feeding tube is removed when
the muscle-perichondral flap interposed. aspiration is rare and minimized by speech-language
pathology intervention. Aspiration and swallowing
Wound Closure rehabilitation are evaluated clinically (Table 35-1) and
A minimum of two different suction drains are posi- endoscopically or radiologically (Table 35-2).
tioned. One suction drain in each lateral neck, where Swallowing rehabilitation exercises tend to stimulate
node dissection has been performed, extending across and improve tongue base and arytenoid retrainment to
levels II and III and curving inferior and superior to the protect airway and avoid or reduce aspiration. It usually
impacted closure in the central neck. The drains are requires from 2 to 4 weeks, in case of HSL, and longer
maintained to continuous suction, and if necessary to periods, in case of EHSL.
TABLE 35-1 Dysphagia Score

Salvage total laryngectomy for massive and persis-
tent aspiration is rarely required. The few cases it must
Score Symptoms be performed usually follow large pharyngeal resections
together with HSL. In those cases in which completion
1 Normal deglutition
2 Occasional cough during saliva deglutition, not laryngectomy is not accepted by the patient, percutane-
related to food introduction ous endoscopic gastrostomy may provide adequate
3 Occasional cough during food introduction nutrition replacement although secretion aspiration will
4 Frequent cough during food introduction unquestionably continue to plague the patient.
5 Frequent cough not related to food introduction
6 Aspiration pneumonitis
Suggested Readings
Bocca E: Surgical management of supraglottic cancer and its
TABLE 35-2 Endoscopic and Radiographic lymph node metastases in a conservative perspective (six-
Evaluation of Swallowing teenth Daniel C. Baker, Jr, memorial lecture.) Ann Otol
Rhinol Laryngol 100:261-267, 1991.
Penetration Aspiration Scale Bocca E, Pignataro O, Oldini C, Sambataro G, Cappa C:
Score Criteria Extended supraglottic laryngectomy. Review of 84 cases.
Ann Otol Rhinol Laryngol 96:384-386, 1987.
1 Material does not enter airway Ogura J: Personal experience with three quarter laryngectomy.
2 Material enters airway, contacts glottis, stimulates Tumori 60:527-529, 1974.
cough reflex, and is ejected completely Ogura JH: Supraglottic subtotal laryngectomy and radical
3 Material enters airway, contacts glottis, stimulates neck dissection for carcinoma of the epiglottis. Laryngo-
cough reflex, and is not completely ejected scope 68:983-1003, 1958.
4 Material enters airway, passes below glottis, Ogura JH, Dedo HH: Glottic reconstruction following subto-
stimulates cough reflex, and is ejected tal glottic-supraglottic laryngectomy. Laryngoscope 75:865-
completely 878, 1965.
5 Material enters airway, passes below glottis,
Silva N, Lore JM Jr: Partial horizontal supraglottic laryngec-
stimulates cough reflex, and is not completely
tomy. A method of reconstruction. Laryngoscope 87:1165-
ejected
1168, 1977.
6 Material enters airway, passes below glottis, and
no effort is made to reject
Spriano G, Antognoni P, Piantanida R, Varinelli D, Luraghi
R, Cerizza L, Tordiglione M: Conservative management of
T1-T2N0 supraglottic cancer: a retrospective study. Am J
Otolaryngol 18:299-305, 1997.
Suarez C, Rodrigo JP, Herranz J, Rosal C, Alvarez JC:
The training period should be delayed by 1 week in Extended supraglottic laryngectomy for primary base of
cases of salvage HSL after radiation or chemoradiation, tongue carcinomas. Clin Otolaryngol Allied Sci 21:37-41,
to allow adequate wound healing. 1996.
If the surgical procedure is extended to include a part Wasserman T, Murry T, Johnson JT, Myers EN: Management
of the vocal fold(s) or the tongue base, the duration of of swallowing in supraglottic and extended supraglottic
rehabilitation is significantly prolonged. laryngectomy patients. Head Neck 23:1043-1048, 2001.
CHAPTER
Supracricoid Partial Laryngectomy
36 with Cricohyoidopexy
or Cricohyoidoepiglottopexy
Authors F. Christopher Holsinger, Kitti Jantharapattana,
Gregory S. Weinstein, and Ollivier Laccourreye
Commentary by Robert L. Ferris, Meijin Nakayama, and Joshua S. Schindler
considerations must be reflected on when evaluating a

Preoperative Considerations patient for SCPL. As with any conservation laryngec-
Supracricoid partial laryngectomies (SCPLs) meet the tomy, patients with poor pulmonary function (severe
qualifications of conservation laryngeal surgery by chronic obstructive pulmonary disease or asthma) or
restoring the physiologic speech and swallowing without impaired microvascular circulation (such as with insulin-
the need for long-term tracheotomy or enteral feeding dependent diabetes mellitus, immunologic disorders, or
tube (see Holsinger et al, 2005). These procedures are peripheral vascular disease) should generally not be con-
indicated for selected endolaryngeal tumors. The fol- sidered good candidates. If the patient can walk two
lowing are contraindications to this procedure: flights of stairs, the patient most likely has adequate
n Tumor originating from the epilarynx pulmonary reserve to tolerate the procedure (see Brunelli
n Involvement of interarytenoid space or posterior et al, 2002).
commissure
n Tumor extension below the upper border of the
In general, the age limit of 70 years captures most
cricoid cartilage
patients with adequate functional reserve to tolerate
n Mucosal involvement of both arytenoids
postoperative aspiration, and motivation to adjust to
n Major invasion of the preepiglottic space
incorporate swallowing strategies. RLFerris
n Invasion of the hyoid bone
n Extralaryngeal spread of tumor
n Fixed arytenoid cartilage Although preoperative radiation therapy is not a
clear-cut contraindication, wound healing and rehabili-
tative potential is markedly different in these patients
Tumor extension below the upper border of the cricoid
(see Laccourreye et al, 1996). Oropharyngeal muscula-
cartilage and extralaryngeal spread of the tumor are
ture and cervical fibrosis can impair glottic elevation,
generally described as contraindications to SCPL. For
hyoepiglottic motion, and tongue-base mobility, extend-
well selected cases with limited subglottic extension
ing the time necessary for swallowing rehabilitation. For
below the upper border of the cricoid without cartilage
these patients a percutaneous gastrostomy should be
invasion, SCPL is amenable; tumor extension should
performed to anticipate delayed return of swallowing,
be well evaluated by high-resolution (1- to 2-mm
as long as 9 months in some patients.
slices) computed tomography (CT) scan of the head
and neck, with attention to the larynx. Likewise for
well-selected cases with limited extralaryngeal spread Persistent edema from radiated tissues may
of tumor, particularly at the anterior larynx, SCPL is compromise laryngeal mobility necessary for
amenable, for instance, to tumors with minimal deglutition, or result in laryngeal stenosis, requiring
invasion of the cricothyroid membrane. SCPL prolonged tracheostomy or gastrostomy use. RLFerris
surgeries for these particular cases, however, are not
recommended for surgeons early in their experience
with SCPL. MNakayama Another concern with post–radiation therapy (RT)
SCPL is submucosal spread and lack of adequate
salvage due to unrecognized residual disease.
Patient selection is always crucial for a successful RLFerris
postoperative course. Oncologic but also functional
346
CHAPTER 36 Supracricoid Partial Laryngectomy with Cricohyoidopexy or Cricohyoidoepiglottopexy 347
Thyroid
cartilage
Thyroid
cartilage
Arytenoid Hyoid
cartilages bone
Cricoid
cartilage
Posterior
cricoarytenoid m.
Cricoid
Inf. laryngeal n.
cartilage
Inf. laryngeal n.
Recurrent
A laryngeal n. B
FIGURE 36-1. The cricoarytenoid (CA) joint includes two cartilages: the “signet-ring” cricoid
and the arytenoid cartilages (main, corniculate, and cuneiform); laryngeal musculature: the
posterior CA, the lateral CA, and the interarytenoid; and nerves: the recurrent laryngeal nerve,
and the superior laryngeal nerve.
Another important factor in patient selection is the other hand they appear to be a valid alternative to
patient’s availability for close follow-up after the opera- total laryngectomy and chemoradiation protocols in
tion. Preoperatively it is important to discuss with the selected patients classified as T3 (see Dufour et al, 2004;
patient that the recovery process is challenging. The Laccourreye et al, 1996; Weber et al, 2004).
patient and family must set realistic expectations for From a functional perspective the SCPLs are built
both voice outcomes and the rigor of postoperative around the cornerstone of the cricoarytenoid (CA) unit
rehabilitation. A solid relationship between the patient as the fundamental unit of laryngeal function 1 (Figure
and speech-language pathologist must be established 36-1). Speech and swallowing are made possible by the
during the initial preoperative evaluation. This relation- CA unit, with special attention to the attachments of the
ship can foster a more realistic set of expectations for posterior and lateral CA muscles, which are responsible
postoperative care and, as a result, can facilitate a for neoglottic abduction and adduction postoperatively.
smoother postoperative recovery. This therapeutic rela- All these structures—muscular, neurovascular, and
tionship between patient and speech therapist is crucial cartilage—must be preserved during SCPL to ensure
to achieve good functional outcomes (see Holsinger optimal functional outcomes.
et al, 2005).
The SCPL remains an important part of the surgical
approach to laryngeal cancer. On one hand, this “open”
surgery has been shown to increase local control for The detailed anatomy of the CA unit, emphasizing
selected tumors classified as T1b to T3 when compared the innervations of intrinsic laryngeal musculature,
with endoscopic laser resection, the vertical partial lar- has been recently described (see Nakayama et al,
yngectomies, or radiation therapy (see Chevalier et al, 2007). MNakayama
1997; Laccourreye et al, 1994, 1997, 2000). On the
For closure, a pexy is created between the cricoid

We perform percutaneous gastrostomy placement
cartilage and the hyoid bone. The pexy is performed
in all of our partial laryngectomy patients at the
either by impacting the cricoid cartilage to the hyoid
time of the procedure unless they have a specific
bone, resulting in a cricohyoidopexy (CHP) (see Labayle
contraindication. We have found this to be safe and
and Bismuth, 1971; Laccourreye et al, 1990) or by
eliminates concerns regarding adequate nutrition,
impacting the cricoid to the hyoid bone and preserved
periodic malposition, or loss of a nasogastric feeding
portion of the epiglottis, resulting in a cricohyoidoepi-
tube and premature return to oral feeding. We do
glottopexy (CHEP) (see Laccourreye et al, 1990; Piquet
agree that gastrostomy placement is especially
et al, 1974). In selected cases, the anterior arch of the
important in those patients who have previously been
cricoid might be also resected, with a resulting tra-
treated with radiation or chemoradiation therapy as
cheocricohyoidoepiglottopexy (TCHEP) (see Crevier-
well as those who have more substantial supraglottic
Buchman et al, 1994).
resections with CHP. JSSchindler
Caution should be exercised in these cases for

Patients who require surgical salvage following
excessive subglottic tumor extension as well
radiation therapy or chemoradiation therapy for
as paratracheal nodal metastasis, potentially
glottic and supraglottic cancers should be strongly
necessitating postoperative adjuvant therapy,
considered for organ preservation surgery with
which can impair functional results. RLFerris
supracricoid partial laryngectomy using CHEP or CHP.
These patients can do extremely well. Loss of
the epiglottis for supraglottic cancers does make
TCHEP, removal of the anterior arch of the cricoid, swallowing significantly more difficult in the
has been reported, but in practice this procedure postoperative period and rehabilitation can take
could be considered risky from both an oncologic substantially longer, especially if one arytenoid also
and functional standpoint. It should be reserved as an needs to be removed. Laryngeal stenosis, persistent
extreme option during SCPL surgery for unexpected edema, and limited vocal fold mobility associated with
extension of the tumor. Most of the patients who radiation therapy may also complicate recovery and
require TCHEP may be best served by total ultimate function following partial laryngectomy.
laryngectomy, or if possible, an organ-preservation JSSchindler
chemoradiation. MNakayama
Operative Technique
Considerations STEP 1. The neck is slightly extended and a shoulder roll
is used. The bed is turned 180 degrees from the anes-
The bed must be turned 180 degrees from the anesthesia
thesia machine (see Step 18 for why this is important).
machine. The procedure is performed under general
anesthesia.
STEP 2. A U-shaped apron incision is then made begin-
ning in the lower neck, about 2 cm cephalad from the
All patients who elect for partial laryngectomy must sternal notch and then extending laterally.
be prepared for total laryngectomy. Meticulous
intraoperative frozen section margins must be A T-shaped incision is another option; the advantage
obtained to confirm that the patient is free of disease. of this incision is that the tracheostoma can be easily
The surgeon cannot compromise on surgical margins defined and located anywhere along with the
in order to complete the surgery because longitudinal suture line. MNakayama
postoperative radiation therapy is an extremely poor
option for positive margins identified on final pathology
result. If necessary, the decision must be made to Later in the procedure, the tracheotomy will be
complete the laryngectomy and patients must be placed through the central portion of this incision. If a
prepared for this prior to surgery. We strongly single or bilateral neck dissection is planned, this inci-
recommend a 1-hour session with a qualified speech- sion can be placed from mastoid tip to mastoid tip in a
language pathologist prior to the operative date to standard “utility flap.”
discuss rehabilitation following partial and total If only an SCPL is performed, for example, with a
laryngectomy. JSSchindler CHEP for an early radiation failure for glottic cancer,
the incision need not extend so far up the neck.
Typically the lateral arms of the incision can be placed STEP 8. Inferior to the thyroid, the pretracheal fascial
about midway between the lower neck and mastoid tip plane is gently finger dissected, and a cervicomediasti-
in this situation. nal release of the trachea is performed, down to the level
of the carina.
It is critical that this finger dissection is performed with

STEP 3. A broad-based subplatysmal flap is then
care to staying in the midline overlying the anterior wall
raised to about 2 cm above the hyoid bone and the
of the trachea as not to devascularize the trachea’s
inferior flap raised to immediately below the sternal
lateral or posterior blood supply.
notch.
STEP 4. The sternohyoid and sternothyroid muscles Anterior mediastinal release should be done
are identified in the midline and separated along comprehensively. Without adequate release of the
the linea alba (midline raphe) with the use of anterior 200 to 270 degrees of the trachea, there will
electrocautery. be excessive tension at the pexis when closure is
attempted. This is particularly true for salvage after
These strap muscles can be divided and tagged with radiation therapy. JSSchindler
absorbable sutures for later reapproximation, as a final
layer of closure over the laryngeal impaction. RLFerris
STEP 9. The larynx should now be released from its
attachments in the neck. First, the sternohyoid muscles
STEP 5. The central compartment lymphatics from the are divided along the upper edge of the thyroid cartilage
hyoid bone to the thyroid isthmus are removed. with the use of electrocautery.
This provides additional staging information, as well as STEP 10. The middle laryngeal vessels are ligated.
more direct access to the laryngeal structures for entry
into the cricothyroid space. RLFerris
STEP 11. The sternothyroid muscles are then divided at
their insertion along the oblique line of the thyroid
cartilage.
I’m careful here to include superficial lymphatics extend-
ing from the hyoid down to the pyramidal lobe area or During these maneuvers care is taken not to extend
delphian lymph nodes and more inferiorly to just above dissection beyond the lateral edge of the muscle to
the isthmus area. avoid injury to the superior laryngeal neurovascular
Frozen section is obtained if suspicious lymph nodes pedicle.
are encountered.
STEP 12. The larynx is then rotated to expose the con-

STEP 6. The thyroid isthmus is identified and divided strictor muscles.
with electrocautery and bipolar hemostasis obtained.
I like to use my thumb on the thyroid cartilage notch
and grasp with my fingertips along the contralateral side
STEP 7. The thyroid lobes are elevated laterally with the of the thyroid cartilage’s lateral edge.
use of electrocautery exposing the anterior trachea
walls.
STEP 13. The pharyngeal constrictors are incised along
the lateral edge of the thyroid cartilage down to the level
This maneuver reduces restriction and tethering of the of the cricoid cartilage.
trachea by Berry’s ligament. RLFerris
STEP 14. The inner perichondrium of the pyriform is

Be mindful not to elevate Berry’s ligament—particularly deflected from the thyroid ala as in a total laryngectomy
on the side(s) with CA subunit(s) to be preserved— bilaterally.
because you risk injury to the recurrent laryngeal
nerve (RLN). JSSchindler This maneuver is a key point in the preservation of the
branches of the superior laryngeal nerve (SLN) devoted
Hyoid Care should be paid to disarticulate the cricothyroid

bone
joint but to not harm the RLN. Hot instruments may be
used at the anterior aspect of the joint, but cold
instruments should be used at the posterior aspect of
the joint. RLN is running 1 to 2 mm lateral from the
posterior aspect of the joint and the nerve is generally
surrounded by nets of abundant veins. Identification of
nerve is generally not necessary and extra precaution
Thyroid should be paid not to injure the abundant veins while
cartilage
disarticulating the joint. MNakayama
The RLN is posterior and inferior to the joint; thus the

CA joint entry should be performed with a medial and
anterior motion to avoid slippage of the instrument
Cricoid and nerve injury. RLFerris
cartilage
Now the larynx should now be completely mobilized.
This maneuver should be done carefully. The adductor

branches of the RLN lie just posterior to CA facet.
Entry into the cricothyroid joint can be done with a
Cottle elevator, round knife, or No. 15 blade and
should be done from posteriorly to anteriorly to avoid
FIGURE 36-2. The disarticulation of the cricothyroid joint is inadvertent injury to this nerve. There is a small
shown here. Great care should be taken so as not to harm ligamentous attachment at the bottom of the inferior
the underlying inferior/recurrent laryngeal nerve, just inferior to cornu that should be divided sharply from posterior to
the tip of the inferior cornu. anterior as well. JSSchindler
to innervation of the mucosa of the pyriform sinus.

STEP 16. The endolarynx is entered by a horizontal
A cottonoid can facilitate the deflection of the pyriform
cricothyroidotomy, performed at the superior edge of
mucosa.
the cricoid cartilage.
Identify the joint with a sharp Freer as a way to find Place the patient transiently on room air, so as to reduce
the joint capsule. Occasionally, use of a No. 15 blade the chance of oxygen ignition and airway fire.
will create a controlled entry into the CA joint and Use electrocautery, scissors, or even a No. 15 blade
avoid a traumatic sequence of forcing the instrument scalpel to enter the endolarynx. The use of “cold steel”
in the vicinity of the RLN. RLFerris is associated with increased bleeding, but facilitates
frozen section histologic assessment of margins. Bipolar
cautery can then later be used for hemostasis.
Once released, a suture may be placed in the An endotracheal tube is placed through the cricothy-
perichondrium high and low in the pharyngeal rotomy to ease visualization and tumor resection. This
constrictor muscles and left loose (see Step 29). maneuver allows the surgeon to evaluate the inferior
These will be tied over the pexis after impaction to margin of the tumor.
reconstitute the pyriform sinuses and are tremendously
valuable for swallowing. The surgeon will find them
much easier to place now than after resection or Be careful not to extend the cricothyrotomy wider than
impaction. JSSchindler necessary to place the endotracheal tube at this time.
An excessively wide cricothyrotomy runs the risk of
dividing the lateral CA muscle(s). These will be the
STEP 15. The cricothyroid joint is then disarticulated only adductors of the remaining arytenoid(s) when
bilaterally (Figure 36-2), taking care not to harm the completed. JSSchindler
underlying inferior or RLN.
STEP 17A. For CHEP, a transepiglottic laryngotomy is STEP 20. Scissors or monopolar cautery is used to incise
performed by an horizontal incision through the preepi- down to just above and anteriorly to the body of the
glottic space, placed at the superior border of the thyroid arytenoid cartilage on the non–tumor-bearing side
cartilage. (Figure 36-3B).
One blade is placed within the larynx while the other

blade is placed within the deflected pyriform sinus and
The anterior commissure is generally midway between
the aryepiglottic fold.
the bottom of the thyroid notch and the bottom of the
The following structures are divided: upper part of
thyroid cartilage. Be sure to cut straight posteriorly in
the aryepiglottic fold, then the false vocal cord anterior
the midline just at the thyroid notch to avoid coming
to the body of the arytenoid cartilage, and last, the
too close to the anterior commissure and violating
thyroarytenoid muscle anterior to the vocal process of
the tumor. Extend the dissection laterally on the less
the arytenoid. Transection ends at the superior border
involved side to gain better exposure and direct
of the cricoid cartilage.
visualization of tumor to obtain an adequate mucosal
margin. JSSchindler
These cuts can be tricky for the novice or occasional

STEP 17B. For a CHP, the hyoepiglottic ligaments SCPL surgeon. Adequate visualization and palpation
(median and lateral) are transected at the level of of the larynx are critical. Be sure not to remove the
their insertion along the inferior border of the hyoid arytenoid or violate the CA joint on the side(s) to be
bone. preserved. I like to feel the vocal process and cut just
anterior to this as extend down through the paraglottic
This maneuver drops the preepiglottic space and pro-
space. JSSchindler
vides visualization of the mucosa of the vallecula. The
mucosa is then incised at its junction with the tongue
base.
STEP 21. This vertical transection is then connected with
the median cricothyroidotomy. The surgeon must follow
I like to use a Deaver retractor placed through the the curvature of the cricoid cartilage, high posteriorly
mouth into the vallecula to enter the pharynx (as in and low inferiorly. Anteriorly, the cricothyroid muscle
total laryngectomy). This can be challenging because and infraglottic mucosa are transected at the superior
the retractor is often just behind the hyoid bone, border of the cricoid cartilage with the use of scissors
but allows one to enter the pharynx and remove the or the electrocautery knife.
superior preepiglottic space. Adequate release of the
preepiglottic tissue laterally allows better visualization
of the pharyngeal mucosa. When removing the
preepiglottic space, be careful not to extend the Once anterior and inferior to the vocal process, bevel
dissection too far laterally and injure the SLN, as the cut to meet the anterolateral edge of the
mentioned previously by the authors. JSSchindler cricothyrotomy. This will preserve the lateral CA
muscle fibers and complete the division of the
cricothyroid muscle. JSSchindler
STEP 18. The surgeon must now move to the head of
the patient.
STEP 22. The thyroid cartilage is then grasped between
both hands and broken apart as if the surgeon were
STEP 19. Using an Allis clamp, either the petiole of opening a book.
the epiglottis is grasped (CHEP) or the tip of the This allows you to rotate the specimen along the most
epiglottis is grasped (CHP); resection then follows by involved side and to perfectly visualize the tumor (see
transection of the aryepiglottic folds bilaterally with Figure 36-3B).
electrocautery (Figure 36-3A).
While using a headlamp, a Metzenbaum scissors STEP 23. Based on the tumor extent as well as assess-
can be placed (closed) between the vocal folds, then ment preoperatively of laryngeal mobility (arytenoid car-
opened widely to expose the glottic tumor extent, tilage and true vocal cords), a decision is now made
prior to incising the false or true vocal folds. RLFerris regarding whether the arytenoid cartilage on the tumor-
bearing side is removed.
Hyoid
bone Hyoid
bone
Thyroid
cartilage
Oblique
arytenoid m. Thyroid
cartilage
Cricoid
cartilage
Posterior
cricoaryte-
noid m.
Cricoid
cartilage
A B
FIGURE 36-3 A, The epiglottis is grasped (CHEP) or the tip of the epiglottis is grasped (CHP);
resection then follows by transection of the aryepiglottic folds. B, Scissors or monopolar
cautery is placed anteriorly to the body of the arytenoid cartilage on the non–tumor-bearing
side.
Spare the corniculate cartilage: When resecting A 4-0 Vicryl suture can be used to suture the
arytenoid cartilage, corniculate cartilage should posterosuperior arytenoid mucosa over the exposed
be spared for postoperative swallowing function. cartilage, reducing the postoperative chrondritis and
MNakayama adding bulk to mimic an intact cartilaginous arytenoid
for approximation during phonation with the retained,
contralateral arytenoid. RLFerris
The posterior cuts, in front of or including the

arytenoid, can be made more precisely using a No. 15
Indications for arytenoid resection on tumor-bearing
blade than with a scissors. This also permits margins
side are as follows:
n Fixed vocal cord preoperatively
being taken directly at this point. RLFerris
n Paraglottic space invasion radiographically
Mucosal extension of tumor onto the face of the

Resection of the ipsilateral arytenoid cartilage allows
arytenoid is also a good reason to consider removing
the surgeon to completely resect the paraglottic space,
the arytenoid on the tumor-bearing side. JSSchindler
including a portion of the lateral CA muscle and overly-
ing cricothyroid muscle. If the arytenoid cartilage is
resected, the interarytenoid muscle, posterior arytenoid
STEP 24. In CHEP the ventricles must be inspected
mucosa, and corniculate cartilage are spared to allow
bilaterally to ensure that no mucosa is left behind.
for creation of a neoarytenoid that will be useful to
reduce postoperative aspiration (Figure 36-4). This prevents postoperative laryngocele formation.
Arytenoid
cartilage
Mucosa
reconstructing
arytenoid
Lumen of
esophagus Cricoid
cartilage
Arytenoid
Mucosa cartilage
reconstructing
arytenoid
A Cricoid
cartilage
Lumen of
larynx
FIGURE 36-4. When the arytenoid cartilage is resected, surrounding soft tissue can be
mobilized to create a “neoarytenoid,” which might aid in glottis closure, thus potentially
reducing postoperative aspiration.
STEP 26. To reposition the arytenoids, one or two 3-0

Inspect the pyriform sinuses with a finger as well. Vicryl sutures are set at the anterior aspect of the carti-
It is easy to violate these inadvertently during lage above the vocal process and sutured through to the
resection and any holes are easily closed prior to cricoid cartilage anteriorly.
reconstruction. JSSchindler
When both arytenoids are spared, the suture should be
tied to the lateral portion of the cricoid.
Although the ventricle is essentially completely

This “arytenoid suspension suture” is an air knot and
resected during an SCPL, retained mucosa of any
can be placed through the cricoid cartilage itself to
kind may enable mucus trapping and cyst formation,
secure it, or through the perichondrium. RLFerris
leading to a progressively enlarging laryngocele. This
can be aspirated transcutaneously under computed
tomography (CT) or ultrasound guidance, or When one arytenoid has been totally resected, the
marsupialized transorally using a CO2 laser. RLFerris suture for the remaining arytenoids should be placed to
the anterior arch of the cricoid cartilage. This moves the
arytenoid as much as possible to the midline to reduce
the gap created by the resection of the contralateral
Reconstruction arytenoids.
Also, in such cases, the completion of the corniculate
STEP 25. Before impaction the remaining arytenoid flap, using the preserved retroarytenoid mucosa on the
cartilage(s) must be repositioned; transection of the thy- side of the resected arytenoids, will create neo-nonmobile
roarytenoid muscles leads to a posterior slide and swing arytenoids, which reduces the risk of aspiration (see
of the arytenoids (Figure 36-5). Figure 36-4).
Thyroid
All three impaction sutures should be used to close
cartilage the neoglottis simultaneously, and each is tied down
Vocal Arytenoid in succession with six to eight half-knots. This will
cord cartilage reduce pulling them through the tissues or cricoid, by
Cricoid distributing tension of the closure to all three stitches.
cartilage RLFerris
The intubation tube is removed and the tracheotomy

incision is performed, aligned with the skin. Ventilation
A is then performed by the tracheotomy.
Arytenoid
cartilage
Often the tracheotomy is far lower in the trachea than
a standard tracheotomy. The interspace between
Cricoid
cartilage rings five and six or six and seven is common. Be
sure that there is enough room above the carina for
the tracheotomy tube. This is not generally a
B problem. JSSchindler
Arytenoid
cartilage
STEP 28. Impaction.
Sutures
For CHP, the larynx is approximated by suturing the
Cricoid hyoid bone to the cricoid. For the CHEP, the remaining
cartilage portion of the epiglottis as well as the hyoid bone are
both impacted to the cricoid cartilage.
C Prior cervicomediastinal tracheal release (see Step 8)
allows the trachea to be ascend superiorly and minimize
FIGURE 36-5. This schema demonstrates the position of the tension on the impaction; 1-0 Vicryl sutures on a curved
arytenoids cartilage in normal position (A) and after resection
65-mm needle are used. A 1-0 Vicryl suture on a large
in a retroplaced location toward the posterior hypopharyngeal
curved needle (65 mm) must be used for the impaction.
and esophageal introitus (B). Transection of the thyroarytenoid
muscle leads to a posterior slide and displacement of the
arytenoids. Sutures should be placed to resuspend the This is necessary to incorporate sufficient tissue
arytenoids anteriorly, shown here (C) after repositioning. above and below the site of laryngeal impaction/
reconstruction. RLFerris
A good guide for when the arytenoid has been
adequately repositioned is when it no longer contacts
Three stitches placed 8 to 10 mm apart from the
the posterior pharyngeal wall as the suture is tied
midline are passed from inferior to superior, submuco-
down. (See the authors’ description and pay careful
sally around the cricoid cartilage, and then to the epi-
attention to Figure 36-5.) Using any remaining superior
glottis and hyoid in the CHEP and around the hyoid
or posterior arytenoid mucosa to cover the exposed
and tongue base in the CHP (Figure 36-6). Every stitch
cricoid surface will speed healing, limit granuloma
must begin caudally, and proceed from cricoid to epi-
formation, and help prevent stenosis. Often this
glottis and/or hyoid.
redundant mucosa is what vibrates and allows better
voicing following SCPL as well as closure for
Measuring the 10-mm spacing between stitches at
swallowing. JSSchindler
each entry hole of the needle will ensure symmetric
impaction and align the supraglottis with the neoglottic
structures to avoid laryngeal stenosis and minimize
STEP 27. The tracheotomy must be performed and
aspiration of the bolus. RLFerris
aligned with the skin incision allowing for easy recan-
nulation if postoperative respiration problems occur
At the time of impaction, the surgeon must take care
after removal of the tube.
to align the hyoid with the cricoid. If the cricoid is pos-
To do so, the stitches that are placed for impaction are terior to the hyoid bone, the arytenoid cartilage will be
approximated and the head of the patient is set back located far from the epiglottis and/or tongue base,
into normal position (from the previously extended resulting in an increased risk for aspiration together
position). with severe dysphonia.
Hyoid bone
Constrictor
muscles
Hyoid bone
Constrictor
muscles
Cricoid Cricoid
cartilage cartilage
A B
FIGURE 36-6. Three stitches placed 8 to 10 mm apart from the midline are passed from
inferior to superior, submucosally around the cricoid cartilage, and then to the epiglottis and
hyoid in the CHEP and around the hyoid and tongue base in the CHP.
STEP 29. The deflected pyriform sinuses are reposi-

I have not found that maintaining the sutures in a tioned lateral to the impaction to re-create the funnel
submucosal plane is necessary. Although desirable, shape of the hypopharyngeal inlet by restoring the
do not risk fracturing the cricoid to accomplish this lateral pharyngeal gutters.
with the large and sometimes unwieldy 65-mm needle.
I bring the central suture through the petiole of the This is accomplished by placing two 3-0 Vicryl stitches
epiglottis in CHEP and then widely into the base of in the fascia of the released inferior constrictor muscles.
tongue and around the hyoid bone. This may help These stitches from the bilateral constrictors are then
flatten the tongue base some and push the midportion tied anteriorly to its contralateral stitch after the com-
of the epiglottis posteriorly to facilitate glottic paction is completed (Figure 36-7).
competence. In CHP, I pass the sutures through the
base of tongue mucosa and then widely into the base
of tongue as with CHEP closure to accomplish the STEP 30. Suction drains are placed.
same thing. Be mindful to include the mucosa in
the sutures because this aligns the mucosa with the Two or three No. 10 flat Jackson-Pratt drains are
cricoid mucosa and helps limit stenosis. To ensure placed to maintain negative pressure and counteract
good approximation of the cricoid and hyoid bone, I the air leak from the impaction or the tracheotomy
have an assistant hold the middle suture crossed to site. I prefer to maintain these on wall suction
approximate the two and then tie the sutures on either (–100 cm H2O) for 72 hours at which point they should
side. There must be no gaps in the pexis when hold self-suction (bulb). They may be removed, as per
completed. JSSchindler routine criteria, at postoperative day 5 or 6. RLFerris
Hyoid bone
Cricoid
cartilage
Constrictor
muscles
First tracheal ring Hyoid bone
Cricoid
cartilage
Constrictor
muscles
First tracheal ring
FIGURE 36-7. To reconstitute the funnel shape of the hypopharyngeal inlet, the deflected
pyriform sinuses are repositioned. This is accomplished by placing two 3-0 Vicryl stitches
in the fascia of the released inferior constrictor muscle. These stitches from the bilateral
constrictors are then tied anteriorly to the contralateral stitch after the compaction is
completed.
STEP 31. The wound is closed in layers. First, the frequent in this population. On postoperative day 1,
sternohyoid muscles and supporting “strap muscles” daily chest physiotherapy should be instituted and the
can be used to close over the impaction, then the patient should be instructed to walk.
platysma muscle and finally the skin edges carefully The decision for tube removal and a timetable for
approximated. decannulation starts by postoperative day 3. The tra-
cheostomy tube is plugged and the tracheotomy tube is
removed when the patient tolerates the tube plugged
Postoperative Management continuously during the day. If laryngoscopy demon-
strates arytenoid edema (as is often the case with SCPL
Airway and Tracheostomy Management
following radiation therapy), use steroids and consider
A cuffed tube is used for the first 12 hours because it delaying the decannulation algorithm. If the patient
provides comfort to the patient on the first postopera- cannot tolerate tracheotomy tube occlusion, frequent
tive night. We advocate deflating this cuff early on the reassessment should be performed in order to hasten
first postoperative day because it helps restore the laryn- decannulation, either as an inpatient or on an outpatient
geal closure reflex (see Sasaki et al, 1977). basis with very close follow-up.
Because all patients aspirate during the postoperative
period, proper patient selection with pulmonary func- Stomal tube should be removed by 2 days post-SCPL,
tion assessment preoperatively is crucial. Postoperative at which time saliva and secretion from the oropharynx
antibiotics are also given because all of these patients are blocked by an extensive edema of neoglottis and
have, in fact, silent aspiration and occult pneumonitis. seldom flow into trachea. The contour of tracheal
Broad-spectrum antibiotic coverage is continued until stoma should be well established to avoid stenosis of
the tracheotomy site is closed and healed. Antireflux the stomal opening. MNakayama
therapy is also indicated to fight against silent reflux,
I typically place a No. 6 or 8 cuffed tracheotomy tube keep the muscles active and prepared to begin
at the time of the procedure. It is critical to deflate the swallowing shortly. Once the patient has had the
cuff early because this also prevents the continued ability to Valsalva restored, through Passey-Muir valve
presence of irritating secretions from sitting at the placement, corking, or decannulation, we begin a
pexis. I replace the tracheotomy tube with a No. 6 protocol of ice chips and water and advance through
cuffless tube on postoperative day 5. On the first thick liquids and soft solids rapidly. We have found
postoperative visit—typically days 10 to 12—the tube that asking the patient to actively displace the occiput
can be corked or a Passey-Muir valve can be placed if posteriorly often opens the hypopharynx and facilitates
the airway remains inadequate. JSSchindler swallowing. This is particularly useful in patients who
have undergone CHP reconstruction because they
have no epiglottis to deflect secretions away from their
Swallowing airway. A small amount of aspiration must be tolerated
in the postoperative period and should not slow efforts
Once the patient has been decannulated, resumption of
to resume oral feeding. If a patient continues to
normal deglutition should follow a standardized algo-
aspirate, consider evaluation of the neoglottis for
rithm. We advocate early and initial removal of the
sensation. Patients with an insensate larynx are at
tracheotomy tube prior to the feeding tube because
grave risk for clinically relevant aspiration, and
decannulation may promote recovery of the coughing
progression to oral feeding will be slow. JSSchindler
reflex and thus facilitate resumption of normal swallow-
ing. The surgeon must know that there two main factors
that might significantly delay the recovery of swallow-
ing function: (1) complete resection of an arytenoid
Complications
cartilage and (2) transection or injury to the main trunk Major complications include perichondritis, laryngeal
of the SLN. If such events occur and if the patient pres- stenosis, pneumonia from aspiration, cervical wound
ents with the following factors, advanced age more than infection, symptomatic laryngocele, ruptured pexis, and
75 years, severe bronchitis, diabetes mellitus (DM), laryngeal chondroradionecrosis (see Laccourreye et al,
arteritis, or preoperative radiation therapy, we advocate 1996; Naudo et al, 1998).
early completion of percutaneous gastrostomy that will The ruptured pexis after SCPL is a rare event. The
be used until resumption of swallowing without aspira- incidence was reported at 0.8%. The suspected cases
tion is documented on modified barium swallow. always present with postoperative chronic aspiration;
Prior to feeding tube removal, the patient should moreover, they may be palpated a gap between hyoid
demonstrate secretion management with swallowing of bone and cricoid cartilage (see Laccourreye et al, 1997).
saliva for 3 to 5 days. Therefore, immediately after In the event of ruptured pexis, the revision of SCPL
feeding tube removal, the patient’s diet should consist is recommended. If the anterior cricoid cartilage is
exclusively of a soft mechanical diet, such as pudding, strong enough or destabilized, new sutures can be passed
Jell-O, and soft solids, which maximize sensory feed- around the first two tracheal rings, the hyoid bone, and
back during swallowing. Honey, thick liquids, or car- the tongue base (see Laccourreye et al, 1997).
bonated beverages are then gradually introduced, To avoid a ruptured pexis, tension-free sutures must
keeping in mind that thin liquids are the most difficult be placed at the time of initial surgery. This is facilitated
consistency to learn to swallow. Proper positioning with adequate cervicomediastinal tracheal release (see
during swallowing is also emphasized to the patient: the Step 8) (see Laccourreye et al, 1997). The incidence of
head is leaned forward (“chin tuck”) and the shoulders postoperative laryngeal stenosis is rare, seen in only
lifted. This maneuver facilitates a safe swallow by 3.7% of all cases. A delayed laryngeal stenosis is more
helping to tuck the neoglottis under the tongue base to common after CHP (see Diaz et al, 2000).
improve closure and help to propel the bolus into the Obstructive sleep apnea may also present after
hypopharynx. Further positioning benefit is gained by supracricoid partial laryngectomy (see Israel et al, 2006)
having the patient sleep, as well as eats, in an upright and should be included in the surgeon’s postoperative
position to help manage the secretions. Learning these survey.
maneuvers is greatly facilitated by a team of speech
therapists, nurses, and chest physical therapists. Suggested Readings
Brunelli A, Al Refai M, Monteverde M, Borri A, Salati M,
We initiate swallowing therapy immediately following Fianchini A: Stair climbing test predicts cardiopulmonary
deflation of the cuff with a “spitting protocol” with complications after lung resection. Chest 121:1106-1110,
simple lip and tongue expectoration of secretions. All 2002.
patients will have difficulty managing their secretions Chevalier D, Laccourreye O, Brasnu D, Laccourreye H, Piquet
following this procedure and simple spitting helps JJ: Cricohyoidoepiglottopexy for glottic carcinoma with
fixation or impaired motion of the true vocal cord: 5-year
oncologic results with 112 patients. Ann Otol Rhinol Lar- and transglottic carcinomas. Laryngoscope 100:735-741,
yngol 106:364-369, 1997. 1990.
Crevier-Buchman L, Laccourreye O, Monfrais-Pfauwadel Laccourreye H, Laccourreye O, Weinstein G, Menard M,
MC, Menard M, Jouffre V, Brasnu: Computerized evalua- Brasnu D: Supracricoid laryngectomy with cricohyoidoepi-
tion of acoustic parameters of voice and speech after partial glottopexy: a partial laryngeal procedure for glottic carci-
supracricoid laryngectomy with cricohyoidoepiglottopexy. noma. Ann Otol Rhinol Laryngol 99:421-426, 1990.
Ann Otolaryngol Chir Cervicofac 111:397-401, 1994. Laccourreye O, Muscatello L, Laccourreye L, Naudo P, Brasnu
Diaz EM, Jr, Laccourreye L, Veivers D, Garcia D, Brasnu D, D, Weinstein G: Supracricoid partial laryngectomy with
Laccourreye O: Laryngeal stenosis after supracricoid partial cricohyoidoepiglottopexy for “early” glottic carcinoma
laryngectomy. Ann Otol Rhinol Laryngol 109:1077-1081, classified as T1-T2N0 invading the anterior commissure.
2000. Am J Otolaryngol 18:385-390, 1997.
Dufour X, Hans S, De Mones E, Brasnu D, Menard M, Laccourreye O, Ross J, Brasnu D, Chabardes E, Kelly JH,
Laccourreye O: Local control after supracricoid partial Laccourreye H: Extended supracricoid partial laryngectomy
laryngectomy for “advanced” endolaryngeal squamous cell with tracheocricohyoidoepiglottopexy. Acta Otolaryngol
carcinoma classified as T3. Arch Otolaryngol Head Neck 114:669-674, 1994.
Surg 130:1092-1099, 2004. Laccourreye O, Weinstein G, Naudo P, Cauchois R,
Holsinger FC, Laccourreye O, Weinstein GS, Diaz EM, Jr, Laccourreye H, Brasnu D: Supracricoid partial laryngec-
McWhorter AJ: Technical refinements in the supracricoid tomy after failed laryngeal radiation therapy. Laryngoscope
partial laryngectomy to optimize functional outcomes. J Am 106:495-498, 1996.
Coll Surg 201:809-820, 2005. Nakayama M, Hirose H, Okamoto M, Miyamoto S,
Israel Y, Cervantes O, Abrahão M, Ceccon FP, Marques Filho Yokobori S, Takeda M, et al: Electromyography of the
MF, Nascimento LA, et al: Obstructive sleep apnea in cricoarytenoid unit during supracricoid laryngectomy with
patients undergoing supracricoid horizontal or frontolateral a cricohyoidoepiglottopexy procedure. J Laryngol Otol
vertical partial laryngectomy. Otolaryngol Head Neck Surg 121:87-91, 2007.
135:911-916, 2006. Naudo P, Laccourreye O, Weinstein G, Jouffre V, Laccourreye
Labayle J, Bismuth R: Total laryngectomy with reconstitution. H, Brasnu D: Complications and functional outcome
Ann Otolaryngol Chir Cervicofac 88:219-228, 1971. after supracricoid partial laryngectomy with cricohyoido-
Laccourreye O, Brasnu D, Laccourreye L, Weinstein G: Rup- epiglottopexy. Otolaryngol Head Neck Surg 118:124-129,
tured pexis after supracricoid partial laryngectomy. Ann 1998.
Otol Rhinol Laryngol 106:159-162, 1997. Piquet JJ, Desaulty A, Decroix G: Crico-hyoido-epiglotto-
Laccourreye O, Laccourreye L, Garcia D, Gutierrez-Fonseca pexy. Surgical technic and functional results. Ann Otolar-
R, Brasnu D, Weinstein G: Vertical partial laryngectomy yngol Chir Cervicofac 91:681-686, 1974.
versus supracricoid partial laryngectomy for selected carci- Sasaki CT, Suzuki M, Horiuchi M, Kirchner JA: The effect of
nomas of the true vocal cord classified as T2N0. Ann Otol tracheostomy on the laryngeal closure reflex. Laryngoscope
Rhinol Laryngol 109:965-971, 2000. 87:1428-1433, 1977.
Laccourreye H, Laccourreye O, Weinstein G, Menard Weber RS, Forastiere A, Rosenthal DI, Laccourreye O:
M, Brasnu D: Supracricoid laryngectomy with cricohyoido- Controversies in the management of advanced laryngeal
pexy: a partial laryngeal procedure for selected supraglottic squamous cell carcinoma. Cancer 101:211-219, 2004.
CHAPTER
Total Laryngectomy
37 Authors F. Christopher Holsinger and Mihir K. Bhayani
Commentary by Ollivier Laccourreye, Kerry D. Olsen, Steven M. Olsen, Ashok R. Shaha,
and Stephen J. Wang
Total laryngectomy (TL) is the classic operation first

comorbidities. Rarely TL is required for intractable
performed by Billroth on New Year’s Eve in 1863. Mul-
aspiration, extension of invasive tumors (i.e., thyroid)
tiple modifications have taken place since the original
into the larynx, hypopharyngeal or cervical esophageal
operation, and now it is described as a wide-field TL. It
cancer requiring laryngopharyngectomy, and extensive
involves removal of the entire larynx, strap muscles,
tongue cancer requiring total glossectomy. KDOlsen
paratracheal lymphatics, and sometimes the ipsilateral
and SMOlsen
thyroid lobe.
Indications for the surgery are any advanced endo
laryngeal tumor that is not amenable to partial laryn-
geal surgery. Also, patients who have undergone previous
radiation therapy with or without chemotherapy with a There has been a paradigm shift away from open
resultant dysfunctional larynx (intractable aspiration “conservation” surgery for laryngeal tumors. Partial
and/or dysphagia refractory to therapeutic maneuvers) laryngectomy is rarely performed now in lieu of
are also candidates for a TL. Although not a contrain- endoscopic laser excision. Indications for TL as a
dication, significant tumor extension into the hypophar- primary surgical treatment are rare, unless there is
ynx necessitating a partial pharyngectomy or extensive major cartilage destruction or soft tissue extension of
tongue base involvement requires that the surgeon be disease. However, there do remain indications for TL
prepared to perform free-tissue transfer as part of the as a salvage surgical procedure. Salvage laryngectomy
reconstruction. In these cases, microvascular reconstruc- is technically more complicated and a different
tion facilitates optimal function outcomes and dimin- surgical procedure than primary TL. Issues related to
ishes the rate of pharyngocutaneous fistula, especially healing, making the appropriate diagnosis, and
after previous radiation treatment. radiation-related complications are major concerns in
radiation failure salvage TL. ARShaha
In these cases, the use of a pedicle muscular flap

together with the completion of a preoperative
percutaneous gastrostomy is also a valuable
option. OLaccourreye Preoperative Considerations
Preoperative imaging of the head and neck using com-
Free-tissue transfer or other vascularized muscle flap puted tomography (CT) or magnetic resonance imaging
may also be considered for placement over the (MRI) is helpful when determining if there is adenopa-
pharyngeal closure line for TL performed after previous thy that should be addressed at the time of TL. Imaging
chemoradiation treatment, in order to diminish the also facilitates tumor staging by determining if there is
incidence and severity of pharyngocutaneous cartilage invasion, involvement of the prevertebral
fistula. SJWang fascia, and/or encasement of the carotid artery.
Precise endoscopic evaluation under anesthesia of
the primary tumor is imperative to determine the extent
In general, the indications for TL include surgical of the tumor, ideally with rigid zero and angled high-
salvage after failed radiation or chemoradiation, and resolution endoscopes. If there is involvement of the
T4 larynx cancer. TL is rarely required for patients with hypopharynx and/or tongue base, operative plans can
mobile vocal cords unless they have failed prior organ be adjusted accordingly. Laryngoscopy can be done at
preservation therapy or have significant medical the time of the laryngectomy if the patient is prepared
for possible free-tissue or pedicle flap reconstruction.
359
A careful in-office examination with attention to vocal Intubation should be performed with a small
cord mobility, subunit involvement, submucosal extent, endotracheal tube (No. 6 or 7). ARShaha
or cervical adenopathy is critical. Subglottic extent can
be assessed with a flexible laryngoscope after
anesthetizing the vocal cords. If a tissue diagnosis is STEP 2. A curvilinear incision is marked in a natural
needed, in-office biopsy can be obtained with an skin crease about two fingerbreadths below the
endoscopic cups forceps. Information from the cricoid cartilage that extends to posterior border of
physical examination is augmented with imaging to the sternocleidomastoid (SCM) muscle on both sides
determine cartilage extension or nodal disease, for (Figure 37-1).
example. It is important to realize that imaging of the
A low midline incision can lead to stomal retraction or
larynx is often unreliable due to variability in cartilage
stenosis and difficulty with tracheoesophageal speech.
ossification, effacement of mucosal surfaces, or
If a neck dissection is included with the surgery,
inflammation. KDOlsen and SMOlsen
extending the incision to the level of the mastoid tip is
indicated.
A preoperative evaluation is very important, both with

We tend to perform tracheotomy at the beginning of
fiberoptic laryngoscopy and direct laryngoscopy. Vocal
the procedure to remove anesthesia equipment from
cord function and mobility are crucial to ascertain in
the operative field. If the tumor is obstructive, we
the preoperative evaluation. Generally patients with
perform awake tracheotomy with local anesthesia. The
advanced laryngeal cancer have a paralyzed vocal
decision to incorporate the tracheostomy site into the
cord, and the extent of disease must be evaluated,
laryngectomy incision depends on the length of the
especially the supraglottic extension, and extension
patient’s neck. In patients with long necks, we perform
into the pharyngeal mucosa and base of the tongue.
the tracheostomy 2 to 3 cm above the sternal notch
The subglottic extension is also important to assess.
and use an incision at the level of the thyroid cartilage
A majority of parastomal recurrences are directly
for the laryngectomy. With short necks we often
related to major subglottic extension or paratracheal
incorporate the stoma into a lower apron incision.
extension of disease with tracheoesophageal lymph
KDOlsen and SMOlsen
nodes. Patients who have received radiation and
chemotherapy are difficult to evaluate. Appropriate
diagnosis of recurrent disease may be difficult and
STEP 3. The incision is deepened to the level of the
evaluation with endoscopy, CT scan and positron-
platysma muscle.
emission tomography (PET) scan may be important.
Sometimes the diagnosis of recurrent cancer may be Maintaining dissection to the platysma muscle facili-
difficult, especially if the mucosa appears to be normal tates identification of the external jugular vein and
and a salvage TL may be necessary in a functionless greater auricular nerve.
larynx. Patients undergoing TL for salvage surgery
need to be evaluated for appropriate reconstruction.
Some patients may have pharyngeal involvement and STEP 4. Incise through the platysma muscle and raise
require partial pharyngectomy or circumferential subplatysmal flaps superiorly to the level of the mandi-
pharyngectomy necessitating appropriate ble and inferiorly to the level of the clavicle.
reconstruction, either with pectoral myocutaneous flap
or with a free microvascular reconstruction. Because Skin hooks are placed over wet gauze to prevent desic-
the incidence of fistula formation in salvage surgery is cation of skin flaps while retracting.
high, a pectoral myocutaneous flap may be used as a
cushion. ARShaha
STEP 5. Using electrocautery, the fascia on the inferior
border of the submandibular gland is incised to identify
Surgical Technique the posterior belly of the digastric muscle, and the fibro-
fatty tissue is released posteriorly to the SCM. The
fascia of the SCM is then unwrapped, beginning at the
STEP 1. The patient is placed in the supine position on
level digastric muscle to its tendinous coalescence at
the operating room table. After induction of general
the clavicular head (Figure 37-2).
anesthesia, a shoulder roll is placed to extend the neck.
I prefer to turn the bed 180 degrees from the anesthesia This maneuver allows for retraction of the SCM as
machine to have complete access to the neck and later the internal jugular vein is identified and forms an
to approach the larynx from above the patient’s head. “outer tunnel.”
CHAPTER 37 Total Laryngectomy 361
Incision
FIGURE 37-1. Incision placement for total laryngectomy. Place in a natural skin crease and
extend to hash mark seen at midpoint of sternocleidomastoid muscle on posterior border. If
neck dissection is indicated, extend the incision superiorly to the mastoid shown, as by dotted
line. The contralateral side mirrors this incision.
STEP 6. The anterior surface of the internal jugular vein This develops the inner tunnel. Fibrofatty tissue has
is now identified and dissected from the digastric to the been swept in a wide field from the SCM to the carotid.
level of the omohyoid muscle. This muscle is then tran-
sected at this point and the vein is skeletonized to the
level of the clavicle. STEP 8. Along the inferior portion of the common carotid
artery the dissection can turn medial by transecting the
strap muscles at the level of the manubrium (Figure 37-3).
The surgical sequence depends on the extent of
By doing this, the fibrofatty contents of the paratracheal
surgery. When a unilateral neck dissection is required,
bed can be swept medially.
we perform unilateral neck dissection followed by
The end of the anterior jugular vein is encountered
laryngectomy. If bilateral neck dissections are
in this step and must be isolated and ligated (Figure
required, we perform ipsilateral neck dissection and
37-4). Ensure meticulous hemostasis when dividing the
laryngectomy. The pharynx is then closed prior to
strap muscles because the muscle will retract under the
proceeding with contralateral neck dissection to
clavicle and pose an unneeded challenge to control if
minimize edema during the pharynx closure. KDOlsen
bleeding is encountered.
and SMOlsen
When laryngectomy alone is desired, we perform a

STEP 7. Dissection is directed along the carotid artery less aggressive lateral dissection. The SCMs are
allowing for the fascial tissue to be mobilized further retracted laterally; the omohyoid, sternohyoid, and
medially. sternothyroid are divided inferiorly; and a plane is
created medial to the carotid from the upper trachea
Release of the tissue along the carotid artery facilitates to the hyoid. We do not routinely create the described
identification of the superior thyroid artery and the inner and outer tunnels. KDOlsen and SMOlsen
hypoglossal nerve.
Skin flaps
raised
Fascial
incisions
Strap
muscles
divided
FIGURE 37-2. After subplatysmal flaps are raised and FIGURE 37-3. The sternocleidomastoid muscle is retracted
secured, fascial incisions are made along the dashed lines. laterally, creating the outer tunnel, and the strap muscles are
exposed and incised.
STEP 9. Once the anterior tracheal wall is encountered, STEP 12. The contralateral lobe is reflected laterally off
the fibrofatty contents are lifted superiorly to the first or the trachea and its vascular pedicle preserved to mini-
second tracheal ring. mize the risk of hypothyroidism especially in previously
radiated patients (Figure 37-5).
Be aware of tumor erosion through the cricoid or first
tracheal ring so that tumor is not incised. Thyroid lobectomy is indicated if there is subglottic
extension of tumor or direct extension of tumor into the
gland.
STEP 10. These maneuvers are repeated on the contra-
lateral side. In such cases the lobectomy also eases the
completion of an ispsilateral paratracheal lymph node
dissection. OLaccourreye
STEP 11. The thyroid gland is encountered and divided
at the isthmus, and the thyroid lobe ipsilateral to the If parathyroid tissue is encountered, it can be pre-
tumor can sometimes be taken with the specimen, espe- served in situ or removed and later reimplanted if devi-
cially when there is concern that the tumor has spread talized during paratracheal dissection.
beyond the confines of the larynx. A central compart-
ment dissection should always be performed from hyoid When preserving a thyroid lobe, the isthmus is divided
to manubrium, including all lymphoadipose tissue, and the gland is reflected laterally off the trachea
including not only the delphian nodes but also lymphat- using cautery. Dissection is carried down to the
ics associated with the “strap” muscles. tracheoesophageal groove, creating a plane lateral to
the pharyngeal constrictors. The recurrent laryngeal
nerve is identified and divided. The superior thyroid
This is especially important for patients with anterior or pedicle is reflected laterally with the gland and
subglottic tumor extension. KDOlsen and SMOlsen preserved. KDOlsen and SMOlsen
Superior
thyroid
artery
Omohyoid
Internal divided
jugular
vein
Thyroid
divided,
Anterior jugular lobe
vein identified dissected
and divided laterally
Fat and fascia

dissected
toward midline
FIGURE 37-4. When releasing the strap muscles, care must FIGURE 37-5. The thyroid gland is divided at the isthmus.
be taken to identify the main trunk of the anterior jugular vein The lobe that is on the contralateral side of the tumor is then
and ligate it. reflected off the trachea while preserving its vascular pedicle.
STEP 13. The superior pedicle is preserved on the spared STEP 15. Suprahyoid musculature is released using
thyroid lobe and laryngeal branches are ligated. electrocautery from the hyoid bone from the midline
proceeding out along the greater horns on both sides
(Figure 37-7).
STEP 14. The fatty contents of level IA are incised
The stylohyoid ligament must be released to get full
and lifted off the anterior bellies of the digastric and
mobilization of the greater horn.
underlying mylohyoid to the level of the hyoid bone
The hyoid bone should gently but firmly be rotated
(Figure 37-6).
out of the neck, so as the place tension on its muscular
This step is done only to facilitate identification of the attachments. By pressing the contralateral horn inter-
hyoid bone because level IA is an extremely unlikely nally, the ipsilateral hyoid is rotated out of the neck,
echelon for metastatic disease and the incidence of providing improved visualization during this muscular
metastasis from laryngeal cancer at level I is quite small. release.
Byers advocated this maneuver to provide a precise and Be cognizant of hypoglossal nerve injury as dissec-
more elegant surgical approach to the hyoid (RM Byers, tion proceeds laterally. If you carefully dissect only on
personal communication). the bone, the nerve will not be injured.
While dissecting on the surface of the submandibular

salivary gland, one needs to be absolutely careful to This step facilitates the mobilization of the larynx and
avoid injury to the lower division of the facial nerve eases all the steps that allow the surgeon to expose
(ramus mandibularis). ARShaha the larynx before the entry. OLaccourreye
Hypoglossal
nerve Hypoglossal
nerve
Posterior
belly
digastric
muscle Suprahyoid
musculature
released
Fascia
and fat
dissected
toward
hyoid
FIGURE 37-6. The hyoid bone is identified by incising the FIGURE 37-7. The suprahyoid musculature is released off the
fascia of level IA and reflecting it inferiorly off the anterior hyoid bone. It is important to perform the dissection on the
belly of the digastric muscle. Note the close proximity of the bone to avoid injury to the hypoglossal nerve and lingual
hyoid bone to the hypoglossal nerve, especially at the lesser artery.
cornu, emphasizing the importance of identifying the hyoid
bone.
Dissection is then carried from medial to laterally With regard to the superior laryngeal neurovascular
releasing the suprahyoid musculature from the bundle, dissection with a hemostatic forceps in a
superior surface of the hyoid. Care must be taken at transverse direction reveals the artery and vein
the lesser cornu to avoid inadvertent injury to the positioned just anterior to the nerve. The common
lingual artery or hypoglossal nerve. Once the laryngeal pedicles are isolated, divided, and ligated.
suprahyoid musculature is released Allis clamps are As pointed out, the superior thyroid pedicle can be
placed on the body of the hyoid and on the greater preserved when the thyroid gland is saved. After
cornu to aid with retraction. The posterior soft tissue dividing the pedicle a laryngeal or cricoid hook is
attachments are then sharply dissected free from the placed on the midportion of the posterior edge of the
tip of the greater cornu approximately 2 cm back thyroid ala rotating the cartilage anteriorly.
toward the midline. KDOlsen and SMOlsen Electrocautery or the Freer elevator is used to free the
constrictor muscle from the thyroid ala along the entire
length of the cartilage on both sides. KDOlsen and
STEP 16. Dissection now is directed to releasing the SMOlsen
pharyngeal constrictors from the thyroid ala on both
sides (Figure 37-8A).
It is important to preserve pyriform sinus mucosa
The superior laryngeal vessels are identified here, and here by releasing the muscle and fascia from the inner
the end-terminal branches are divided. surface of the thyroid cartilage (see Figure 37-8B).
I prefer to use a Freer elevator to elevate the pyriform

My practice is to perform the hemostasis of the vessel mucosa off the inner surface of the thyroid cartilage.
originating from these trunks distantly only at the level SJWang
where they penetrate the musculature and mucosa of
the pharynx that will be transected for resection of the
specimen. This maneuver allows for preservation of the This step should be performed only on the
distant vascularization of the muscles and mucosa that noninvolved tumor side because posteriorly the
will be used for closure, thereby reducing the risk for paraglottic space is in contact with the internal portion
subsequent development of a fistula. OLaccourreye of the pyriform sinus. OLaccourreye
Constrictor
muscles
released
Constrictor
muscles
released
Pyriform
B sinus
FIGURE 37-8 A, The pharyngeal constrictor muscles are released from the thyroid ala using
the electrocautery knife. B, After the constrictors are released and the superior laryngeal
pedicle has been identified and ligated, the mucosa of the pyriform sinus is released from the
inner perichondrium of the thyroid ala using an elevator. This step should be avoided on the
tumor side if tumor is located in the pyriform sinus.
Tracheal
incision
Posterior
lamina of Larynx
cricoid dissected
off of
esophagus
FIGURE 37-9 A, A tracheotomy is performed at the second or third tracheal ring. The incision
is beveled superiorly to avoid stomal contraction. B, The tracheal incision is carried through
the posterior tracheal wall and the trachea is lifted off the cervical esophagus in an avascular
place to the level of the posterior cricoid lamina.
If tumor is present along the pyriform sinus, this step

If the patient already has a tracheotomy tube placed
should be avoided to maintain an adequate mucosal
preoperatively, the airway is entered inferior to the
margin.
previous tracheotomy site and the endotracheal tube
is transferred to the new tracheotomy. SJWang
STEP 17. At this stage all fascial and muscular attach-
ments have been released from the larynx and luminal The endotracheal tube at this time can be removed
entry is now possible. from the upper airway and transferred to the new
tracheotomy.
One more step—the transection of the cricopharyngeal After transecting the anterior wall of the trachea, as
muscles—improves the exposure and facilitates the the incision is extended laterally and superiorly, a
entry. OLaccourreye heavy Prolene or nylon stitch should be placed on the
anterior wall of the trachea, suturing it to the skin to
avoid any withdrawal of the trachea in the
STEP 18. The airway is entered between the first and mediastinum. This is more important in obese and
second tracheal rings (Figure 37-9A). short-necked individuals. The stitch eventually
facilitates suturing the trachea to the skin around the
This is dependent on the amount of subglottic extension stoma. ARShaha
determined by preoperative endoscopy.
In the majority of cases we enter the pharynx in the There are three points of entry: the vallecula, the
region of the vallecula. Traction is placed on the pyriform sinuses, and the retrocricoid region. The entry
suprahyoid musculature, and the muscle is carefully point should always be dictated by the precise
divided until the lateral and medial glossoepiglottic evaluation of the tumor extent. The surgeon must keep
folds are apparent. The epiglottic tip is visualized in mind that the entry should always be performed as
through the mucosa and a pharyngotomy is made far as possible from the tumor margin. To ease the
above the epiglottis. A Deaver retractor placed in the entry, the preoperative deep tattoo (blue ink) of the
mouth can aid in identifying the vallecula. Entrance margins of resections performed at the time of the
location is dictated by the tumor location and preoperative endoscopy is extremely valuable (see
extent. KDOlsen and SMOlsen Chapter 40). The perioperative visualization of the
tattoo points at the level of the pharyngeal
musculature and mucosa facilitating (especially for
less experienced surgeons) entry within a noninvolved
With extensive tongue base involvement we perform region. OLaccourreye
dissection from the trachea from inferior to superior as
described, otherwise we work from superior to
inferior. KDOlsen and SMOlsen STEP 22. The epiglottis is grasped with an Allis clamp,
and using Metzenbaum scissors the mucosa is incised
along the aryepiglottic folds bilaterally to preserve as
STEP 19. Metzenbaum scissors were used to extend the much mucosa as possible in patients with isolated
tracheotomy in a superior oblique fashion. glottis disease (Figure 37-10). For supraglottic tumors, a
wide resection of the mucosa must be performed,
This step is performed to prevent stenosis of the stoma. according to the preoperative tumor mapping.
Constant visualization of the tumor as the mucosa is cut

STEP 20. The posterior tracheal wall is incised with a helps maintain an adequate margin.
scalpel and the trachea is separated from the underlying
cervical esophagus to the level of the postcricoid region
(see Figure 37-9B). After we perform a pharyngotomy in the vallecula, the
epiglottis is grasped with an Allis clamp and a Deaver
retractor is placed through the mouth and used to
retract the tongue base superiorly. Direct visualization
of the tumor is used to determine the degree of
I find it helpful to define the common parting wall
mucosal preservation as cuts are made along the
bluntly with a hemostat, and then cut the posterior
medial pyriform mucosa. KDOlsen and SMOlsen
tracheal wall with a scalpel down to the clamp,
avoiding possibility of inadvertent entry to the cervical
esophagus. SJWang
STEP 23. The final cut is made along the postcricoid area
and joined with the inferior dissection, which releases
the entire specimen from the field (Figure 37-11A).
STEP 21. The vallecula is entered with the aid of a
Yankauer suction tip as a guide on the contralateral side
of the tumor. When performing the top-down laryngectomy with a
prior tracheotomy in place, the following order is used.
After cuts are made down the pyriform to the level of
the cricoid, attention is directed to the trachea.
Placement of a broad Deaver blade retractor through Tracheal cuts are beveled from anteroinferior to
the mouth with the retractor tip in the vallecula can be posterosuperior extending toward the posterior
used to guide mucosal entry. SJWang tracheal wall. The trachea is then freed by isolating the
space between the esophagus and trachea and
dividing the posterior tracheal wall. A finger is placed
in the esophagus to aid in identifying planes as the
If the tumor is in the suprahyoid epiglottis or remaining soft tissue attachments between the larynx
vallecula, the surgeon should approach from below and pharynx are divided, freeing the specimen. Care is
(through, for instance, the contralateral pyriform taken during these cuts to preserve healthy pharyngeal
sinus) so as to minimize the chance of cutting through mucosa. KDOlsen and SMOlsen
tumor.
Larynx
divided along
aryepiglottic
fold
FIGURE 37-10. The pharynx is entered at the level of the vallecula or pyriform sinus
depending on location of the tumor. The epiglottis is grasped and mucosa is released off the
aryepiglottic folds allowing for adequate tumor margins. This step completes the laryngectomy.
Larynx
removed
FIGURE 37-11. After removal of the larynx

and placement of nasogastric feeding tube,
the mucosal remnant is closed in vertical
fashion using a running Connell suture.
Alternatives to closure include T-closure and
transverse closure. Interrupted sutures can
also be used in place of running suture. A B
STEP 24. Frozen sections from the surrounding

mucosa should be sent and confirmed to be negative The tracheoesophageal puncture is a good option in
for tumor. primary TL. However, in patients who are undergoing
salvage TL after chemoradiation therapy, surgeons
need to be cautioned about tracheoesophageal
STEP 25. Gloves and instruments are changed. puncture. There may a risk of nonhealing of the
tracheoesophageal puncture and expansion of the
tracheoesophageal puncture, leading to aspiration and
subsequent pneumonia. I generally prefer to postpone
Frozen section margins can be assessed off the main the tracheoesophageal puncture until 4 to 6 months
specimen or from separately submitted margins after the TL and perform it as a secondary surgical
depending on the tumor location, extent, and degree procedure. ARShaha
of remaining mucosa. We do not routinely change
instruments and gloves unless direct manual
manipulation of the tumor was unavoidable. KDOlsen
and SMOlsen STEP 28. Pharyngeal closure is performed using a 3-0
Vicryl suture as a running Connell stitch (see Figure
37-11B).
STEP 26. A wide cricopharyngeal and upper esophageal
A nasogastric feeding tube should be placed prior to
myotomy can be performed using a No. 15 blade
beginning the closure (if another feeding tube is not in
scalpel.
the patient already).
We may also perform a lateral release the inferior con-
strictor muscles from the pharynx to increase the surface
area and vibratory potential of the reconstructed In patients previously radiated, I avoid the insertion of
pharynx. a nasogastric feeding tube and rather advocate the
completion of preoperative percutaneous endoscopic
gastrostomy in order to reduce the factors (direct
I do not systematically perform these two procedures irritation, induced gastric reflux) that impair healing at
because they also increase the risk for the level of the suture line. OLaccourreye
devascularization at the level of the suture line and, in
my practice, did not improve the speech and voice
quality when using a voice prosthesis. OLaccourreye
Closure can be vertically or horizontally oriented
depending on the amount of remnant mucosa. I prefer
a simple straight-line vertical closure to minimize
The role of cricopharyngeal myotomy in a patient who tension.
has undergone TL remains controversial. When the The constrictor muscles, strap and SCM muscula-
TL is performed, one has already performed ture, and even the thyroid gland can be used for a
cricopharyngeal myotomy, as the constrictor “layered” closure of soft tissue over the pharyngeal
musculature is resected. We do not make any suture line. However, in the setting of radiation failure,
separate efforts to do additional cricopharyngeal we prefer to cover this closure with a pectoralis major
myotomy. As a matter of fact, it may be somewhat muscle flap to ensure optimal blood supply and soft-
concerning because the pharyngeal and cervical tissue support.
esophageal mucosa may become thin, leading to a
risk of injuring the mucosa. ARShaha
I generally prefer a transverse closure. A transverse
closure can be easily performed by removing the
STEP 27. If indicated, a tracheoesophageal puncture shoulder rest and bending the neck. A two- or
can be performed at this point (see Chapter 39). three-layer closure is preferred, with either Monocryl
or Vicryl sutures. The mucosa is closed in a Connell
fashion with knots inside the mucosa, and the
We avoid immediate tracheoesophageal puncture in pharyngeal musculature is closed as a buttress to
patients with prior radiation or planned postoperative protect the mucosa. ARShaha
radiation to allow the stoma to heal and to avoid
undue risk of infection and fistulization. KDOlsen and
SMOlsen
Interrupted sutures also can be used.
STEP 29. Medial heads of the SCM are released from

Over time, many techniques and materials have been the sternum to facilitate tracheal stoma approximation
advocated to perform closure of the remaining to the skin.
pharynx. The review of the literature does not clearly
demonstrate the superiority of one of the various
reported techniques and materials over the other. STEP 30. The trachea is sewn to the skin with interrupted
Whatever the technique used, I advocate the 2-0 or 3-0 Prolene suture using a modified vertical mat-
completion of a multilayer closure with the first plane tress technique. This technique is important for two
being submucosal and the second one muscular, reasons. First, such suture technique everts the stoma
covering the first layer. Also, I suspend the superior edges, providing a more suitable platform to later accom-
part of the constrictor muscles to the previously modate a laryngectomy tube and/or tracheoesophageal
transected infrahyoid muscles in order to reduce the puncture (TEP) filter. Second, this maneuver drapes
force directly transmitted to the mucosal line of suture skin over the exposed cartilaginous rings, minimizing
at the time of swallowing. chondritis.
In addition, I use any spared tissue (strap muscle,
thyroid gland) to cover the suture line, and finally in
previously radiated patients, I often cover the suture I prefer use of a permanent suture, such as 2-0
line with a pedicle muscle flap to bring vascularized Prolene, which I find minimizes tissue reaction and
tissue at the level of the suture line. OLaccourreye crusting of the stoma during the postoperative healing
period. SJWang
I prefer to test for the closure for any microscopic

leak after closure by insufflating the neopharynx with a Prior to pharynx closure, while awaiting margins, we
1 : 1 solution of sterile povidone-iodone (Betadine) paint close the inferior aspect of the stoma. A semicircle of
and saline solution administered through the mouth skin is removed in the midline and the skin is sewn to
with a 30- to 60-mL Asepto syringe. Povidone-iodine is the trachea using interrupted modified vertical
a cheap and readily available colored solution that mattress sutures. The needle is passed first from
allows the surgeon to notice small leaks that might not superficial to deep taking a large bite of skin and
otherwise be seen. Some surgeons advocate the use of a subcutaneous tissue. The needle is then passed from
diluted solution of hydrogen peroxide; however, this external to internal around a tracheal ring. Finally the
might provide unwanted irritation to a mucosal suture needle is passed back through a smaller bite of skin
line. If an iodine-based solution is used, the surgeon from deep to superficial. Passage of the initial bite
should ensure that all remaining fluid is removed from through the skin first avoids the risk of blind needle
the neopharynx to prevent postoperative nausea and injuries to a high-riding innominate or other upper
vomiting. mediastinal structures. We do not routinely release the
medial heads of the SCM and have not noted difficulty
approximating the stoma to the skin. At the end of the
Meticulous pharyngeal closure is critical to avoid
case, prior to skin closure, a semicircle of skin is
fistula formation, particularly given that many
removed from the midline of the superior flap to create
laryngectomies are now performed for salvage after
the superior stomal skin edge. This is closed in the
failed organ preservation approaches. After placing a
same fashion after drains are placed and the skin flaps
feeding tube, we perform a three-layer closure in a
are closed. KDOlsen and SMOlsen
T-shaped configuration. The horizontal limb increases
the width of the re-created pharynx. A total of three
running Connell sutures are used: one started inferiorly When I am concerned that the tracheostoma is small
and one on each superolateral corner. The free ends and may be at risk for future stenosis, I will make a
of the sutures are tagged. Beginning with the inferior vertical incision at the top of the residual posterior
stitch the sutures are run to a common midpoint and tracheal wall and create a corresponding “V” in the
tied together. A second layer of interrupted horizontal midline of the superior neck skin flap. Closure of the
mattress sutures are then placed just lateral to the “V” to the inferior-most point of the posterior tracheal
initial closure, further inverting the suture line. A third wall in the midline results in a wider tracheostoma.
layer is closed by approximating the suprahyoid SJWang
musculature, the pharyngeal constrictors, and the
thyroid isthmus over the pharyngeal closure. After
completing the closure the pharynx is flooded with STEP 31. Drains are placed on either side of the esopha-
saline to ensure the closure is watertight, and the gus and secured to the skin.
tagged ends of the Connell sutures are cut. KDOlsen
and SMOlsen Place the drains away from the pharyngeal suture line
to prevent fistula formation.
STEP 32. Skin is closed in layers with interrupted Vicryl

sutures for the platysma and staples or running nonab- I prefer to feed the patient on the seventh or eighth
sorbable suture for the skin. day if the wound is healing well. If there is any wound
collection or cellulitis or edema or delay of wound
healing, a Gastrografin swallow may be of some help.
Because there is considerable pharyngeal However, I do not use Gastrografin swallow as a
contamination during TL, I do not use subcuticular routine procedure. If there has been complex
absorbable stitches. Given the higher than usual reconstruction, either with a pectoral myocutaneous
incidence of wound collection, seroma, and/or minor flap or a free flap, I prefer to get a Gastrografin
wound infection for TL, I generally prefer interrupted swallow on day 8 or 9, and then feed the patient. It is
stitches with Prolene or nylon or staples. The drains not uncommon to see a minor fistulous tract that
are placed in the lateral portion of the neck, lateral to usually heals over time. ARShaha
the sternomastoid muscle, keeping the tip of the drain
away from the pharyngeal suture line. Preoperative
and postoperative antibiotics are commonly used with
Of course, the most feared short-term complication
cefazolin and metronidazole (Flagyl), which is used for
of TL is the development of a pharyngocutaneous
4 to 5 days. ARShaha
fistula. This is detected by skin changes (peau d’orange
appearance), foul drainage from the wound or the drain,
inability of the skin flaps to stay down despite suction
STEP 33. A tracheotomy tube is placed into the tracheal
drainage, or fever.
stoma in exchange for endotracheal tube at the end of
the procedure. Occasionally patients with salvage laryngectomy return
with a late fistula, which may be seen 2 to 3 weeks
The tracheal stoma can also be left unintubated, or a after surgery. This is the main reason these patients
laryngectomy tube can be placed rather than a should be closely observed, even when they are
tracheotomy tube. SJWang discharged home. ARShaha
If these classic signs are not present, but the surgeon

Postoperative Care
remains concerned, a modified barium swallow can be
Most patients are transferred to a regular head and neck used to identify fistula if suspicion is high. However, this
surgical ward after the recovery room, provided there technique has more sensitivity to distinguish small invo-
is adequate nursing expertise and support. Intensive lutions of mucosa in the tongue base from a “true”
care unit (ICU) stay is indicated for patients with other fistula. Although some surgeons advocate maintaining
medical comorbidities that require ICU observation. drains in place until there is no fistula after oral intake,
Patients should be started on appropriate gastroin- there is no evidence to support this approach.
testinal prophylaxis and thromboprophylaxis. Antibiot-
ics may be continued while the drains are in place.
One of the key points in the successful management
Tracheotomy tube can be removed on postoperative
of a fistula is its early detection. Therefore, any time
day 1. A laryngectomy tube can be placed if it appears
the temperature curve or the clinical appearance of
there is significant postoperative edema to maintain
the skin suggests the development of a fistula, I
stoma patency.
advocate the completion of the following maneuver:
If adequate bowel sounds are auscultated, enteral
the strong and slow anterior palpation and pressure of
feedings are started on postoperative day 1 and increased
the suture line from the mandible to the stoma to
to goal rate very slowly. The patient should be posi-
demonstrate the existence of pus at the skin-stoma
tioned in a dependent fashion to prevent gastric reflux
junction. OLaccourreye
along the suture line. Once the goal rate is reached, and
only then, bolus feedings should be initiated. After cri-
copharyngeal myotomy, adherence to this regimen is
important to minimize exposure of the hypopharyngeal Control of the fistula can be achieved by the suction
suture line to acidic gastric secretion. drainage if fluid is going through the drain. Otherwise,
Hospitalization following TL usually lasts 5 to 7 local wound care with daily packing at the site of drain-
days. Oral feedings are started between days 7 and 14. age and observation will lead to closure of the fistula
Patient factors such as radiation status, smoking history, within 4 to 6 weeks. If the fistula is large and local
thyroid function, and preoperative nutritional status, wound therapy does not result in closure, operative
which all influence wound healing, affect the timing of intervention is necessary. At this time, free-tissue or a
oral feeding initiation. pedicled muscle flap may be necessary.
Suggested Readings
Although not scientifically demonstrated, in my clinical
practice I have found that regular oral application Boyce SE, Meyers AD: Oral feeding after total laryngectomy.
(every 2 hours) and injection (twice a day) of honey at Head Neck 11:269-273, 1989.
the fistula site were extremely helpful in the Hui Y, Wei WI, Yuen PW, Lam LK, Ho WK: Primary closure
nonsurgical successful management of the fistula. To of pharyngeal remnant after total laryngectomy and partial
me, this is related to the fact that honey reduces the pharyngectomy: how much residual mucosa is sufficient?
Laryngoscope 106:490-494, 1996.
surface osmotic pressure at the level where it is
Iteld L, Yu P: Pharyngocutaneous fistula repair after radio-
placed, reducing the bacterial proliferation and
therapy and salvage total laryngectomy. J Reconstr Micro-
increasing the granulation tissue formation. surg 23:339-345, 2007.
OLaccourreye Mendelson AA, Al-Khatb TA, Julien M, Payne RJ, Black MJ,
Hier MP: Thyroid gland management in total laryngec-
tomy: a meta-analysis and review. Otolaryngol Head Neck
Surg 140:298-305, 2009.
Penel N, Fournier C, Lefebvre D, Lefebvre J: Multivariate
analysis of risk factors for wound infection in head and neck
Conclusion squamous cell carcinoma surgery with opening of mucosa.
Study of 260 surgical procedures. Oral Oncol 41:294-303,
TL involves removal of the larynx with lymphatics in 2005.
the paratracheal bed and the strap muscles. It can be Seikaly H, Park P: Gastroesophageal reflux prophylaxis
done with minimal complications and a short hospital decreases the incidence of pharyngocutaneous fistula after
stay. total laryngectomy. Laryngoscope 105:1220-1222, 1995.
CHAPTER
Stomaplasty for Hands-Free Voice
38 with Tracheoesophageal Puncture
Author Greg Reece
Commentary by Brian B. Burkey and Frans J. M. Hilgers
Preoperative Considerations One of the limitations for this technique indeed is a

too-high position of the TEP, because the caudal rim
of the button puts undue pressure on the voice
The successful use of an automatic speaking valve
prosthesis, even when a very soft button like the
should indeed be the ultimate goal of
LaryButton is used. Therefore there is a tendency to
postlaryngectomy voice and speech rehabilitation.
place the TEP lower in the trachea, but the author
Giving back the ability back to speak hands-free
rightfully warns against overdoing this because it
“frees” the patient from the necessity to digitally
makes the maintenance of the TEP more difficult.
occlude the stoma, and thus from continually pointing
Moreover, when a TEP comes more or less in an
to his or her disability. However, many patients are
intrathoracic position, this increases the likelihood of
capable of using an automatic speaking valve by
early leakage due to intrathoracic underpressure in the
applying a peristomal adhesive with a special retainer
esophagus, inadvertently opening the valve of the
for the speaking device. The advantage of these
prosthesis, as recently has been shown (P. Keck,
adhesives is that patients do not need a potentially
personal communication). FJMHilgers
irritating intrastomal appliance. The disadvantage with
these adhesives, however, is that all the pulmonary
pressure during speech is directed toward its seal, Most patients who have had laryngectomy have also
which might loosen, making speech impossible due to received previous radiation therapy. The skin and soft
air leakage. And of course, some patients have tissues around the stoma must be pliable and relatively
vulnerable or irritable skin, preventing the use of an healthy to tolerate the stomaplasty procedure.
adhesive patch. Nevertheless, peristomal adhesives The stoma must be located in a superficial, flat plane
should always be tried first in my opinion, not in the such that there is space for the external part of the
least to motivate a patient for additional surgery if button to avoid contact with other structures. Patients
unavoidable. FJMHilgers with prominent sternal tendons of the sternocleidomas-
toid (SCM) muscle will need resection of the sternal
part of the tendons to flatten the stomal surface (see
Figure 38-1).
Selection criteria for this procedure include the This is absolutely essential and is best dealt with
following: during the laryngectomy. The sternal heads of the
Inability to wear a Barton-Mayo button (BMB) for SCM muscle should be released to promote healing
hands-free speech due to an abnormally shaped stoma with the proper geometry. BBBurkey
and an inadequate rim of cicatrix around the entire
perimeter of the stoma (Figure 38-1). Cutting the sternal attachment of the SCM muscle is a
A tracheoesophageal puncture (TEP), if present, good recommendation, and preferably should be
must be functional and located at least 1 to 1.5 cm carried out at total laryngectomy and primary TEP.
below the mucocutaneous scar to avoid blockage of the This refinement of the surgery also allows more often
puncture site by the button’s shaft. If the TEP is located the successful application of peristomal adhesives,
more than 1.5 cm below the mucocutaneous scar, it will making the need for this elective surgery
be difficult for the patient to maintain the TEP after superfluous. FJMHilgers
stomaplasty.
373
FIGURE 38-1. Two of the most common reasons for referring a patient for a
tracheostomaplasty: the stoma is oval or deformed in shape, and there is an insufficient rim of
scar tissue from the 10 o’clock to 2 o’clock position to retain a Barton-Mayo button for
hands-free speech.
Patients with significant cardiopulmonary disease or Operative Procedure

insufficient respiratory reserve to produce tracheo-
esophageal (TE) speech are not good candidates for this This surgical procedure is unique, and only fairly
procedure. recently a series of 21 patients has been published
(see Moreno et al, 2010). The results are rather good,
Also, patients who have had flap reconstruction of the with ultimately 15 (71%) of the patients achieving
pharynx have a lesser chance of excellent TE voice. If successful hands-free speech. I have personally no
flap reconstruction is necessary, thinner flaps facilitate experience with this operation, but I like the logic and
the best voice, for example, radial forearm free flaps. the straightforwardness of it. The various steps of the
BBBurkey procedure are clearly described, and this operation
should be comfortably performable by any
experienced head-and-neck surgeon. FJMHilgers
The two main selection criteria for this procedure, in
my view, should be that the patient has “proven” to be Initial Preparation and Patient Positioning
unable to use an automatic valve by means of one of
the available peristomal adhesives and is motivated Because the stoma is a heavily contaminated structure
enough to undergo an additional surgical procedure to and the skin has been irradiated, IV antibiotics are given
achieve hands-free speech. Motivation is a key word to the patient in the holding room.
in this procedure, in my view. Because this is elective
surgery, many patients are reluctant to undergo yet I agree completely. The use of a prophylactic broad-
another surgery. Therefore, not only the patient needs spectrum antibiotic cannot be stressed enough.
to be optimally motivated, but also the rehabilitation Because this is elective surgery, the effect of
team. Otherwise, the chance of a disappointing result complications is even higher than in the former cancer
is high. FJMHilgers surgery, so prevention is key. FJMHilgers
CHAPTER 38 Stomaplasty for Hands-Free Voice with Tracheoesophageal Puncture 375
The choice for an autologous graft for this elective

“augmentation” surgery is logical and the TFL tendon
obviously is the tendon of choice, due to its ease of
harvesting and low complication rate. FJMHilgers
A 4-cm-long incision is designed over the skin of the

distal lateral thigh parallel to the axis of the limb and
dissection carried down to the TFL tendon (Figure
38-3). Obtaining the TFL graft prior to performing the
TEP tube
stomaplasty avoids contamination of the graft donor
site.
A 1-cm-wide flap of fascia is incised and placed in
the end of a Crawford fascial stripper (see Figure 38-3),
which is carefully pushed forward to remove a strip of
fascia about 13 to 15 cm long. The graft is defatted,
wrapped in a sterile saline-soaked sponge, and placed
on a Mayo stand for later use. Pressure is used to obtain
hemostasis.
The TFL donor site is closed and covered with a
sterile dressing, and the leg is wrapped from the ball of
FIGURE 38-2. The usual positioning of the 6-mm reinforced the foot to the upper thigh with a 6-inch-wide elastic
endotracheal tube for surgery. The tube is not sutured to the (Ace) wrap.
skin around the stoma because it must be free to be moved
around and in and out of the stoma as required during the
Primary closure of the residual fascia can often be
procedure. TEP, transesophageal puncture.
done and will lead to a better contour of the leg when
healed. BBBurkey
The patient is placed on the operating table in a
supine position with a shoulder roll to assist with neck
extension. General anesthesia is induced through a STEP 2. Mark the location for the incisions to create a
6-mm reinforced endotracheal tube placed in the trache- subcutaneous tunnel around the stoma.
ostomy. A No. 6 endotracheal tube is used because this
size tube easily allows a No. 12 BMB to slide over the
tube during the procedure (Figure 38-2). Creation of the tunnel is shown to be quite easy and
straightforward. However, I would recommend the
I never have been fond of the BMB, because it is rather reader to also take notice of the cited paper of the
rigid and the edge of the tracheal collar and that of the author. One can read there that besides the creation
valve retainer are sharp. Therefore, for regular use I of this tunnel, additional procedures sometimes are
sometimes have asked our prosthetist to sand and needed. for example, the SCM muscle had to be cut
smooth these edges to avoid damage to the peristomal four times, a Z-plasty was needed twice, and four
skin or stoma mucosa. Using a softer button with less times advancement flaps. So the surgeon should be
sharp edges is preferable in my opinion. FJMHilgers prepared to do something extra besides the basics of
the procedure described here. FJMHilgers
The patient’s neck, upper chest, and one thigh are
prepared with an antimicrobial solution, such as
povidone-iodine, and draped in a sterile fashion. The The marks should be 1 cm in length and located approx-
right thigh is preferred if the surgeon is right-hand imately 1 cm from the mucocutaneous scar of the tra-
dominant. cheotomy stoma. The marks are made in a radial fashion
The balloon of the endotracheal tube is fully inflated, at the 3, 6, and 9 o’clock positions around the stoma
and the peristomal skin and upper walls of the trache- (Figure 38-4). An incision at the 12 o’clock position
ostomy are cleaned with povidone-iodine solution to should be avoided, if possible, because of a high risk of
sterilize these surfaces as much as possible. Excess wound-healing problems.
povidone-iodine solution is suctioned to prevent
aspiration.
It is important to keep in mind that the pharynx may
STEP 1. The first step of the tracheostomaplasty is to be just deep to the skin immediately superior to the
harvest the tensor fascia lata (TFL) tendon graft from the stoma. BBBurkey
thigh donor site.
Plane of the TFL
End of Crawford
fascial stripper
Crawford
fascial stripper
Graft
FIGURE 38-3. The process of harvesting a tensor fascia lata (TFL) graft from the patient’s
right thigh. It is important that the cutting blade is locked in place to avoid premature
transection of the graft and that firm tension is applied parallel to the stripper as the
instrument is pushed forward. Once the stripper has reached the muscle, the cutting blade is
unlocked, and the graft is transected and removed with the instruments.
STEP 3. Incise the skin and create the subcutaneous

tunnel around the stoma.
A Jacobson hemostat is used to bluntly dissect the tunnel

around the stoma in the subcutaneous plane circumfer-
entially around the stoma from one incision to the next
Head
3 o’clock
(Figure 38-5).
incision To decrease the chances for infection, irrigate the
9 o’clock subcutaneous tunnel several times throughout the pro-
incision
cedure with an antibiotic solution containing 50,000
units of bacitracin and 500,000 units of polymyxin B
per liter of saline irrigation fluid.
1 cm 1 cm
This is an interesting “habit.” I am neither aware of

such irrigation being used in other head and neck
procedures nor sure that it is evidence based.
Prophylactic broad-spectrum antibiotic coverage
starting at least half an hour before the first incision
6 o’clock
and continued during 24 hours should be enough.
incision
FJMHilgers
STEP 4. Slide a No. 12 short BMB over the endotracheal

tube to support the stoma.
FIGURE 38-4. The location for the peristomal incisions. It is
important that the transesophageal puncture be located at The BMB is used to size the diameter of the stoma for
least 1 cm below the tracheocutaneous scar. The 1-cm long hands-free speech and to support the stoma during the
incisions are placed 1 cm away from the tracheocutaneous next step of the tracheostomaplasty.
scar.
Superior tunnel
Umbilical tape
Hemostat
FIGURE 38-5. The technique used to create a subcutaneous tunnel from the incision at the
9 o’clock position to the 3 o’clock position. The Jacobson hemostat is used to grab the end of
the umbilical tape.
The BMB is placed on the endotracheal tube as

This is an interesting reasoning. I am not sure whether
follows:
n Place a No. 12 short BMB (outer diameter, 17 mm)
reduction of the subcutaneous fat is at all important
and if the fear of atrophy is realistic. In any case, it
into a cup of povidone-iodine at the start of the case
seems a quite traumatic part of the procedure to me,
to “sterilize” the device.
n Briefly deflate the balloon cuff on the end of the
especially in radiated patients. In the series
copublished by the author, there were 6 of 21 patients
endotracheal tube, wipe the end of the tube with a
with cellulitis requiring therapy and another 5 requiring
povidone-iodine–soaked sponge, slide the BMB over
minor revision surgery, which might reflect this. In fact,
the end of the endotracheal tube, and place the tube
actually only 8 (38%) of the 21 patients were reported
into the stoma and reinflate.
n Slide the BMB down over the endotracheal tube and
to have no complications, which makes me wonder if
this part of the procedure is not too traumatic and
into the stoma (Figure 38-6).
whether it is really necessary. FJMHilgers
STEP 5. Remove the excess subcutaneous fat from the Pull a piece of povidone-iodine–soaked umbilical
underside of the stomal skin. tape through the subcutaneous tunnel. Pull up on the
Postoperatively, after a patient starts routinely wearing ends of the tape and, holding the ends of the tape, saw
the BMB, the pressure of the BMB shaft on the stomal back and forth with the tape to remove additional fatty
skin is sufficient to minimize blood flow to the fat tissue from the underside of the skin over the subcutane-
located between the skin and TFL graft. Insufficient ous tunnel. Pull the BMB back out of the stoma and
blood flow will cause this fat to atrophy. If the fat atro- over the tube.
phies, the diameter of the stoma is effectively enlarged.
STEP 6. Place the TFL graft into the subcutaneous
Because the blunt dissection of the tunnel leaves too
tunnel.
much fatty tissue on the underside of the skin of the
stoma, the following maneuver described is necessary to Suture the TFL graft to one end of the povidone-iodine–
minimize the amount of fat tissue between the skin and soaked umbilical tape. and pulled through the subcuta-
TFL graft. neous tunnel (Figure 38-7). After the graft completely
Tape pulled
circumferentially through
subcutaneous tunnel
Tape exiting the

3 o’clock incision
Barton-Mayo button
(BMB)
FIGURE 38-6. The umbilical tape has been pulled around the circumference of the
subcutaneous tunnel. Each end of the tape is then pulled back and forth in a “sawing” fashion
about 3 times to remove additional subcutaneous fat so that the tendon will be located almost
immediately under the dermis when placed during the next step.
TFL graft
TFL graft coming out
sutured to end of superior
of umbilical tape tunnel
TFL graft
Umbilical tape
6 o’clock
incision
FIGURE 38-7. After the end of the tensor fascia lata (TFL) graft is sutured to the tape, the
graft is guided through the tunnels by gently pulling the tape through the tunnel.
9 o’clock
incision
3 o’clock
incision
Slit through graft
6 o’clock
incision
FIGURE 38-8. After a 1-cm slit is made in the center of one end of the graft, the other end of
the graft is pulled through the slit. The Barton-Mayo button has been placed in the stoma and
an assistant pulls firmly in opposite directions on each end of the graft while the surgeon
sutures the graft to itself to set the appropriate stoma diameter.
encircles the stoma, cut the suture and remove the After obtaining hemostasis, place a No. 10 round
umbilical tape. The ends of the graft are held with a Blake drain in the subcutaneous tunnel circumferen-
hemostat and a small slit is made in one end of the TFL tially and allow to exit from a site several centimeters
graft so that the other end of the graft can be pulled from the stoma (Figure 38-10).
through the slit (Figure 38-8). The reason for using a small closed-suction drain is
to remove any fluid (serum or blood) that gets between
the graft and surrounding vascularized tissue of the
STEP 7. Set the diameter of the stoma. subcutaneous tunnel. Additionally, the continuous
vacuum keeps this tissue against the graft. The drain is
Slide the BMB over the endotracheal tube and into the
kept in place for the first 5 postoperative days, which
stoma again. Have an assistant pull the ends of the
appears to decrease the incidence of postoperative
tendon graft in opposite directions firmly to cinch the
cellulitis.
stomal skin in a pursestring fashion (see Figure 38-8).
Suture the ends of the graft near the slit together with
multiple interrupted 4-0 polydioxanone (PDS) sutures
placed in a horizontal mattress pattern (Figure 38-9).
Tapered needles are used to avoid cutting the graft.
Pull the BMB out of the stoma so that additional Suction drainage is an important part of any surgical
sutures can be placed on the inner side of the graft at procedure to remove fluids from the wound and to
the slit. This may seem like a trivial maneuver, but the speed up the adhesion and healing of the tissues.
TFL grafts have some degree of creep over time. The However, when the drain is left in too long, it might do
additional closure of the ring created by the TFL graft more harm than good. Therefore my suggestion is to
keeps the diameter of the graft close to the desired size. always remove the drain when the production is close
Replacing the BMB into the stoma should be a little to zero in small wounds like this. With 6 cases of
more difficult. postoperative cellulitis in 21 patients, despite using
Trim excess tendon from the ends of the graft and prophylactic antibiotics, I am not sure that the claim in
irrigate the wound copiously with the antibiotic the last sentence is warranted. FJMHilgers
solution.
TFL graft
sutured to itself
with several
4-0 PDS sutures
FIGURE 38-9. The 4-0 polydioxanone (PDS) sutures are preferred because they take a long
time to resorb, which gives sufficient reinforcement for the tendon to heal to itself at the
appropriate diameter. Because the graft is sutured so close to the incisions, it is best to place
the knots of the sutures on the underside of the graft to avoid later extrusion. TFL, tensor
fascia lata.
Size 10 round Blake

drain in subcutaneous tunnel
surrounding graft
FIGURE 38-10. Although there is little

space in the tunnel after placing the
graft, there is a potential space in which
a seroma can form and become
infected. Placing a closed suction drain
has markedly decreased the infection
rate associated with this procedure.
The drain may reduce the chances for
infection by removing any fluid that Short size 12 BMB
accumulates in the tunnel around the
graft, and the vacuum may pull the
subcutaneous tissue around the graft to
eliminate dead space and to facilitate
graft revascularization. BMB, Barton-
Mayo button.
FIGURE 38-11. The completed tracheostomaplasty before a LaryTube is placed to protect the
airway. For adequate graft healing to occur, the patient is not allowed to digitally occlude the
stoma or wear a Barton-Mayo button for at least 3 weeks.
Postoperative Protocol
To clarify this issue, all but one of the cases of
cellulitis that Dr. Hilgers mentions occurred before Protect the airway and observe overnight. Extubate the
we started using a drain. After we started using a patient and place a No. 8 (outer diameter: 12 mm)
drain routinely and keeping it in place for 5 days, LaryTube in the stoma to protect the airway.
we have only had one infection, a very mild case
of cellulitis. GReece In view of the use of a No. 12 BMB (outer diameter
17 mm), using a No. 8 LaryTube is a logical step. It
releases the pressure from the tissues immediately
STEP 8. Close the peristomal incisions. and allows the stoma to shrink slightly. This increases
the likelihood that the later application of one of the
Each of the radial incisions is closed with a buried
various commercially available buttons enables airtight
absorbable 3-0 monofilament suture in the dermis and
stoma occlusion with an automatic speaking valve.
an interrupted 5-0 chromic suture in the skin. Bacitracin
This specific soft silicone trachea cannula also allows
ointment is applied to all incisions (Figure 38-11).
the immediate (re)application of a heat and moisture
exchanger (HME), which is an important protection
I typically treat the patient with a broad-spectrum oral measure for the airway, immediately improving
antibiotic for 7 days to minimize the chance of tracheal climate and rendering the use of an external
perichondritis. BBBurkey humidifier superfluous. This should decrease the
chance for postoperative respiratory distress, as
well. FJMHilgers
Again, this is a habit we do not share with the author.
Only systemic prophylactic use of antibiotics has been
proven to be relevant for infection prevention. Observe the patient for respiratory distress over-
FJMHilgers night. If the airway is stable and patent the following
morning, the LaryTube is removed.
An appropriate (hydrocolloid) adhesive for continued retaining the actual automatic speaking valve was
HME use is applied! FJMHilgers large and probably more irritating than the present
generations of soft silicone buttons. All in all, I think
that the technique presented here, in combination with
To allow adequate wound healing and to avoid
a soft silicone button, is a step forward. However, and
stomal dilation, patients are instructed to avoid digital
I cannot stress this enough, optimal results are only
occlusion of the stoma or placement of a stoma button
obtained when all parties are optimally motivated,
in the neostoma for a minimum of 3 weeks after surgery.
not only the patient but also all members of the
multidisciplinary rehabilitation team. I am sure that is
So far this article (see Moreno et al, 2010) is the only why, besides having an innovative surgical technique,
study describing this stomaplasty technique, and I the published results from the M.D. Andersen group
hope that many studies will follow that confirm the are so good. FJMHilgers
validity of this concept. In the 1980s another
stomaplasty technique was described in Germany (see
Hermann and Koss, 1985). These authors describe the
creation of a “chimney,” either during primary surgery,
or secondarily at a later date. The idea was to create Suggested Readings
an extra retention space cranial to the stoma that Herrmann IF, Koss W: Finger-free speech following total
could hold a specially designed spacer that also laryngectomy. Instrumentation and technic of surgical voice
allowed the use of an automatic speaking valve. This rehabilitation. HNO 33:124-129, 1985.
technique is not widely used any longer in Europe Moreno MA, Lewin JS, Hutcheson KA, Bishop Leone JK,
because of the inconsistent results, not only because Barringer DA, Reece GP: Tracheostomaplasty: a surgical
the secondary technique was somewhat complicated, method for improving retention of an intraluminal stoma
but probably also because the spacer needed for button for hands-free tracheoesophageal speech. Head
Neck 32:1674-1680, 2010.
CHAPTER
Tracheoesophageal Puncture in the Clinic
39 via Transnasal Esophagoscopy
Authors Mihir K. Bhayani and F. Christopher Holsinger
Commentary by Peter C. Belafsky, Amy C. Hessel, and Andrew J. McWhorter
Since Billroth first described total laryngectomy more

thus the patient may require frequent adjustments
than a century ago, voice restoration has played an
as the wounds heal and stabilize. Also the quality of
important role in postoperative rehabilitation. Speech
voice may be poor due to copious secretions and
functions not only as a means of communication, but
edema causing unreliable vocalization. It is important
also a form of self-expression and one of the unique
to counsel patients being considered for primary TEP
qualities that makes us uniquely human. Throughout
about this postoperative healing period.
the years, many techniques have been developed for the
In contrast, patients who undergo a secondary
acquisition of alaryngeal speech from pure esophageal
TEP tend to have a very smooth transition to voice
speech to the electrolarynx.
because the stoma is usually well healed and the
In the early 1980s, Blom and Singer introduced the
mucosa of the neopharynx is stable. However, in
tracheoesophageal puncture (TEP) with a voice prosthe-
correctly selected primary TEP patients, the time to
sis that is now the primary modality of voice rehabilita-
voice (no matter what the quality) is considerably
tion after laryngectomy (see Singer and Blom, 1980,
sooner than having to wait the 6 to 8 weeks for
1981). Primary TEP can be performed at the time of
laryngectomy healing time, or the 3 to 4 months while
surgery with a red rubber catheter inserted through the
going through postoperative radiation. ACHessel
newly formed puncture site and left in place for approx-
imately 1 to 2 weeks. Once oral feedings have begun,
the red rubber catheter is removed and the voice pros- Secondary TEP is done in the postoperative period
thesis is inserted. The overall success rate in primary and was originally conducted in the operating room
TEP has been shown to be up to 97% with this method. using rigid esophagoscopy for direct visualization of the
Despite this success rate some authors have suggested proposed TEP site and general anesthesia. This was an
an association between primary TEP and complications efficacious technique but had its own associated draw-
such as fistula formation, infection, stenosis, and leakage backs including the need for general anesthesia and the
(see Chone et al, 2005). Therefore some patients have difficulties associated with exposure in the postradiated
a delayed TEP after healing from the laryngectomy or patient using rigid techniques. Also, cervical osteophytes
completing postoperative radiotherapy. and neopharyngeal stricture may prevent introduction
of the rigid esophagoscope into the esophagus without
an event (see Eliachar et al, 1994; Le and Wilson, 1992;
Some surgeons prefer to place the prosthesis at the Parker, 1985; Singer et al, 1983).
time of surgery in order to not have to resize later due Flexible esophagoscopy requiring only intravenous
to edema in the parting wall postoperatively, but the (IV) sedation allows for direct visualization of the lumen
feeding access is lost in this method. AJMcWhorter throughout the procedure and bypasses the difficulty of
passing the rigid esophagoscope. The main drawback to
this type of procedure is that it still requires IV sedation
I have found the major benefit of a primary TEP is the (see Barkin et al, 1991; Hong et al, 1995).
faster time to speech. By placing the TEP at the time With the introduction of the transnasal esophago-
of initial surgery, the patient can depend on beginning scope (TNE), the same advantages of a regular esopha-
communication rehabilitation soon after he or she goscope can be attained without the need for IV sedation.
achieves successful oral swallowing. But many of The TNE introduces a new in-office technique that
these primary TEP patients have more difficulty with facilitates secondary TEP using only local anesthesia
occlusion of their stoma initially due to pain or (see Bach et al, 2003; Lebert et al, 2009). Patients toler-
crusting. Obtaining a seal digitally or with a button can ate the procedure well and can return to work or home
be frustrating because air leaks are often common and that day without having undergone a general or IV
anesthetic.
383
We first described using TNE to place a failed The key to patient tolerance of the procedure with the
TEP in 2001 (see Belafsky et al, 2001; Doctor et al, larger-caliber transnasal esophagoscopes is adequate
2007). PCBelafsky nasal anesthesia. AJMcWhorter
Preoperative Considerations We use a combination decongestant (phenylephrine)

Indications for this procedure are any postlaryngectomy and anesthetic spray (tetracaine [Pontocaine]). No
patient who meets criteria for voice rehabilitation via need to pack. One spray reduces a step. PCBelafsky
the voice prosthesis. Patients must demonstrate motiva-
tion for voice restoration and have the manual dexterity
to occlude the tracheal stoma. The posterior tracheal wall is injected with either 1%
or 2% lidocaine with 1:100,000 epinephrine. Only a
small volume is necessary to provide sufficient anesthe-
Insufficiently patent stoma also is a contraindication.
sia. The trachea should also be anesthetized with 4%
PCBelafsky
atomized lidocaine because secretions (during the pro-
cedure) may elicit a cough reflex.
Contraindications to the office-based procedure
include significantly displaced esophageal lumen from
We do not need to atomize the tracheal anesthesia
posterior tracheal wall, excessive flap bulk that does not
but just spray 2 mL of 4% lidocaine into the
accommodate the length of standard size voice prosthe-
stoma. PCBelafsky
sis, and evidence of a pharyngeal fistula. Relative
contraindications include a significantly deviated nasal
septum that does not allow for the transnasal esopha- Care must also be taken in patients with free-tissue
goscope to pass and any coagulopathy that may predis- or pedicled muscle flaps for reconstruction because the
pose the patient to a significant epistaxis. bulk of the flap may distort the path of the neopharyn-
geal lumen away from the posterior tracheal wall. A
We have never had any problems from epistaxis or computed tomography (CT) scan or modified barium
bleeding from the puncture site and do not see this swallow prior to the procedure may assist in determin-
as a contraindication. PCBelafsky ing the exact position of the lumen with relation to the
posterior tracheal wall as well as the amount of tissue
bulk in between the anterior esophageal wall and the
Patients who have had the parting wall dissected posterior tracheal wall.
and reconstructed with a flap require an adequate
time for the tissues to reapproximate prior to This is very important: I always recommend
performing the puncture. A safe period is thought be preprocedure imaging to evaluate the anatomy of the
3 months. AJMcWhorter neopharynx in relation to the stoma before doing the
procedure (CT scan or modified barium swallow
[MBS]). This becomes even more important in those
Another relative contraindication is anxiety with
patients who have had major microvascular free-flap
fiberoptic examination. In the best scenario, this
reconstruction. The neopharynx and upper esophagus
procedure takes about 10 minutes but sometimes
may get shifted off the midline if there is a bulky flap
requires 15 to 30 minutes to get good visualization.
or heavy scarring, so to expedite the success of the
If the patient has anxiety with prolonged transnasal
TEP procedure it is important to know which direction
fiberoptic examination, he or she may be a better
to direct the fistula. In addition, if the free flap was
candidate for a procedure done under
needed to reconstruct the cervical esophagus, there
anesthesia. ACHessel
may be significant tissue between the posterior
tracheal wall and the lumen of the pharynx. This may
Adequate topical anesthetic usage is paramount make the procedure more complicated and might be
when performing any in-office procedure. The nose used as a relative contraindication to an in-clinic
must be adequately decongested with either topical 4% procedure. ACHessel
or 10% cocaine or phenylephrine (Neo-Synephrine).
This not only increases the amount of local anesthetic
absorption, but also eases the introduction of the esoph-
Operative Technique
agoscope. After adequate decongestion, topical lido-
caine spray and cottonoid pledgets soaked in 4% The patient is sitting upright in the office examination
lidocaine are used. chair.
CHAPTER 39 Tracheoesophageal Puncture in the Clinic via Transnasal Esophagoscopy 385
Transillumination
from scope
Esophagoscope
positioned
Stoma
Posterior
tracheal STOMA
wall
FIGURE 39-1. Anterior view of patient as esophagoscope is passed through the nose to the
level of the tracheal stoma. The inset illustrates the transillumination from the esophagus to the
posterior tracheal wall, which represents the target site for the puncture.
STEP 1. After adequate local anesthesia is attained, STEP 3. The esophagoscope is positioned in the esoph-
introduce the TNE lubricated with 2% lidocaine jelly into agus until the scope’s light is aimed to the anterior
the naris. esophageal wall, transilluminating the desired location
of puncture on the posterior tracheal wall (Figure 39-1).
The scope is then advanced through the nose into the
The optimal puncture site location is in the midline
nasopharynx and passed through the oropharynx to the
approximately 1 to 1.5 cm below the skin edge along the
level of the neopharynx. The scope is then advanced
posterior tracheal wall.
through the neopharynx, hypopharynx, and then into
the esophageal inlet. Too proximal placement of the fistula can prevent use
of some methods for hands-free voicing and too
There should be two clinicians: one performing the distally can make safe replacement of the prosthesis
endoscopy and one doing the puncture. PCBelafsky challenging. AJMcWhorter
Appropriate placement for the TEP is determined by

Before starting, make sure that the air and water ports
direct visualization of the compression into the esopha-
of the TNE are working. As the scope is passed
gus by ballottement of the posterior tracheal wall at
behind the tongue and into the neopharynx, this lumen
the point of illumination. The surgeon must estimate
is usually passively closed. It is necessary to blow it
the relationship between the trachea and course of the
open with air in order to get into the lumen of the
neopharyngeal-esophageal segment. I have found that
neopharynx. ACHessel
the course of the digestive tract is variable. Some patients
have a neopharyngeal-esophageal passage that is imme-
diate behind the trachea. However, usually there is some
STEP 2. At this point the patient is asked to flex the head
deviation to the left. In some patients, this left-ward
anteriorly and to swallow to assist in the advancement of
course is striking, almost to the point of a C-shaped turn
the scope into the neopharynx and cervical esophagus.
behind the trachea. By dimming the room lights and
The entire length of the esophagus may be examined watching the light emanating from the tip of the TNE,
under direct visualization using insufflation as nec this relationship can be cheaply and instantly clarified
essary. just prior to placing the needle.
STEP 5. Advance a guidewire through the 18-gauge

needle into the esophagus through the posterior tra-
cheal wall (Figure 39-3).
Once the wire’s placement is confirmed under direct

visualization, the 18-gauge needle is removed.
We use a Boston-Scientific Jagwire. We gently use

the 18-gauge needle to enlarge the fistula by moving
and twisting the needle in and out over the guidewire
before removing it entirely. PCBelafsky
Scope
STEP 6. Using a Seldinger technique, the newly formed
tract is dilated along the guidewire (Figure 39-4).
If needed a small incision along the guidewire can be

made using a No. 11 or 15 scalpel blade to ease the
Needle passage of the dilator.
introduced
If you use the needle to enlarge the fistula you rarely

need the scalpel. For a dilator, we cut the tip off a
micropipette (very cheap and works well). PCBelafsky
FIGURE 39-2. Lateral view showing the introducer needle

being placed at the site of transillumination. STEP 7. A small hole is made using the 18-gauge needle
in the distal end of a 12 Fr red rubber catheter so that
the guidewire can travel through the catheter.
We use a 6-inch cotton tip applicator (Kendall,
Mansfield, MA) for ballottement and to put pressure
Use of a dilator with a peel-away catheter can
on and blot any hemorrhage. PCBelafsky
facilitate placement of the red rubber catheter without
using the guidewire. AJMcWhorter
Location strategies with transillumination and
ballottement are key identifying steps in
successful placement of the prosthesis; lack of We use a 14 Fr Silastic Clean Cath (Bard Clean Cath,
visualization is a contraindication to fenestration of CR Bard Inc, Covington, GA) instead of a red rubber
the wall. AJMcWhorter catheter. This has more rigidity than the red rubber and
is easier to advance over the guidewire. PCBelafsky
In those patients in whom the lumen of the esophagus

is slightly off to the right or left, it is still possible to Be sure to advance the red rubber over the wire
perform the TEP. The needle should still be positioned without losing sight of it from inside the esophageal
in the midline posterior tracheal wall, but once through lumen. These wires are short and may get
the mucosa, the needle can be aimed toward the inadvertently withdrawn from the esophagus while
appropriate side. This will keep the TEP prosthesis in trying to get the end to come through the red catheter.
the midline and accessible for the patient and speech In addition, make sure you have the end of the wire
pathologist. However, the tract will travel diagonally before pushing the red rubber into the opening of the
and rest into the lumen of the esophagus. ACHessel trachea. You do not want to push both the catheter
and the wire into the esophagus. ACHessel
STEP 4. Introduce an 18-gauge needle under direct visu-

alization into the posterior tracheal wall (Figure 39-2). STEP 8. The catheter is then advanced along the guide-
wire into the newly formed tract as the guidewire is
A slightly downward angle is used to facilitate later
slowly withdrawn (Figure 39-5).
placement of the guidewire. This also minimizes the risk
of puncturing the posterior esophageal wall with the Proper placement is confirmed under direct vi
needle on introduction. sualization.
CHAPTER 39 Tracheoesophageal Puncture in the Clinic via Transnasal Esophagoscopy 387
Guidewire
inserted
through
needle
FIGURE 39-3. A guidewire is placed through the introducer needle and passed down the
esophagus.
Red rubber
catheter
advanced
over guidewire
Dilator
advanced
along
guidewire
FIGURE 39-5. A red rubber catheter is advanced over the

guidewire into the esophagus under direct visualization. The
FIGURE 39-4. A dilator is passed over the guidewire to dilate catheter is secured to the patient’s skin, and the guidewire is
the puncture site. removed.
office setting. Secondary tracheoesophageal puncture is

Try to not to kink the red rubber and the wire together
possible in the office with minimal complications
as you guide it into the fistula. Try to use the
because of the safe and direct visualization of the punc-
hemostats or pick-ups on the red rubber only as it is
ture into the esophagus. Patients are able to phonate
pushed into the lumen. If the wire is badly kinked or
shortly after the procedure and are able to return to
damaged, it may get stuck inside the red rubber when
their daily routine the same day.
you attempt to pull it out. If the wire is stuck and
cannot be withdrawn, remove the entire red rubber or Suggested Readings
wire and start again. It is better than breaking the wire
inside the esophageal lumen. ACHessel Bach KK, Postma GN, Koufman JA: In-office tracheoesopha-
geal puncture using transnasal esophagoscopy. Laryngo-
scope 113:173-176, 2003.
Barkin JS, Hartford JD, Mikalov A, Flescher LM: Creation of
STEP 9. The red rubber catheter is secured in place
tracheo-esophageal fistula for voice restoration using the
using tracheostomy ties and the red rubber catheter is
flexible fiberoptic endoscope. Gastrointest Endosc 37:469-
tied in a knot to prevent reflux of gastric material. An 470, 1991.
additional stay-stitch (2-0 or 3-0 silk) can be placed to Belafsky P, Postma G, Koufman J: Replacement of a failed
provide a second layer of security, preventing accidental tracheoesophageal puncture prosthesis under direct vision.
extubation. Ear Nose Throat J 80:862, 2001.
Chone CT, Gripp FM, Spina AL, Crespo AN: Primary
versus secondary tracheoesophageal puncture for speech
If the ballottement of the membranous wall reveals a
rehabilitation in total laryngectomy: long-term results with
well-defined indentation, a No. 11 blade scalpel can
indwelling voice prosthesis. Otolaryngol Head Neck Surg
be used to directly incise the posterior wall. The 133:89-93, 2005.
puncture site is then dilated with a hemostat, and the Doctor VS, Enepekides DJ, Farwell DG, Belafsky PC:
red rubber catheter then placed. AJMcWhorter Transnasal oesophagoscopy-guided in-office secondary
tracheoesophageal puncture. J Laryngol Otol 26:1-4,
2007.
I use umbilical tape to secure the red rubber to Eliachar I, Wood BG, Lavertu P, Tucker HM: Improved endo-
the neck. I also make sure patients know that scopic technique for establishment of tracheo-esophageal
they may place their LaryButtons or tubes back into puncture. Otolaryngol Head Neck Surg 110:242-246, 1994.
the stoma. They can eat around the red rubber Hong GS, John AB, Theobald D, Soo KC: Flexible endoscopic
tracheo-esophageal puncture under local anaesthetic. J Lar-
catheter. ACHessel
yngol Otol 109:1077-1079, 1995.
Le T, Wilson JS: A tracheo-esophageal puncture technique for
voice restoration after laryngectomy. Gastrointest Endosc
STEP 10. If the speech pathologist is present, an appro- 38:700-702, 1992.
priately sized voice prosthesis can be measured and Lebert B, McWhorter AJ, Holsinger FC: Secondary tracheo-
introduced immediately if desired. The patient will then esophageal puncture with in-office trans-nasal esophagos-
take sips of water to ensure there is no leakage around copy. Arch Otolaryngology Head Neck Surg 135:1190-1194,
the prosthesis prior to use. 2009.
Parker GA: Simplified tracheoesophageal puncture for inser-
tion of a voice prosthesis. Laryngoscope 95:608, 1985.
This is possible but can be difficult in a fresh stoma.
Singer MI, Blom ED: An endoscopic technique for restoration
We have the speech-language pathologist see the
of voice after laryngectomy. Ann Otol Rhinol Laryngol
patient the following week. PCBelafsky 89:529-533, 1980.
Singer MI, Blom ED, Hamaker RC: Further experience with
Conclusion voice restoration after total laryngectomy. Ann Otol Rhinol
Laryngol 90:498-502, 1981.
Transnasal esophagoscopy has improved the diagnostic Singer MI, Bloom ED, Hamaker RC: Voice rehabilitation after
and therapeutic ability of the otolaryngologist in the total laryngectomy. J Otolaryngol 12:329-334, 1983.
SECTION B Transoral Endoscopic Head and
Neck Surgery
CHAPTER
Transoral Laser Microsurgery:
40 Supraglottic Laryngectomy
Author F. Christopher Holsinger
Commentary by Marc Remacle, Wolfgang Steiner, and David Howard
Preoperative Considerations This ideal lesion is, however, rather infrequent. A T1

Transoral laser microsurgery (TLM) is a widely accepted infrahyoid exophytic lesion without extension to the
part of mainstream head and neck surgical practice. petiole of the epiglottis is also a very good and more
Resection of supraglottic carcinomas via TLM was first frequent indication. MRemacle
popularized by Steiner after the preclinical work by
Vaughan and colleagues in the late 1970s. Steiner’s
Good exposure of supraglottic tumors is rarely a
groundbreaking technical innovations, first begun in
problem but it is important to remember that adequate
Germany in the 1980s, led to the systematic study and
flexion of the neck on the trunk is necessary and
implementation of this technique across the globe.
not overextension of the head on the neck. It may
Squamous carcinomas of the supraglottic larynx,
be necessary to use a smaller nondistending
classified as T1-T2 and selected T3 lesions, are ame-
laryngoscope working from the lateral aspect along
nable to transoral laser microsurgery and supraglottic
the floor of the mouth with the tongue pushed to the
laryngectomy (TLM-SGL).
opposite side. Additionally, it is important to remember
To achieve optimal outcomes, strict criteria relating
that it may take time to get the maximal exposure.
not only to the tumor but also the patient’s anatomy
With a distending laryngoscope it may be very
and medical condition, must be considered.
beneficial to place the upper blade in the vallecula and
First, the ideal tumor is an exophytic lesion confined
the lower blade into the posterior supraglottic lumen
to the suprahyoid epiglottis without extension to the
to facilitate excision of portions of the epiglottis to
tongue base or glottic larynx. The ideal patient has
improve access to the remainder of the supraglottis
excellent exposure and good cardiovascular and pulmo-
and allow complete removal of the tumor. WSteiner
nary function. Pearson advocated attention to the T’s of
and DHoward
adequate exposure for TLM: tilt, trismus, teeth, tumor
(personal communication). Exposure for TLM requires
adequate inter-incisor opening of at least 2.5 to 3 cm There is no age limit for endoscopic TLM-SGL.
and ideally more. Prominent maxillary dentition or a However, the patient’s cardiopulmonary reserve must
class I overbite may limit exposure. During distention be carefully considered. As with “open” supracricoid
laryngoscopy with wider aperture endoscope, the partial laryngectomies (SCPLs), if the patient can
tongue must be displaced anteriorly for good exposure. walk two flights of stairs, the patient most likely has
However, patients with a retrusive chin and/or narrow adequate pulmonary reserve to tolerate the procedure
mandibular arch are often difficult to expose because (see Chapter 36).
the tongue simply cannot be displaced. By covering the Preoperatively it is essential that the patient and his
mandibular dentition and then gently pulling the tongue or her support network meet with a qualified and expe-
out of the mouth with gauze, this difficulty can be mini- rienced speech-language pathologist. Having reasonable
mized. For patients with a short distance between the preoperative expectations helps the patient navigate
mandibular mentum and laryngeal-hyoid complex, postoperative swallowing rehabilitation, which is the
exposure can be particularly difficult. chief hurdle after TLM-SGL. Even for a large resection,
389
if the patient is previously untreated and healthy, I also from other manufacturers for fine phonosurgical
expect the resumption of oral intake to begin around instruments, bipolar laryngeal cautery, and laryngeal
postoperative day 5. If the patient has been previously palpation.
radiated, swallowing rehabilitation is much more pro- Surgical clips (LT200 LIGACLIP, Ethicon, J&J, Cin-
tracted and I routinely place a percutaneous endoscopic cinnati, OH) and suction electrocautery (Karl Storz
gastrostomy. 8606D and 8606F) are critical for managing vascular
structures, especially the superior laryngeal artery. Ade-
quate suction is essential, with at least two separate
Preoperative assessment by an experienced speech-
systems needed: one for the endoscope and another via
language pathologist is essential. However, it can
handheld microscopic instrumentation.
still be difficult to predict postoperative swallowing
function in patients undergoing resection for larger
Production of plumes and smoke can be a problem. In
tumors. Still, we do not routinely advocate a
fact, we are used to working with three suctions: one
percutaneous endoscopic gastrostomy. This
connected to the laryngoscope for the plumes, one to
procedure carries its own morbidity and occasional
a suction-coagulation tube, and one to a forceps for
mortality, particularly in older adult patients and those
the plumes and the liquids. MRemacle
with large tumors. We place a small-caliber, soft
nasogastric feeding tube and assess the patient over
Prior to surgery, the surgeon must instruct members
the first 10 days postoperatively. Subsequent long-
of the nursing and surgical support personnel about
term percutaneous gastrostomy is occasionally
these unique instruments and their use, especially in the
necessary. WSteiner and DHoward
event of hemorrhage. A team that has been prepared
preoperatively favors good patient outcomes and more
Approximately 30 minutes prior to the start of the adeptly assists the surgeon while at work.
procedure, the patient is given a broad-spectrum antibi- To that end, I prefer to have a video monitor with
otic for microbial prophylaxis. a high-definition optical beam splitter (Karl Storz
KIPUSAZ55) so that all personnel in the operating
An intravenous (IV) dose of steroid (100 mg of room have the opportunity to visualize the surgical field,
methylprednisolone, for instance) decreases the risk of from anesthesia personnel to nursing to trainees.
local postoperative edema, which could prevent the
extubation. MRemacle It is usually necessary and preferable to have more
than one video monitor to allow assistants, nursing
staff, and anesthesia personnel to see the operation
satisfactorily. Video recording is essential for future
Special Equipment and evaluation and teaching. WSteiner and DHoward
Laser Safety Precautions
For the patient, three layers of eye protection are typi-
Technique
cally used: the eyes are taped shut, then saline-soaked Direct laryngopharyngoscopy is performed under apnea
gauze and eye patches are applied, and finally, the head and prior to endotracheal intubation (see Chapter 34).
is wrapped in moistened green operative towels. The The surgeon must be in the operating room during
neck and chest are also covered so that no skin or induction of general inhalational anesthesia. Once ade-
mucosal surfaces are exposed or unprotected. quate general anesthesia is achieved, the patient’s teeth
A distending laryngoscope is required, such as that are carefully protected. I prefer to have the dental oncol-
designed by Steiner (Karl Storz, Tuttlingen, Germany). ogy team prepare customized mouth guards using Aqua-
However, the Lindholm laryngoscope is particularly plast. This customized dental guard for both mandibular
well suited for the more cephalad aspects of the and maxillary dentition minimizes inadvertent dental
resection. injury but also may optimize exposure by eliminating
Large ringed forceps with teeth are needed for grasp- the use of thicker anesthetic dental guards.
ing the epiglottis, but smaller toothed and smooth Zero-, 30-, and 70-degree endoscopy is performed
grasping forceps are needed for managing mucosal prior to intubation. This careful inspection of the glottic
margins. For more precise tissue handling, Bouchayer and subglottic larynx prior to intubation is useful to
laryngeal basket forceps are indispensable for grasping discern subtle mucosal changes in the larynx and to
fragile mucosa, while not avulsing or traumatizing the visualize problem areas such as the ventricle and infra-
tissue. petiolar epiglottis that require angled visualization and
I have assembled my own “set” of instruments for areas such as the subglottis and interarytenoid that are
TLM-SGL, relying on Steiner’s set from Karl Storz, but difficult to examine after an endotracheal tube is placed.
CHAPTER 40 Transoral Laser Microsurgery: Supraglottic Laryngectomy 391
For the purpose of this description, we describe a

I agree. My preoperative assessment includes a direct
complete supraglottic laryngectomy (ELS IVA). For
laryngoscopy with 0-, 30-, and 70-degree endoscopy.
superficial exophytic lesions of the suprahyoid epiglot-
But if for some reason the delay between the
tis, a more limited resection is indicated (ELS I). Accord-
assessment and the surgery is too long (more
ingly, for tumors with spread to the pyriform sinus or
than 2 to 3 weeks), checking the tumoral extension
“three-fold” lesion (see Chapter 34, Figure 34-3), a
again before starting the procedure is always
more extensive resection may be required.
indicated. MRemacle
A principal advantage of the adaptive technique of
TLM is that when possible, as much normal mucosa
and underlying laryngeal infrastructure and neurovas-
Once these areas have been inspected and the extent culature can (and should) be preserved. For instance, if
of the tumor documented, the patient is intubated using the tumor if lateralized to one aspect of the epiglottis
a flexible, laser-safe endotracheal tube. A bivalve or and a 5-mm clear margin can be obtained, then I try
distending laryngoscope is then used to visualize the when possible to preserve a remnant of the contralateral
relationships between the supraglottic larynx and oro- epiglottis.
pharynx and hypopharynx. Finally, I aim to achieve 5-mm margin for previously
To optimize exposure the neck is gently flexed but untreated supraglottic cancers, but more generous
the head is extended at the atlanto-occipital joint. Thus margins of even 8 to 10 mm for radiation failure.
a shoulder roll is not necessarily used.
Exposure through the laryngoscope is maintained This 5-mm clear margin is also a wise rule. But
using either the modified Killian gallows suspension because this is already the case with open partial
apparatus (Pilling Surgical, Inc., Durham, NC) or fixa- laryngectomy, this not always possible in some areas
tion to a specialized laryngoscope holder and support such as the tip of the epiglottis or inferior part of the
table, such as the Göttingen (Figure 40-1A). Whether ventricular fold. A 2-mm margin is then considered as
the laryngoscope is attached to a gallows suspension safe and acceptable. With this regard, frozen sections
device or a support table mounted over the chest, the are useful if available. MRemacle
surgeon should use a system that allows the laryngo-
scope and operating table to be moved and rotated in a
single unit. The use of a Mayo stand is not recom-
mended for more lengthy procedures.
Operative Steps
TLM is an adaptive surgical technique, in contrast to
“open” or transcervical conservation laryngeal surgery, STEP 1. With ringed wide-mouth forceps, grasp the
in which all mucosa and tissue between cartilaginous epiglottis and pull inferiorly so as to expose fully the
and muscular structures is removed. At times this vallecular mucosa.
approach sacrifices normal mucosa to ensure en-bloc
If the friable tumor prevents an adequate grasp of the
resection or wound closure.
epiglottis, I may sometimes perform sagittal division or
In 2009, the European Laryngological Society (ELS)
split of the epiglottis to facilitate more optimal traction-
proposed a schema to classify TLM-SGL, based on the
countertraction and better exposure (Figure 40-2).
extent of resection. The schema is defined by whether
A semilunar incision is made to define entirety of the
or not there is a partial or complete removal of the
underlying hyoid bone. By skeletonizing this structure,
epiglottis, preepiglottic space, false cords/ventricular
a complete resection of the preepiglottic space is
folds, the arytenoid and associated sesamoidal cartilages
possible (Figure 40-3).
(see Figure 40-1B), and pharyngoepiglottic and/or ary-
epiglottic folds. Resection of associated mucosa from
the pyriform sinus and/or vallecular and tongue base
STEP 2. Next, address the pharyngoepiglottic folds.
should be considered.
If it is possible from a tumor standpoint, I try to pre-
serve as much of these folds as possible. In many cases
The Göttingen surgical principles of TLM have always
the underlying neurovascular branching of the superior
proposed a custom-tailored procedure for each
laryngeal nerve actually creates this fold. Bourgery and
patient, to carry out complete tumor removal but
Jacob described the complex branching of the superior
maximize retention of normal tissue and hence
laryngeal neurovascular bundle, more than a 150 years
subsequent function. The ELS scheme proposes
ago, demonstrating a slightly superomedial location of
standardized procedures that would in theory allow
the nerve relative to the artery. From the entrance of the
more discussion of multicenter results in proposed
main trunk at the threefold region (see Figure 34-3), the
prospective studies. WSteiner and DHoward
branching of the nerve and artery is highly variable. It
is easy to distinguish the “main” trunk of the pulsatile
Microscope
Laryngoscope
35-40 cm
Tongue base
Epiglottis
Cuneiform tubercle Cuneiform

cartilage
Corniculate tubercle
Pyriform
Arytenoid cartilage sinus
FIGURE 40-1. Establishing the operative field and orientation.

A, Patient positioning and the intraoperative setup. The
endoscope is fixed to the laryngoscope holder. Internal
distension and strategic external compression provide exposure
of the target anatomy. B, Endoscopic anatomy of the
supraglottic larynx. B
Tongue
base
Epiglottis
Preepiglottic
fat
Corniculate Cuneiform
tubercle tubercle
Esophagus
Epiglottis
FIGURE 40-4. Resection of preepiglottic fat.
artery. We use two surgical clips (see earlier for details)

for the main trunk of the superior laryngeal artery. It is
inadvisable to place clips on the superior laryngeal nerve
(SLN) because this might delay mucosal reinnervation
postoperatively. Smaller-caliber vessels may be cauter-
ized using suction electrocautery (Karl Storz 8606D and
B 8606F) but where there is doubt or concern, place a clip.
FIGURE 40-2. Close-up view of the epiglottis before Transoral laser microsurgery has an overall low
(A) and after (B) the sagittal split. The epiglottis is retracted
morbidity but postoperative bleeding can be a serious
superolaterally with a toothed forceps to provide traction-
complication after supraglottic tumor resection.
countertraction.
Although we completely agree that preservation of the
superior laryngeal nerve is preferable if possible, it is
extremely important in our experience to clip the
vascular pedicle adequately. Indeed, we always strive
to apply two good Ligaclips. Cautery of the pedicle
Hyoid alone is inadequate. WSteiner and DHoward
bone
Epiglottis
STEP 3. Once the hyoid has been defined and the lateral
aspect of the neurovascular supply is under control, the
surgeon can then resect all preepiglottic fat from the
hyoid down along the thyroidhyoid membrane caudally
to the superior border of the thyroid cartilage (Figures
40-4, 40-5, and 40-6).
Here the surgeon can easily enter the neck by resecting

a portion of the membrane and even expose the thyro-
hyoid muscle, if need be.
FIGURE 40-3. Mucosal incisions into the vallecula are made
and continued deeply, even to expose, when necessary, the
hyoid bone. We do not routinely expose the hyoid bone to
adequate deal with the preepiglottic space. Of course
in very large tumors it may be necessary and can
superior laryngeal artery from its companion nerve. But even be resected. The tumor dictates the extent of
the surgeon should respect tissue planes to avoid inad- resection, not a reproduction of conventional open
vertently lacerating one or the other prior to achieving procedures. WSteiner and DHoward
endoscopic exposure to clamp the superior laryngeal
Hyoid
bone Epiglottic
pediole
Thyroid
cartilage
Thyrohyoid
Vocal ligament
cord
FIGURE 40-5. Moving from cephalad to caudad, after FIGURE 40-7. The inferior aspect of the resection begins by
preepiglottic space fat is removed, the superior border dividing the aryepiglottic fold and then extending the incision
of the thyroid cartilage is encountered next. to include the false cord and paraglottic space.
If the surgeon must resect the ventricular band, I recom-

mend halting the resection and examining the lateral
aspect of ventricle and its transition to the true cords,
using a 70-degree rigid endoscope.
Sup. laryngeal STEP 7. At times the tumor descends from the preepi-
a./n. glottic space into the paraglottic space. Here I attempt
a more traditional en-bloc resection.
This approach allows the surgeon to maintain an aware-

ness of the overlying and medial mucosal landmarks to
the often serpentine submucosal extent of tumor in the
paraglottic space.
FIGURE 40-6. Using vascular clips, the surgeon controls the

We recommend cutting directly into and through the
superior laryngeal artery, ideally without disturbing the
tumor, in more than one area if necessary, to establish
adjacent branches of the superior laryngeal nerve branches.
the depth and preserve as much paraglottic tissue
as possible. If there is gross deep infiltration, then
STEP 4. I routinely sample the preepiglottic space for obviously the thyroid perichondrium becomes an
frozen section to ensure an adequate resection, because extremely useful deep assessment layer. WSteiner
its predominantly fibrofatty contents can be difficult to and DHoward
manage en bloc. Thus precise technique and attention
to detail are essential for a comprehensive resection. I have a very similar approach to the author’s:
I try to perform an en-bloc resection as much as
possible. If for some reason (volume, access, etc.)
STEP 5. Depending on the amount of caudal spread of this is not possible, I split the lesion according to
the tumor, the surgeon can then resect the aryepiglottic Steiner. MRemacle
(AE) folds as well as the ventricular bands and false cord
(Figure 40-7).
STEP 8. During the case I use a two-dimensional laryn-
However, one must not dogmatically always resect
geal schema, such as those used by Ambrosch and
structures unless the tumor is tracking to each individ-
Steiner, to “map” the extent of tumor spread as well as
ual region.
to precisely define from where frozen section margins
have been taken. When possible, I tend to mark the
specimen under microscopic visualization in the patient,
STEP 6. If the AE fold is taken, I generally try to incise
then complete the final cuts to ensure accuracy.
with the laser at the cephalad base of the arytenoid, and
where possible preserve the sesamoidal cuneiform and To facilitate marking the specimen in this way, I disas-
corniculate cartilages. semble a surgical marking pen and then mount its felt
Regardless, I always involve the speech rehabilitation

team on postoperative day 1. A bedside swallowing
Mark for margin
evaluation can be helpful in patients with partial supra-
glottic resections. A formal modified barium swallow
may helpful in designing rehabilitative strategy at the
end of the first postoperative week. Postoperative speech
should be normal.
While patients are maintained without enteral nutri-
tion and nothing by mouth, I treat them with parenteral
or liquid oral antibiotics via nasogastric tube for 5 to 7
days. I also administer a proton pump inhibitor and
encourage them to expectorate their secretions at least
for 24 to 48 hours postoperatively, until postoperative
edema resolves. The rehabilitation after TLM-SGL is
very similar to the regimen pioneered by Laccourreye
and associates and is detailed in greater detail in
FIGURE 40-8. The use of frozen section margins is critical.
I prefer to mark the margin of interest in situ and under the
Chapter 36.
microscope, to diminish errors in orientation. To facilitate this, If the surgeon enters the neck, the neck can be
I remove the felt-tip of a surgical marking pen and then attach wrapped with Elastoplast to minimize the risk of cervi-
it to a Bruning’s injection needle. The area of interest is then cal emphysema. In such cases, the patients often, if not
marked under the microscope and then sent to the surgical always, complain of tenderness, which usually subsides
pathology suite for histologic assessment. within 48 to 72 hours.
tip onto a Bruning’s injection needle. This device can be Suggested Readings
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shown in Figure 40-8 on the epiglottic sagittal split) or Huettenbrink KB, editor: Lasers in otorhinolaryngology.
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TLM-SGL. The airway is widely patent after removal 113-142.
of part of or all of the supraglottic larynx. Early on in Ambrosch P, Kron M, Steiner W: Carbon dioxide laser micro-
their experience, some surgeons prefer to perform tra- surgery for early supraglottic carcinoma. Ann Otol Rhinol
cheotomy in the event of catastrophic hemorrhage in Laryngol 107:680-688, 1998.
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l’homme: comprenant la médicine opératoire, Paris, 1832,
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Delaunay.
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I do agree with the author: I rarely perform
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Gesichtsbereich. 6.3.9. Operationen mit Laser. In: Duale New York, 2000, Georg Thieme.
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Remacle M, Hantzakos A, Eckel H, Evrard AS, Bradley PJ, von Krebsfrühstadien im Larynx—vorläufige Ergebnisse.
Chevalier D, et al: Endoscopic supraglottic laryngectomy. Arch Otorhinolaryngol 231:637-643, 1981.
A proposal for a classification by the working committee Steiner W, Martin A, Ambrosch P, Pradier O, Kron M: Results
on nomenclature, European Laryngological Society. Eur of transoral laser microsurgery for supraglottic carcinoma.
Arch Otorhinolaryngol 266:993-998, 2009. Ann Otol Rhinol Laryngol. In press.
Steiner W: Experience in endoscopic laser surgery of malignant Vaughan CW: Transoral laryngeal surgery using the CO2 laser.
tumours of the upper aero-digestive tract. Adv Otorhinolar- Laboratory experiments and clinical experience. Laryngo-
yngol 39:135-144, 1988. scope 88:1399-1420, 1978.
CHAPTER
Transoral Laser Resection
41 of Glottic Tumors
Authors Apostolos Christopoulos, F. Christopher Holsinger,
and Robert L. Ferris
Commentary by Manuel Bernal-Sprekelsen, Isabel Vilaseca, Mark S. Courey, Eric J. Moore,
Giorgio Peretti, and Cesare Piazza
Preoperative Considerations head and neck tumors by transnasal techniques.

Evaluate the Extent of Tumor These tumors had previously required rigid endoscopy
on Clinical Examination, Endoscopy, under general anesthesia. Staging and diagnostic
and Radiologic Examination biopsy through indirect techniques has multiple
advantages over rigid endoscopy. These include
To perform successful transoral laser microsurgery decreased time to diagnosis, avoidance of a separate
(TLM) for glottic cancer, the surgeon must have a procedure under a separate general anesthesia,
precise knowledge of tumor extent within and beyond and reduction in the overall cost of medical care.
the glottis. Anatomic sites of particular interest include Widespread application of these techniques and
the subglottis and cricoid cartilage, the ventricle and adoption of these as a new gold standard await
false cords, the anterior commissure and thyroid carti- completion of equivalency studies comparing
lage, the supraglottic larynx, and the arytenoid carti- transnasal diagnostic and staging techniques
lage. For early glottic lesions, this can sometimes be with those of rigid endoscopy. MSCourey
achieved by flexible fiberoptic laryngoscopy. However,
the gold standard is always operative endoscopy with
angled visualization of the ventricle and subglottis. Videostroboscopic examination of the larynx can
yield information of the depth of cordal invasion and
An adjunctive crucial issue to be preoperatively guide the surgeon on the type of cordectomy and/or
evaluated by flexible endoscopy is the normal or partial laryngectomy necessary to achieve a sound onco-
impaired vocal cord mobility. Even though on a purely logic resection with minimal functional compromise.
subjective basis, the surgeon should always define
the vocal cord mobility as normal, impaired (for mass In the preoperative setting as well as during operative
effect due to bulky lesions or initial infiltration of the endoscopy, useful adjunctive tools are represented
vocal muscle), or fixed (for massive involvement of the by narrow band imaging and high-definition television,
posterior paraglottic space and/or cricoarytenoid which, in combination, allow to better define the
joint). GPeretti and CPiazza superficial spreading of the lesion by enhancing its
atypical vascular pattern. GPeretti and CPiazza
Advances in office endoscopy techniques and

equipment over the past decade, including flexible Often the terms indirect laryngoscopy and laryngeal
transnasal distal chip endoscopes, improved familiarity stroboscopy are used interchangeably. Distinguishing
with rod lens telescopes, and increased availability between the two examinations promotes an improved
of digital recording units, have resulted in improved understanding of laryngeal anatomy and physiology
glottic visualization through indirect techniques. and allows the surgeon to obtain a better appreciation
In addition, transnasal endoscopes with working of the laryngeal disease process. Laryngoscopy is best
channels for biopsy forceps are now readily available. used to visualize vocal fold abduction, adduction,
These advances have facilitated instrumentation of the morphologic appearance, and to define the extent of
pharynx and larynx in the office setting. In many head lesions. Stroboscopy is used to specifically examine
and neck cancer centers the skills and tools now exist the vocal fold vibratory patterns that occur during
to permit accurate staging and diagnostic biopsy of voice production. Careful visualization of the
397
Vestibular
ligament
I Vestibular
II fold
III Vocal
IV
fold
A
I
Vocalis m.
II Aryepiglottis
m.
III Vocal
ligament
B IV
FIGURE 41-1. Endolaryngeal (A) and coronal (B) views of the larynx showing the varying
depths of laryngeal resection according to the European Laryngological Society’s classification
of cordectomies.
individual patients and to study this technique in clinical

suspected lesion with high-quality indirect laryngeal
trials across institutions (Figure 41-1).
examination indirect laryngoscopy) as can be obtained
A fine cut laryngeal computed tomography (CT)
with rod lens telescopes or flexible distal chip
scan or magnetic resonance imaging (MRI) can be useful
endoscopes, is paramount in determining the extent of
especially if there is doubt regarding thyroid cartilage
the disease. Characteristics of the mucosal vibratory
involvement. The final aspect of this evaluation is a
patterns, as are specifically examined through
suspension laryngoscopy performed in the operating
laryngeal stroboscopy are affected by the size of the
room as described further in this chapter. All T1 and
lesion regardless of whether the lesion is exophytic or
T2 tumors are suitable for TLM. Some T3 and a few
endophytic. Therefore blinded analysis of stroboscopic
very selected T4 lesions can also be approached endo-
characteristics has not been demonstrated to correlate
scopically. This is highly dependent on surgical exper-
with the depth of invasion of a lesion. Once the lesion
tise, and it is suggested to start with T1 lesions when
forms a plaque on the surface of the vocal fold, it
using this technique.
can result in interruption of the normal vibratory
characteristics of the mucosa due to the stiffness
or the plaque regardless of its depth of invasion. Accuracy of CT scan to assess cartilage involvement
However, use of stroboscopy to examine the larynx is about 60%. In many cases, cartilage infiltration
facilitates an appreciation of the normal anatomy is confirmed during the surgery. MRI can improve
around the lesion and provides information to the cartilage assessment up to 80%. MBernal-Sprekelsen
surgeon of how much normal tissue he or she may be and IVilaseca
able to preserve. MSCourey
Carefully Select Patients for TLM According

to Tumor and Patient Characteristics
The European Laryngological Society (ELS) has cat-
egorized endoscopic laryngeal surgery based the depth Patient selection for TLM for glottic cancer follows
and extent of resection, from cordectomy to partial the same criteria as for open partial laryngectomies.
laryngectomy (see Remacle et al., 2000, 2007). This Absolute contraindications to TLM for glottic cancer
schema provides a common nomenclature to describe include extensive thyroid cartilage or strap muscle
more accurately the extent of laser surgery for involvement, cricoid cartilage involvement, lack of one
CHAPTER 41 Transoral Laser Resection of Glottic Tumors 399
functional cricoarytenoid unit, and posterior commis- articulated arm attached to an operating microscope. A
sure involvement. typical spot size is 0.3 to 1 mm in diameter with a
Some patients’ larynges might be difficult or even power output of 3 to 10 watts, depending on spot size.
impossible to expose fully for TLM. Obesity, a short Other centers may elect to use the yttrium-aluminum-
neck, severe retrognathia, hypertrophy of the tongue, garnet (YAG) or potassium titanyl phosphate (KTP)
and dentition are all factors that may present difficulty laser. These lasers are preferentially absorbed by red
in obtaining adequate exposure to perform suspension pigment; hence, they have somewhat improved hemo-
laryngoscopy. The patient should also be free of signifi- static capability when compared with the CO2 instru-
cant cervical spine degenerative disease, which may pre- ment. The KTP laser beam can be delivered either by a
clude proper positioning. micromanipulator connected to the microscope or via
handheld flexible fibers. Laryngoscopes are available
In glottic tumors, difficult exposure occurs almost in that permit simultaneous suctioning of smoke and laser
15% of cases. MBernal-Sprekelsen and IVilaseca plume with beam delivery.
The patient should be counseled as to the possible

The main limit of YAG laser in glottic cancer is the
need for extraction of loose or severely carious teeth.
impossibility to apply a “hands-off” technique.
Moreover, both YAG and KTP lasers, according to
Contrary to other partial laryngectomies, age of the
their physical properties, show an increased
patient is not a formal contraindication for transoral
scattering effect with increased thermal damage
laser microsurgery. MBernal-Sprekelsen and IVilaseca
to the surrounding deep soft and cartilaginous
tissues. GPeretti and CPiazza
For more extensive cordectomies (types IV and V of
the ELS classification), the patient is at risk for postop-
erative aspiration. Therefore a thorough evaluation of
pulmonary function is mandatory. Operative Technique
STEP 1. Administer broad-spectrum antibiotic prophy-

Special Equipment and laxis 30 minutes prior to the start of the procedure.
Cooperate and communicate with the anesthesiologist
In case of endoscopic procedures after radiotherapy
to establish beforehand the particular role of each in the
(RT) or chemotherapy (CHT)/RT failure, antibiotic
management of the airway.
therapy should be started before surgery and
Questions regarding apneic laryngoscopy, use of jet
prolonged for at least 10 days after that in order
ventilation, inhaled oxygen concentrations, and postop-
to prevent chondritis and chondronecrosis of the
erative airway management must be discussed before
laryngeal cartilages. GPeretti and CPiazza
each case.
Before tackling transoral laser resection of glottic
tumors, make sure the operative theater is equipped
STEP 2. First perform a formal direct laryngoscopy
with adequate instrumentation for visualization, tissue
in order to properly assess the location and extent of
manipulation, and hemostasis.
the tumor.
Basic equipment includes an array of laryngoscopes
with laser-safe finish and suction ports, endoscopic Direct laryngopharyngoscopy is performed under apnea
grasping forceps, suctions and suction-cautery, bipolar and prior to endotracheal intubation. The surgeon must
cautery, and clip applicators. Postoperative bleeding be in the operating room during induction of general
could be a disastrous complication following resection inhalational anesthesia. Adequate general anesthesia is
of larger glottic tumors, so meticulous hemostasis is a achieved and the patient’s teeth are carefully protected
crucial part of these procedures. The use of a video using a double reinforced dental guard. Using a stan-
demonstration system gives the opportunity to anesthe- dard laryngoscope that conforms to the natural chevron
sia staff, surgical assistants, and trainees to follow the of the glottis, 0-, 30-, and 70-degree endoscopy is per-
procedure. It also permits documentation of the lesion formed prior to intubation. Use of rigid rod-lens tele-
and the resection procedure for future reference and scopes enhances visualization as the lenses are brought
analysis. into proximity with the tumor and transmits the image
Choose the laser to use according to the character- directly to the surgeon’s eye. This process effectively
istics that you need for the particular resection. eliminates the distance between the patient’s mouth
The CO2 laser is the instrument of choice for TLM opening and the glottis, allowing the advantages of close
for most surgeons. This laser is directed through an inspection and facilitating photo documentation for the
medical record and for teaching purposes. This careful laryngoscopes must be prepared and available with a
inspection of the glottic and subglottic larynx prior to second suction in these situations. Because patency of
intubation is useful to discern subtle mucosal changes the airway is usually not a concern, many head-and-
in the larynx and to visualize problem areas such as the neck surgeons perform the first evaluation and intuba-
ventricle that require angled visualization and areas tion, prior to disruption of the baseline tumor appearance
such as the subglottis and interarytenoid area that are by standard anesthetic induction procedure.
difficult to examine after an endotracheal tube is placed.
A preoperative briefing with the anesthesia personnel,
In our experience, the insertion of the smallest pathologist, operating room personnel, and all other
endotracheal tube does not represent a major team members should be performed prior to the case.
limitation to direct laryngoscopy with rigid 0-degree This ensures that the necessary equipment is available
and angled telescopes and to endoscopic surgical and functional, that the procedure and individual steps
maneuvers. Moreover, the condition of the patient are clear to everybody involved, and that avoidable
intubated and fully paralyzed certainly represents errors are minimized. EJMoore
the ideal setting for an accurate multiperspective
evaluation and palpation of the larynx and adjacent
sites. GPeretti and CPiazza STEP 4. Perform all the necessary tooth extractions. Fit
the patient with a dental guard to protect remaining
dentition. Poor anterior dentition should be removed
For patients with potentially unstable airways, prior to surgery to avoid hazardous dislodging of teeth
intubation with a small endotracheal tube, such as during the procedure.
a No. 5, allows the airway to be secured while still
permitting room for adequate laryngeal inspection.
Some surgeons even advocate removing healthy incisors
The endotracheal tube may be held anteriorly with the
if deemed necessary to achieve adequate glottic expo-
laryngoscope. This allows visualization of the posterior
sure. This should be discussed with the patient prior to
commissure structures. MSCourey
surgery.
For more superficial lesions, subepithelial injection STEP 5. Flex the patient’s neck gently but extend the
into the Reinke’s space of a saline-epinephrine mixture head at the atlanto-occipital joint. Thus a shoulder roll
or 1:10,000 dilution of epinephrine alone with a is not necessarily used.
27-gauge Bruning or butterfly needle helps determine
invasion beyond the superficial lamina propria into the The true vector suspension technique with the patient
deeper structures, such as the vocal ligament or vocalis in cervical flexion and atlanto-occipital extension is
muscle (Figure 41-2B through D). This helps guide to reported to give the best visualization of the anterior
the type of cordectomy necessary for oncologic control. commissure.
In our opinion, the ideal way to obtain a true

STEP 3. The surgeon or anesthesiologist can intubate
suspension laryngoscopy with an adequate
the patient using an appropriate-sized flexible laser-safe
visualization of the anterior commissure, especially
endotracheal tube. Some patients may be considered a
in the “difficult” larynx, is to put the patient in the
difficult intubation because of their anatomy or underly-
Boyce-Jackson position and use a true vertical vector
ing tumor, and a close cooperation between the two
of force by the Zeitels’ suspension system. All the
parties is crucial.
other suspension tools, particularly those resting
on the patient’s chest or on a support table, are
Specifically for glottic tumors, the smaller the inherently suboptimal for this purpose. GPeretti and
tube, the better the exposure. Tube No. 5 or 6 is CPiazza
preferred. MBernal-Sprekelsen and IVilaseca
STEP 6. Carefully choose the appropriate laryngoscope

Paramount to the safe and effective management of the
in order to achieve optimal exposure of all aspects of
airway is clear and open communication between the
the tumor.
otolaryngologist and the anesthetist prior to and during
the procedure. Although these health professionals Fundamental to any laryngologic procedure is the ability
“share” the airway, in most situations the otolaryngolo- to adequately visualize and expose the involved sites of
gist is more adept at obtaining adequate airway expo- the larynx. There are a wide variety of laryngoscopes
sure and navigating distorted laryngeal anatomy. Rigid available that allow binocular exposure as well as
Laryngoscope
Vestibular
ligament
Vestibular
fold
Tumor Tumor
Vocal
fold
Vocalis m.
Thyro-
arytenoid m.
Vocal
ligament
B C D
FIGURE 41-2. A, Laryngoscope suspension system, which is attached to the operating table.
This allows for the whole apparatus to be moved as a unit. B, Coronal view of a superficial
lesion of the vocal cord not invading the vocal ligament or vocalis muscle. C, In this case,
subepithelial injection in the Reinke’s space can help determine the depth of resection.
D, If the lesion is deeply invasive into vocal ligament or vocalis muscle, it will not dissect
from deeper planes thus warranting a deeper resection.
bimanual instrumentation. We currently use a Jako-

maximum magnification that can be achieved by the
Dedo type V laryngoscope or a Steiner closed laryngo-
microscopes currently available is up to 12 to 13 times
scope. An anterior commissure type scope may be used
that of the target anatomy. Commonly a magnification
for adequate visualization of anterior lesions in some
factor of 6 or 7 times feels comfortable and is used by
patients, but one must keep in mind the narrower work
most surgeons. MSCourey
channel that makes the resection more challenging.
The availability of a variety of laryngoscopes will help STEP 9. If full exposure of the glottic structures of inter-
the surgeon gain optimal exposure in the widest est is still not achieved, an assistant could apply pres-
variety of patient anatomy. The laryngoscopes should sure to the anterior neck area over the thyroid or cricoid
be readily available, visible to the surgeon and the cartilages.
assistant in the room, and stored in such a way that
the appropriate accessories (attached suctions, light Tape may be applied to the anterior neck and table to
cords, suspension attachments) are easily accessible. provide any necessary counterforce for complete glottic
The largest laryngoscope with the widest posterior exposure. It should be noted that digital pressure,
aperture that can expose the tumor should be used. although useful for cursory evaluation, might fluctuate
EJMoore throughout the case.
STEP 7. Maintain exposure of the glottis through the Taping the neck in thin patients should be done with
laryngoscope by using either the modified Killian gallows caution in extended transoral laryngectomies because
suspension apparatus or fixation to a specialized laryn- heat produced by the ablating instruments may be
goscope holder and support table (see Figure 41-2A). transmitted to the subcutaneous tissue and result in
injury to the skin. The surgeon must remain aware of
Whether the laryngoscope is attached to a gallows sus-
what is happening in the total operative environment
pension device or a support table mounted over the
and not limit concentration to only what is visualized
chest, the surgeon should use a system that allows the
through the microscope. EJMoore
laryngoscope and operating table to be moved and
rotated in a single unit. The use of a Mayo stand is not
recommended for more lengthy procedures.
We find particularly useful, in selected situations, the
so-called four hands technique in which the surgeon
is helped by an assistant who puts under traction the
STEP 8. An operating binocular microscope is intro-
specimen with a forceps or holds the suction with one
duced for visualization of the glottis.
hand while with the other modulates the compression
and exposure of the larynx from the outside. GPeretti
Using the correct lens and optical system is crucial for
and CPiazza
ease of operation because the focal distance should
allow space for the surgeon to maneuver instruments
through the laryngoscope without interference from the
STEP 10. Observe laser safety precautions by applying
microscope.
three layers of eye protection to the patient.
The current generation of operating binocular The eyes are taped shut, then saline-soaked gauze and
microscopes frequently offers a variable length focal eye patches are applied, then the head is wrapped in
distance. This allows the surgeon to alter the focal moistened green operative towels. The neck and chest
distance up to 500 mm. This extra distance between are also covered so that no skin or mucosal surfaces are
the body of the microscope and vocal folds increases exposed or unprotected.
the working space for the entrance of equipment
into the proximal end of the microlaryngoscope. The
micromanipulators for the CO2 laser can accommodate STEP 11. Despite the use of a laser-resistant endotra-
the additional focal distance as well so a focused laser cheal tube, moistened cotton pledgets may be placed to
beam can be achieved at 500 mm. protect the glottis (contralateral vocal cord in particular)
With regard to degree of magnification, there is a and subglottis from stray laser strikes.
misconception by some that the view of the glottis
can be magnified by 40 times. Actually taking into Familiarity with safe use of the laser instrument and an
account the capabilities of the microscopes, the action plan in the event of airway fire are paramount to
focal lengths of the lenses and the optical system, responsible use of this technique. Apneic technique can
be used during times of laser activity, or the oxygen
content delivered by the anesthetist should be decreased

Use of the minimal power setting that provides
below 30% to reduce the risk for airway fire from
adequate cutting of the tissue is beneficial for several
oxygen leaking around the cuff. Airway fire should be
reasons. The surgeon will better appreciate the
handled by immediate extubation, removal of supple-
boundary between the tumor and normal tissue if
mental oxygen and application of saline into the airway,
power settings are minimized. Also, the margin of the
and reintubation of the patient.
specimen is easier to interpret by the pathologist if
charring is minimized. EJMoore
Reducing the FiO2 to less than 30% lessens the
likelihood of airway fire. However, it does not prevent
it because the FiO2 of air is only 21% and this will
support a fire. If the anesthetic gas mixture contains The surgeon must be familiar with basic concepts
extra oxygen, the threshold for combustion of objects in laser-tissue interactions. Most lasers used for
(such as excessive tumor, dead tissue, or cottonoid surgical intervention have an effect by transferring the
pledgets) is reduced. Fire, if it is initiated, can be laser energy to the tissue. This energy is absorbed
sustained even at this low concentration. In addition, and transformed into heat energy producing a
the oxygen itself is combustible and will support a photothermolytic reaction. If the effect is high enough,
flame once ignition is achieved. In a similar manner, the covalent bonds in the target tissue (also referred
other combustible gasses that support fire, such as to as a chromophore) are broken and the tissue is
nitrous oxide, should be avoided. Commonly, helium vaporized. If the effect is not quite high enough, the
can be substituted. MSCourey tissue around the laser impact site is heated, but not
vaporized. This heating denatures the protein in the
tissue and results in thermal damage. In addition, if
STEP 12. Settings for the laser may vary depending on the tissue is heated to below vaporization thresholds,
the system available to the surgeon. For premalignant carbon debris is created, which further interferes or
and early-stage disease, the optimal results may be obstructs the efficient delivery of laser energy to the
achieved using a pulsed mode to minimize collateral target tissue, resulting in greater subablative heat
thermal damage. buildup. The target tissue with the peak energy
absorption for the CO2 laser is water. For the KTP
We always test the laser with the desired settings on a laser the target is oxyhemoglobin. However, there is
moistened tongue blade to ensure minimal depth of overlap and some absorption of the laser energy by
penetration. At the University of Pittsburgh, CO2 laser other tissues. In theory, by pulsing the laser, turning it
super-pulse settings consisting of 0.6 second on and 0.2 on and off rapidly in the range of microseconds, the
second off may dissipate heat energy while providing exposure time of the tissue to the laser energy can be
enhanced “burst” laser cutting action when using a short enough so that tissue in the immediate area of
simple “spot” size of 250 to 270 microns. The introduc- the laser impact is vaporized and the local blood
tion of the scanning micromanipulator has provided the supply to the region around the intense zone of impact
surgeon with the ability to administer a robotically dissipates the heat in the surrounding tissue before
shaped, pulsed laser beam in several different spot sizes enough is absorbed to create thermal damage. This
and shapes, using a computer-assisted algorithm. These property is related to the target tissue and is referred
computer-generated settings facilitate greater finesse to as the thermal relaxation time of the tissue.
especially when operating on lesions of the true vocal However, because this theoretic advantage cannot be
cord. Using a “repeat” delay setting also facilitates the fully achieved, there is always some thermal injury and
dissipation of heat and associated thermal damage to carbonization. If a pulsed mode laser is used under
surrounding tissues. conditions of constant tissue exposure, the carbon
Regardless of the instrumentation, a precisely con- debris will build up in the field and reduce the
figured laser beam should make a clean cut through efficiency of laser energy delivery resulting in more
healthy tissue without any carbonization. For lesions thermal damage. This undesirable effect is even more
beyond the glottis, wattage can be increased for resec- prominent if the laser energy delivery is in a
tion of more resilient tissue, such as cartilage, or for continuous mode without allowing laser off-time for
purposely transecting through tumor. heat dissipation. With the currently available pulsed
CO2 laser technology, the optimal exposure time to
achieve the least amount of thermal damage is less
Medial traction of the tissue by means of forceps, and than 0.1 second. Laboratory studies show that once
perpendicular laser beam application are necessary to this exposure time of less than 0.1 second is
avoid or reduce carbonization. MBernal-Sprekelsen exceeded, even in a pulse mode, efficiency of delivery
and IVilaseca is reduced, carbonization is increased, and thermal
Epiglottis Epiglottis
Vestibular Tumor Vestibular

fold fold
Vocal Vocal
Tumor fold fold
Corniculate Cuneiform Corniculate Cuneiform

tubercle tubercle tubercle tubercle
Esophagus Esophagus
A C
Vestibular Vestibular
fold remnant fold remnant
Vocal fold
remnant
Tumor
B D
Epiglottis
Vestibular Vestibular
fold remnant fold
Vocal FIGURE 41-3. A, Endolaryngeal view of a left glottic lesion with lateral
Vocal fold extension into the ventricle. B, A vestibulotomy is first performed to better
remnant fold
visualize the lateral extent. C and D, Tumor cuts can be performed en
Corniculate Cuneiform bloc or even through the tumor to better assess depth of invasion. The
tubercle tubercle
surgeon can then clearly see the tumor-tissue interface and follow it to
Esophagus resect to healthy margins. E, Final view with the tumor completely
E resected to negative margins.
STEP 13. A laser vestibulotomy may be performed at this

damage is increased. In summary, the surgeon time to achieve adequate margin for a transglottic tumor
reduces thermal damage by (1) using a pulsed mode with extension into the ventricle. This maneuver has
laser and (2) turning the laser on for less than 0.1 the added advantage of improved visualization of the
second at a time. When using pulsed laser energy, the lateral extent of the tumor into the ventricle (Figure 41-3A
on-time of the laser beam is less than a microsecond. and B).
This is repeated hundreds of times per second.
However, the laser is still off more than it is on and If needed for margin control, some or all of the false
thermal relaxation of the tissue from the local blood vocal fold can resected en bloc from the infrapetiolar
supply cools the tissue. The second method of region anteriorly and extended posterolaterally, even to
reducing thermal damage is to shutter the laser or use the level of the vocal process of the arytenoid. Though
a series of pulses that are on for 0.1 second and then we do not advocate performing, access to the paraglot-
for 0.1 to 0.3 second to allow the surgeon to move the tic space is provided if extended tumor removal is
laser beam and remove any carbon debris that required. It is crucial to orient properly and label this
interferes with energy transmission. MSCourey specimen to assess for the presence of malignancy, par-
ticularly at the depth of the specimen. For anterior
commissure lesions, an intrapetiolar laser resection can

The initial cuts are often lateral and superior to
be done to expose Broyle’s ligament and facilitate resec-
allow the tumor to “drop” away from its attachments
tion of the infrapetiolar anterior margin (see Figure
into the field of vision. As dissection proceeds
41-3C). Anterior, lateral, and posterior extension of the
laterally, the surgeon should search for the branches
tumor can now be clearly assessed.
of the superior laryngeal artery that traverse the
pharyngoepiglottic and aryepiglottic folds. Vessel
Preservation of the false fold potentially enhances the control with clips in these locations can minimize
development of plicae ventricularis as a mechanism distortion of the field by blood and decrease the risk
of voicing if the true vocal folds are too stiff or if of postoperative bleeding. EJMoore
too much tissue has been removed to allow
vibration. MSCourey
STEP 16. Proceed with the laser cordectomy, maintain-
ing an oncologically sound plane of dissection as deter-
STEP 14. Superficially mark the resection margins of the mined by the preoperative and peroperative evaluation.
planned excision with the CO2 laser. For glottic lesions,
maintain a resection margin of 1 to 3 mm (see Figure
41-3C and D). STEP 17. Perform a subepithelial or subligamental
cordectomy for carcinoma in situ or superficially inva-
Whether it is an en-bloc resection for small superficial
sive lesions. This helps avoid unnecessary removal of
tumors or whether tumor needs to be transected for
the vocalis muscle and better voice outcomes are
debulking or depth of invasion evaluation, the surgeon
expected.
must maintain a clear understanding of the three-
dimensional orientation of the specimen throughout A subepithelial cordectomy only removes the epithe-
the procedure. This crucial evolving information is lium. The plane of dissection is the superficial lamina
of paramount importance in the dialog with the pathol- propria. A subligamental cordectomy includes the epi-
ogist throughout the case and in ultimate margin thelium, lamina propria, and vocal ligament. Plane of
assessment. dissection is between the vocal ligament and the vocalis
muscle, sparing the muscle.
The success of the procedure relies on, among other
things, very meticulous assessment of the tumor In patients with small tumors in whom prior biopsy
extent and excellent communication with the frozen has been performed elsewhere, subligamental
section pathologist. We often cut directly through the cordectomy is recommended from the beginning.
tumor early in the case to assess the full depth of the MBernal-Sprekelsen and IVilaseca
tumor boundary. The tumor is then removed with
careful attention to orientation. Each specimen is
meticulously labeled, oriented, and often taken directly STEP 18. For small invasive glottic lesions, carry out a
to the frozen section lab by the surgeon so that direct transmuscular cordectomy through the vocalis muscle
communication with the pathologist can ensue. With (see Figure 41-3E).
few exceptions, the laryngoscope is not moved until
This resection encompasses the epithelium, lamina
the entire visual field has been cleared of tumor by
propria, and part of the vocalis muscle. The resection
frozen section analysis. EJMoore
may extend from the vocal process to the anterior com-
missure. A transmuscular cordectomy is indicated for
lesions reaching the vocalis muscle in their deep margin
STEP 15. Begin the cordectomy procedure by aiming the
without gross invasion.
laser to cut through healthy tissue while maintaining an
adequate margin with the tumor. To facilitate dissection,
maintain medial traction with grasping forceps.
Type III cordectomy is also strongly advocated in
Constant traction throughout the case is useful for case of iatrogenic scar tissue due to previous
easily assessing tumor margins as well as allowing for biopsy distorting the normal layered structure
clean tissue cutting. As the resection advances and the of the vocal fold and making unreliable both
specimen is detached, sequentially replacing the speci- videolaryngostroboscopic and saline infusion findings.
men for reorientation purposes helps avoid distortion Other indications are represented by persistent/
and maintain adequate margin. Dissection can be carried recurrent T1A previously treated by RT or CHT/RT
out in a lateral to medial (and posterior to anterior) and positive surgical margins after types I and II
direction because this gives reliable identification and cordectomies. GPeretti and CPiazza
visualization of the planes of dissection.
STEP 19. For larger lesions invading the vocalis muscle, STEP 23. Achieve meticulous hemostasis throughout
perform a complete cordectomy extending laterally to the case when the laser transects a vessel. While main-
the inner perichondrium of the thyroid cartilage ala. taining the necessary traction on tissues, small vessels
can be managed with a defocused nonpulsed laser
Usually this resection is carried out from the vocal
beam or suction cautery. Larger arteries will be tran-
process to the anterior commissure. Lateral margins are
sected in deeper dissections into the false fold, vocalis
carefully assessed and if necessary, the inner perichon-
muscle, or paraglottic space and should be controlled
drium can be resected.
with bipolar cautery or application of appropriately sized
HemaClips.
STEP 20. If there is extension to the anterior commissure Because feeding vessels to the glottis follow a lateral to
and contralateral cord, to the arytenoid cartilage, or to medial and superior to inferior course, effort should be
the supraglottic or subglottic larynx, the more experi- made to control them as laterally as possible. This
enced TLM surgeon must address this by performing an avoids transecting the same vessel numerous times and
extended complete cordectomy. If necessary, the con- thus surgeon frustration. If a bleeding vessel is difficult
tralateral cord can be resected with the specimen. to visualize or control, temporary packing with
epinephrine-soaked pledgets can be of some assistance.
Bear in mind that before tackling more extensive resec- In extreme cases, life-threatening bleeding can be packed
tions for T3 or even T4 lesions, one must have an expert and controlled by external approach.
understanding of laryngeal anatomy “inside out” as
well as a wealth of experience with early glottic lesions.
An open procedure or nonsurgical alternatives such as STEP 24. As the specimens are removed, the operating
radiation therapy or chemotherapy might be a wiser surgeon should immediately orient them for frozen
choice if the surgeon does not possess this expertise. section margin assessment.
Also, extended total cordectomies leave the patient vul-
nerable to postoperative aspiration, so careful preopera- This can be done by using stitches or for more
tive selection of surgical candidates is mandatory. complex multispecimen resection, by using colored inks.
Avoid using black ink because this can be mistaken
for cauterized tissue. Correct orientation is necessary
STEP 21. Perform additional resections as required to to permit accurate frozen section analysis of the
obtain adequate tumor margins. Care must be taken margins.
to ensure that reexcisions are correctly oriented and
removed from the appropriate area of the specimen bed.
In our practice no frozen section is usually performed
after en-bloc types I through IV cordectomies. On the
STEP 22. Perform a partial resection of the thyroid car-
other hand, in case of more extended procedures
tilage as necessary to achieve a negative anterior or
resembling endoscopic partial laryngectomies, this can
lateral margin.
be a useful diagnostic tool in order to tailor the
resection according to the more complex three-
Cartilage can be resilient to the laser’s cutting capability
dimensional tumor extension. GPeretti and CPiazza
and setting the laser to 10 watts will help cut through
cartilage. Some surgeons suggest “stamping” could be
a useful technique for thicker cartilage. In this technique
STEP 25. Margins need to be precisely assessed in
one can punch spot-size holes in the thyroid cartilage
close collaboration between the pathologist and the
using the laser at small equidistant intervals along the
surgeon.
desired lines of resection. Scissors can then be used to
cut through the dotted line. The margins of excision can be very small (less than
2 mm) but require careful orientation of the specimen.
It is of the utmost importance to emphasize that It is usually best if the pathologist can come into the
precise guidelines and technical standards to safely operating room and observe the procedure through the
perform endoscopic cartilage removal are still lacking monitor or the side arm of the microscope to assist in
in the contemporary literature. The precise way to orienting the specimen.
evaluate the lateral as well as the craniocaudal
extension of such a partial thyroid laminectomy is
entirely subjective and to be considered more a STEP 26. After hemostasis is accomplished, the micro-
personal hazard than a well-defined surgical scope and laryngoscope are removed from the field,
procedure. GPeretti and CPiazza the patient is awakened and extubated and may be
discharged as soon as the airway is adequate.
The surgeon has the best understanding of the laryn-

In prolonged operative cases it is beneficial to release
geal anatomy following the procedure and should be
the pressure on the tongue and diminish venous
present for extubation. In rare cases, airway obstruction
congestion by relaxing the suspension on the
can be the result of supraglottic or tongue base edema
laryngoscope every hour for several minutes. EJMoore
secondary to prolonged instrumentation. Assess the
upper airway thoroughly before extubation and keep
the patient intubated overnight and treat with cortico-
STEP 27: If final permanent pathology reveals tumor at
steroids if there is any doubt. If a patient has been left
the margins of resection, repeat laser excision should
intubated in the initial postoperative period, the extuba-
be performed. If negative margins cannot be obtained,
tion should be done in a controlled environment such
the patient should undergo either radiotherapy or open
that the surgeon can observe the airway and reestablish
surgical excision, that is, vertical or horizontal partial
the airway in a prepared organized fashion.
laryngectomy.
Consider postoperative broad-spectrum antibiotics
if there is significant exposed cartilage at the end of the
procedure.
At this time, if transoral laser microsurgery cannot
Treat the patient for laryngopharyngeal reflux for
achieve a complete resection, patients should
up to 2 months. This helps optimize mucosal healing
preferably be treated with surgery (open partial
while preventing granuloma formation.
surgery). In our hands, radiotherapy is only a second
For subepithelial or subligamental cordectomies, one
choice. MBernal-Sprekelsen and IVilaseca
can expect excellent voice outcome. When there is a
more significant loss of substance from the glottis,
varying degrees of dysphonia are to be expected and
The absence of a committed and experienced frozen-
the patient should be fully aware of this risk
section pathologist is a relative contraindication to
preoperatively.
performance of transoral laryngeal surgery. Relying on
permanent section pathology forces the surgeon to go
back to the operating room in a delayed fashion and The key points influencing a good vocal outcome are
operate in an altered field, and this decreases the to be mainly considered vocal muscle and anterior
accuracy of tumor assessment and adequate excision. commissure preservation. GPeretti and CPiazza
Relying on radiation to “clean up” positive margins
diminishes the advantages of transoral laryngeal
Postoperatively, close coordination with a speech-
surgery. The procedure, by definition, depends on
language pathologist is crucial for optimal functional
narrow margins, and this necessitates meticulous
recovery. For persistent dysphonia with wide glottic
margin analysis. EJMoore
gap, a vocal cord augmentation or medialization thyro-
plasty can be performed.
Every effort should be done in order to obtain free
margins at the first surgical attempt. In case of In most cordectomies absolute voice rest is not
uncertain or positive superficial margins, a close recommended. On the contrary, early voice therapy
endoscopic follow-up program should be carefully will provide a more pliable scar and thus a better
performed in order to precociously detect any voice. MBernal-Sprekelsen and IVilaseca
superficial recurrence. By contrast, in presence of
positive deep margins, an endoscopic second look
should be scheduled as soon as possible and a The effects of voice rest on healing have not been
reresection embraced to exclude persistent disease. In studied empirically. We understand from canine
our experience, more than half of these patients are models that removal of the vocal fold epithelium is
false positives at the pathologist’s evaluation but must followed by near-complete reepithelization in 72 hours.
be distinguished from the true-positive patients who These studies did not address the effects of voice rest
present worse local control and laryngeal on the rate of reepithelization. In addition, the rate of
preservation. GPeretti and CPiazza reepithelization over laryngeal muscle, cartilage, or
in previously radiated tissue has not been studied.
Therefore the benefits of voice rest are unknown. Most
patients with exposed muscle or cartilage develop
Postoperative Management granulation tissue that can take several months to
resolve. Prolonged voice rest may have
The vast majority of patients having undergone TLM a negative effect on the patient’s quality of life. This
for glottic tumors have a patent airway at the end of needs to be considered on an individual basis with
the case and can be extubated without any special sur- each patient. MSCourey
veillance or need for a tracheotomy.
pharyngolaryngeal cancers. Eur Arch Otorhinolaryngol

Our treatment policy for phonosurgical correction of 264:1045-1051, 2007.
postoperative dysphonia encompasses primary Ferris RL, Simental A: Endoscopic surgery for early glottic
(intraoperative) intramuscular fat injection after type III carcinoma. Oper Tech Otolaryngol Head Neck Surg 14:49-
cordectomy and 1 to 2 years’ delayed augmentation of 54, 2003.
the residual cord by injection of nonresorbable fillers Hinni ML, Salassa JR, Grant DG, Pearson BW, Hayden RE,
or medialization thyroplasty by Gore-Tex after type IV Martin A, et al: Transoral laser microsurgery for advanced
resection. In case of major anterior “keyhole” defect laryngeal cancer. Arch Otolaryngol Head Neck Surg
due to type V and VI procedures, an anterior 133:1198-1204, 2007.
Peretti G, Piazza C, Bolzoni A: Endoscopic treatment for early
commissure laryngoplasty technique according to
glottic cancer: indications and oncologic outcomes. Otolar-
Zeitels can be proposed to highly motivated
yngol Clin North Am 39:173-189, 2006.
patients. GPeretti and CPiazza Peretti G, Piazza C, Cocco D, De Benedetto L, Del Bon F,
Redaelli De Zinis LO, et al: Transoral CO2 laser treatment
Following surgery for small glottic lesions, progres- for Tis-T3 glottic cancer: the University of Brescia experi-
sive oral feeding can be resumed immediately after the ence on 595 patients. Head Neck 32:977-983, 2010.
Remacle M, Eckel HE, Antonelli A, Brasnu D, Chevalier D,
effects of anesthesia subside. Resection of an arytenoid
Friedrich G, et al: Endoscopic cordectomy. A proposal for
or partial resection of the supraglottic larynx may put
a classification by the working committee, European Laryn-
the patients at risk for aspiration. In those cases, con- gological Society. Eur Arch Otorhinolaryngol 257:227-231,
sider placing a nasogastric tube temporarily while the 2000.
patient undergoes swallowing rehabilitation. Remacle M, Lawson G, Nollevaux MC, Delos M: Current
state of scanning micromanipulator applications with the
It is easier to place a nasogastric feeding tube while carbon dioxide laser. Ann Otol Rhinol Laryngol 117:239-
244, 2008.
the patient is under general anesthesia and remove it
Remacle M, Van Haverbeke C, Eckel H, Bradley P, Chevalier
if deglutition proves to be safe. MBernal-Sprekelsen
D, Djukic V, et al: Proposal for revision of European Lar-
and IVilaseca yngological Society classification of endoscopic cordecto-
mies. Eur Arch Otorhinolaryngol 264:499-504, 2007.
Steiner W, Ambrosch P: Endoscopic laser surgery of the upper
Suggested Readings aerodigestive tract with special emphasis on cancer surgery,
Stuttgart, Germany, 2000, Georg Thieme Verlag.
Blanch JL, Vilaseca I, Bernal-Sprekelsen M, Grau JJ, Moragas Zeitels SM: Infrapetiole exploration of the supraglottis for
M, Traserra-Coderch J, et al: Prognostic significance of sur- exposure of the anterior glottal commissure. J Voice 12:117-
gical margins in transoral CO2 laser microsurgery for T1-T4 122, 1998.
SECTION A Paranasal Sinus Operations
CHAPTER
Transfacial Approaches: Lateral Rhinotomy
42 and Weber-Fergusson
Author Ehab Hanna
Comments by Paul James Donald, Jonathan Irish, and Carl Henry Snyderman
Indications The incision that is extended into the alar crease can
Transfacial approaches are the most commonly used often heal with a significant “crease,” which can be
surgical approaches for resection of locally advanced minimized by keeping the incision 1 to 2 mm lateral to
sinonasal tumors. They allow adequate exposure of the the alar crease. JIrish
nasal cavity, maxillary sinus, pterygopalatine fossa,
pterygoid plates, ethmoid sinuses, medial and inferior
orbital walls, sphenoid sinus, nasopharynx, clivus, and The incision lines are designed to follow the junction
the medial aspect of the infratemporal fossa. of anatomic subunits of the face. This provides the
best cosmetic results. A common mistake is to place
Endoscopic techniques may be combined with the incision too lateral on the anterior surface of the
transfacial approaches for optimal access and maxilla. CHSnyderman
visualization. CHSnyderman
STEP 3. The basic incision may be extended to include

Incisions
a lip-splitting extension (4) or a Lynch-type extension (5)
The lateral rhinotomy is the standard incision for expo- if further exposure is necessary (Figure 42-1).
sure of sinonasal tumors through a transfacial approach.
It can be used alone, or various extensions of the basic The basic lateral rhinotomy incision provides adequate
incision may be added for further exposure depending exposure when performing a medial maxillectomy. The
on the extent of the tumor. extended incision provides adequate exposure for a
total maxillectomy. A temporary tarsorrhaphy protects
the ipsilateral globe during surgery.
STEP 1. The basic lateral rhinotomy incision is outlined The Weber-Fergusson incision adds a lip-splitting
by connecting three surface points. The first point (1) is and subciliary incision for added exposure of the maxil-
marked halfway between the nasion and the medial lary bone (Figure 42-2).
canthus (Figure 42-1). We prefer to extend the lateral rhinotomy toward the
medial brow, a Lynch-type extension, and avoid the
subciliary incision of the classic Weber-Fergusson to
I consider “notching” the portion of the incision
minimize eyelid complications as is discussed further
within the medial canthus to minimize the risk of
under the section on total maxillectomy.
postoperative webbing. JIrish
STEP 2. The second point (2) is where the alar crease Considering a subconjunctival incision may minimize
begins and the third point (3) is at the base of the colu- the ectropion and suborbital edema seen with a
mella. The basic incision provides adequate exposure classic Weber-Fergusson incision. JIrish
for a medial maxillectomy (Figure 42-1).
411
412 UNIT V Skull Base
5
1 1
5
2 2
3 3
4 4
FIGURE 42-1. Lateral rhinotomy incision.

FIGURE 42-2. Weber-Fergusson incision.
Our preference in addition to directing the incision to

the medial brow is to actually run the incision in the
inferior hairs of the eyebrow, slanting the blade Soft-Tissue Dissection
obliquely in the direction of the hair follicles, thus
disguising the incision but avoiding the “split brow” STEP 1. Elevation of the soft tissues of the cheek is done
appearance resulting from amputation of the hair in a subperiosteal plane over the maxilla and around the
follicles. inferior orbital nerve (ION).
At the sill of the nose we slant the incision into the
nasal floor paralleling the foot of the nasal ala then
making a triangle in the nasal floor, now carrying the STEP 2. The periorbita is elevated over the anterior
cut out of the nasal cavity close to the medial crus of lacrimal crest (ALC) to expose the lacrimal sac (LS)
the lower lateral cartilage. In this way the integrity of (Figure 42-3).
the nasal sill is preserved. The incision then proceeds
down the apex of the ipsilateral nasal philtral column
to the peak of cupid’s bow instead of the hollow of STEP 3. The attachment of the medial canthal tendon to
the philtrum, thus disguising the scar. The junction of the nasal bone is released.
the white lip and the vermilion is then tattooed at the
white roll, aiding precise approximation at the time of
closure. Instead of incising the upper lip in a straight STEP 4. The periorbita is elevated over the medial orbital
line, a triangular incision is made with its apex at the wall exposing the lacrimal crest, the lamina papyracea,
junction of the dry and wet vermilion of the upper lip. and the frontoethmoidal suture.
This is along the line of the lateral aspect of the
sucking tubercle of the upper lip, avoiding a straight This suture serves as a landmark for the position of the
line through the center of the lip and thus avoiding a floor of the anterior cranial fossa, and when followed
whistle deformity later on. PJDonald posteriorly, leads to the anterior and posterior ethmoidal
foramina.
CHAPTER 42 Transfacial Approaches: Lateral Rhinotomy and Weber-Fergusson 413
Great care should be taken when dissecting the

periosteum over the maxilla to keep the periosteum
over the nasal bones undisturbed. This will serve as
the vascular pedicle for the nasal flap after the Lacrimal sac
rhinotomy. PJDonald Canaliculi
Nasolacrimal duct
Lacrimal crest
Infraorbital a./n.
Orbital Dissection
STEP 1. Dissection of the medial periorbita over the

lamina papyracea reveals the anterior ethmoid artery at
the level of the frontoethmoid suture line (Figure 42-4).
STEP 2. The anterior and posterior ethmoidal arteries

are cauterized with bipolar electrocautery, clipped, and
transected.
Division of the nasolacrimal duct prior to posterior

dissection toward the anterior and posterior ethmoid
arteries can facilitate improved exposure. JIrish
FIGURE 42-3. Lateral rhinotomy: soft tissue dissection.
Ant. ethmoidal a.
(divided)
Ant. ethmoidal a.
Canaliculi
Nasolacrimal duct Lacrimal sac
FIGURE 42-4. A and B, Medial orbital dissection.

Maxillotomy: placement of bone cuts. For tumors

that involve the medial maxilla, the preferred location
of bone cuts is inferior to the frontoethmoidal suture
line (below the skull base) and inferior to the
infraorbital nerve. The orbital rim is preserved for
cosmesis. CHSnyderman
1
2 Midfacial Degloving and

Sublabial Approaches
Indications
The midfacial degloving approach is most commonly
used in the management of large benign lesions of the
3 sinonasal region and skull base such as juvenile naso-
pharyngeal angiofibroma, for selected malignancy in
this area and to afford access to the nasopharynx and
infratemporal fossa.
The main advantage of the degloving approach is that
an external facial incision is avoided. Another advantage
is providing simultaneous exposure to the inferior and
FIGURE 42-5. Stenting of the lacrimal canaliculi. medial maxilla, bilaterally. This is particularly helpful
when approaching tumors with bilateral involvement of
the nasal cavity and maxillary sinus. A major disadvan-
tage, however, is the limited superior and posterior expo-
sure, and the need for constant retraction of the soft
tissue envelope for continued adequate exposure.
The optic nerve is located 4 to 5 mm posterior to the
posterior ethmoidal artery.
The midfacial degloving approach may be combined
with endoscopic techniques to avoid a facial incision
STEP 3. The orbital floor should be dissected as far and provide superior visualization of the nasal cavity.
lateral as the inferior orbital fissure. This approach also minimizes trauma to the nasal
vestibule in pediatric patients with a small nasal
aperture. CHSnyderman
STEP 4. The lacrimal sac is identified in its fossa between
the anterior and posterior lacrimal crests.
STEP 1. The approach starts with complete transfixion
If a medial maxillectomy is performed, the lacrimal sac incision of the membranous septum.
is elevated from the fossa, transected, and marsupialized
into the nasal cavity to provide adequate drainage of
the lacrimal system. STEP 2. The transfixion incision is joined endonasally
with bilateral intercartilaginous incisions, with soft tissue
elevation over the nasal dorsum as far superior as the
STEP 5. Silicone stents are placed through the upper nasal root (Figure 42-6).
and lower canaliculi and brought into the nasal cavity to
The nasal skeleton is therefore “degloved” from overly-
prevent postoperative stenosis and epiphora (Figure
ing soft tissues as far lateral as the pyriform aperture.
42-5).
These stents are removed in about 3 to 6 months. STEP 3. A gingivobuccal incision extends bilaterally
across the midline to both maxillary tuberosities
laterally.
When the lateral rhinotomy incision is closed, the
medial canthus is resuspended if possible to prevent
blunting of the medial canthus. CHSnyderman STEP 4. Subperiosteal dissection is continued cephalad
over the face of both maxillae.
CHAPTER 42 Transfacial Approaches: Lateral Rhinotomy and Weber-Fergusson 415
Incisions
Nasal septum B
FIGURE 42-6. A, B, and C, Midfacial degloving: incisions.
Le Fort I and Maxillotomy Approach

STEP 5. The dissection joins the nasal degloving using
sharp dissection over the pyriform aperture attachments The sublabial approach may also be used to access
(Figure 42-7). tumors of the sphenoclival region such as chordoma,
particularly if the lesion extends lower than the hori-
zontal plane of the palate, for example, the lower third
When endoscopic techniques are used, a lesser of the clivus and craniovertebral junction.
dissection may be performed without the need for
intercartilaginous incisions and dissection of the nasal An alternative to a Le Fort I maxillotomy is a
dorsum. CHSnyderman combination of endoscopic endonasal and transoral
approaches for tumors that span the plane of the
palate. Transpalatal approaches are also an
Care during the dissection around the maxillary option. CHSnyderman
tuberosity is important in order to maintain the
postoperative nasal projection. JIrish A Le Fort I osteotomy is done and the maxilla is
displaced inferiorly after posterior osteotomies separate
the maxilla from the pterygoid plates (Figure 42-8).
We prefer a combination of unilateral or half a Le
The major drawback to the facial degloving procedure
Fort I osteotomy with a median or paramedian palatal
is the lack of exposure both anterosuperiorly and
osteotomy for better displacement of the maxilla inferi-
posterolaterally. The scar left by the rhinotomy is
orly and laterally (Figure 42-9). This offers wider expo-
hardly noticeable in most individuals if the wound is
sure because it avoids the cantilever effect of the posterior
carefully approximated and the nasal bone fragment is
maxilla upward, restricting exposure when the anterior
returned and splinted into its normal anatomic
maxillary segment is displaced inferiorly when the bilat-
position. PJDonald
eral (complete) Le Fort osteotomy is used (Figure 42-10).
Osteotomy
lines
Infraorbital a.
FIGURE 42-7. Midfacial degloving:

soft tissue dissection.
Osteotomy line
Osteotome
FIGURE 42-8. A and B, Le Fort I osteotomy.

B
FIGURE 42-9. A, B, and C, Paramedian maxillotomy.
Nasal concha
Nasal septum
Vomer
Maxilla
(right lateral)
Maxilla Soft palate
Maxilla
(left
lateral)
A B
FIGURE 42-10. A, Limited exposure due to the upward displacement of the posterior maxilla
associated with Le Fort I. B, Enhanced exposure by inferior and lateral displacement of the
maxilla associated with paramedian maxillotomy.
Plating is performed prior to osteotomies to maintain small space posteriorly in which to work. The
preoperative occlusion. CHSnyderman paramedian osteotomy helps but there is the risk
of nonunion, and intermaxillary arch bar fixation is
usually required despite the use of rigid plate fixation
The disadvantage of the Le Fort I procedure is due to the fragile nature of the maxillary bone.
that visualization is impaired because the inferior Prior irradiation therapy adds an additional risk of
displacement of the fragment provides only a nonunion. PJDonald
CHAPTER
Maxillectomy
43 Author Ehab Hanna
Commentary by Jonathan Irish and Carl Henry Snyderman
Medial Maxillectomy STEP 3. The anterior wall of the maxillary sinus above
the level of dental roots and medial to the infraorbital
The most common indication for medial maxillectomy nerve is removed.
is in the treatment of tumors of the nasal cavity, lateral
nasal wall, and medial maxillary sinus (Figure 43-1).
Medial maxillectomy includes removal of the lateral STEP 4. Lateral to the infraorbital foramen, the anterior
nasal wall and the medial maxillary segment bounded wall antrostomy may be enlarged to expose the zygo-
laterally by the infraorbital nerve. In addition, a com- matic recess of the antrum.
plete sphenoethmoidectomy is usually performed.
There can be variability in the osteotomy locations

STEP 1. The incision most commonly used for exposure depending on tumor extent and location. JIrish
is the lateral rhinotomy (see Figure 42-1).
Alternatively, a midfacial degloving, as described in

Chapter 42, may be used, and is preferable if bilateral An incision high along the nasal dorsum can result in
medial maxillectomy is needed (see Figures 42-6 and better cosmetic results. JIrish
42-7). Endonasal endoscopic medial maxillectomy and
sphenoethmoidectomy may be also performed for
appropriately selected tumors.
It is important to keep the incision along the nasal alae
at 1 to 2 mm lateral to the nasoalar crease. This
We perform an endoscopic endonasal medial
results in less postoperative retraction and a better
maxillectomy for almost all situations in which a
cosmetic result. JIrish
medial maxillectomy is indicated. Endoscopic
techniques are supplemented with an anteromedial
maxillectomy (Denker’s approach) or Caldwell-Luc
approach when tumor is not limited to the medial
Instead of bringing the incision along the philtrum and
wall. CHSnyderman
the upper lip, another option is to bring the incision
through the nasal sill. This limits the incision along the
lip. The upper lip incision, however, allows better
There has been a significant change in practice
lateral access and exposure, but the nasal sill incision
in recent years as use of endoscopic approaches
can be used in selected cases. JIrish
has been increasingly favored. This has also been
enabled by improved intraoperative imaging, guidance,
and tracking. JIrish
STEP 5. Resection of the lateral nasal wall begins with
an inferior osteotomy along the nasal floor below the
If a lateral rhinotomy incision is used, splitting of attachment of the inferior turbinate, starting at the pyri-
the lip is usually not necessary for adequate form aperture, and carried posteriorly to the posterior
exposure. CHSnyderman maxillary wall (Figure 43-3).
STEP 2. After the lateral rhinotomy is performed and soft STEP 6. With the orbit retracted laterally and protected
tissue exposure is completed as discussed in Chapter with a malleable brain retractor, the lamina papyracea is
42, osteotomies are done as shown in Figure 43-2. identified and, if necessary, resected.
419
Osteotomy lines
FIGURE 43-1. Tumor of the lateral nasal wall.
Resection lines
Lacrimal sac
Canaliculi
C Nasolacrimal duct
Lacrimal crest B
Infraorbital a./n.
FIGURE 43-3. Medial maxillectomy: resection. A, Osteotomy
lines. B, Intranasal osteotomy/resection lines.
A
Comment on Figure 43-3: In my experience the inferior

B
osteotomy is rarely oriented with a vertical anterior
limb as shown here. Usually this is oriented anterior to
posterior, extending from the nasal aperture inferior to
the inferior turbinate as described in the text. JIrish
During this part of the procedure, one must take care

to manage the nasolacrimal duct. One can use a
cutting burr to expose the duct and deliver the duct
with a nerve hook and transect it. The duct can then
be marsupialized to prevent postoperative stenosis
and epiphora. JIrish
FIGURE 43-2. Medial maxillectomy: osteotomies.
CHAPTER 43 Maxillectomy 421
STEP 12. Meticulous multilayered closure of the lateral

rhinotomy is performed and usually results in excellent
healing and acceptable postoperative appearance
(Figure 43-4).
If a sublabial approach is done, the mucosal incisions

are closed with absorbable suture.
Subcutaneous tissue
STEP 13. Nonadherent nasal packing may be left for 1
to 2 days.
Muscle
It is critical to ensure that the nasal alae are level with

the contralateral nasal alae during closure because
this is very noticeable. JIrish
If the periosteum of the anterior surface of the maxilla

is not preserved (due to tumor erosion of the anterior
FIGURE 43-4. Lateral rhinotomy: closure. maxilla), it is necessary to cover the inner surface of
the cheek flap with a split-thickness skin graft to
prevent scar contracture of the cheek. CHSnyderman
Inferior Maxillectomy
This procedure involves resection of the inferior maxil-
lary sinus below the plane of the infraorbital nerve. It
Transection of the nasolacrimal duct also allows for
is most commonly used for neoplasms of the alveolar
increased orbital retraction and improved exposure of
process of the maxilla with minimal extension to the
the posterior lamina papyracea. JIrish
maxillary antrum. Similarly, lesions of the hard palate
sparing the antrum can be treated by an inferior maxil-
STEP 7. A complete sphenoethmoidectomy is done, lectomy. A combination of sublabial and palatal inci-
staying below the level of the frontoethmoidal suture to sions is usually used for exposure and osteotomies are
avoid injury to the floor of the anterior cranial fossa. done around the lesion, ensuring an adequate margin of
resection (Figure 43-5A and B). Alternatively, a midfa-
cial degloving can be used for lesions crossing the
STEP 8. The superior attachment of the middle turbinate midline and involving the inferior maxilla bilaterally
is then transected along the roof of the nose. (see Figures 42-6 and 42-7).
It is preferable to make the anterior bone cut in the

STEP 9. Posteriorly, the lateral nasal wall cuts are con- middle of a tooth socket so that the viability of the
nected with right-angled scissors behind the turbinates. adjacent tooth is not compromised. CHSnyderman
STEP 10. The specimen is thus delivered and examined Total Maxillectomy
for margins with frozen section control.
STEP 1. If the extent of resection requires a total maxil-
If the tumor involves the nasal septum, it should be
lectomy (Figure 43-6), the lateral rhinotomy incision may
included in the resection specimen by adding appropri-
be extended by adding lip-splitting, gingivobuccal, and
ate septal cuts to allow for tumor-free margins.
palatal incisions inferiorly.
The lip-splitting incision, which may be done along the

STEP 11. Closure begins by reattachment of the medial philtrum or in the midline (see Figure 42-1), connects
canthal tendon to the nasal bone in its anatomic the lateral rhinotomy with the sublabial incision, thus
position. allowing more lateral elevation of the facial flap.
Osteotomy lines
FIGURE 43-5. Inferior maxillectomy. A, Site of resection. B, Osteotomy lines. C, Resected

specimen.
STEP 2. The gingivobuccal incision starts from the lip-

splitting incision and extends as far laterally as the
region of the first molar and over the lateral surface of
the maxillary tuberosity.
STEP 3. In patients undergoing total maxillectomy, a

median or paramedian palatal incision is performed over
the hard palate extending from an interincisor space
anteriorly to the junction of the soft and hard palate
posteriorly.
STEP 4. The incision then continues laterally between

the hard and the soft palate to curve posterolaterally
around the maxillary tuberosity, meeting the gingivo
buccal incision (see Figure 43-8).
In patients undergoing total maxillectomy with orbital

preservation, we prefer to extend the lateral rhinotomy
superiorly beneath the medial brow rather than laterally
through a subciliary incision used in the classic Weber-
FIGURE 43-6. Tumor of the maxillary sinus.
Fergusson approach (see Figure 42-2). There are several
advantages to this modification. First, avoiding a sub-
ciliary incision eliminates any disruption to the lower
lid skin-muscle-tarsus complex, which minimizes lower
eyelid complications, particularly ectropion and pro-
longed eyelid edema. Another advantage is avoiding
trifurcation of the incision reducing the risk of skin
breakdown at the medial canthal area. This is especially STEP 10. The medial and lateral osteotomies are then
important for previously irradiated patients, who are connected superiorly across the orbital floor along the
more prone to develop medial canthal skin dehiscence. inferior orbital fissure.
Similarly, because the vascularity of the thin lower eyelid
skin is not affected with the extended lateral rhinotomy
incision, patients who undergo orbital floor recons STEP 11. Inferiorly, a midline sagittal osteotomy is made
truction with implants such as titanium mesh have less across the hard palate.
chance to develop wound breakdown and implant
exposure. The ipsilateral central incisor should be preserved, if
Although the extended lateral rhinotomy incision possible, to enhance prosthesis retention.
has several functional and cosmetic advantages, it does
not compromise exposure and provides an adequate
approach for a safe oncologic resection. The extension STEP 12. The internal maxillary artery is identified at its
of the lateral rhinotomy incision beneath the medial entrance through the pterygomaxillary fissure, ligated,
eyebrow shifts the fulcrum of rotation of the soft tissue and transected.
flap superiorly and laterally, enhancing lateral exposure,
which is not less from that obtained with a classic Weber-
Fergusson incision. Transection of the infraorbital nerve STEP 13. A posterior osteotomy is done to disarticulate
allows even more lateral and posterior elevation of the the maxilla from the pterygoid plates.
soft tissues, to expose the entire maxillary bone as far
lateral as its zygomatic extension, and posteriorly to the
pterygomaxillary fissure and over the pterygoid plates STEP 14. The maxilla is delivered by anteroinferior trac-
(Figure 43-7). Additionally, its postoperative cosmetic tion, and remaining soft-tissue attachments are cut
appearance is superior to the Weber-Fergusson incision. using a curved heavy scissors.
Bleeding is usually encountered at this point, and is

STEP 5. Whichever incision is used, elevation of the
controlled by temporary packing of the cavity, followed
facial flap is usually done in the subperiosteal plane.
by electrocoagulation of bleeding mucosal surfaces or
However, if the tumor has invaded the anterior wall of ligature of bleeding points. The pterygoid plexus of
the maxillary antrum, a supraperiosteal plane is used. veins may be a source of persistent bleeding, and can be
Occasionally, the cheek skin overlying the maxilla is managed by hemostatic figure-eight sutures and Surgicel
included with the specimen if it is involved with tumor. packing. Bleeding is usually minimized if the internal
maxillary artery is ligated before the posterior osteot-
omy is done along the pterygomaxillary fissure.
STEP 6. With the globe protected with a temporary tar-
sorrhaphy stitch, the periorbita is dissected along the
medial, inferior, and lateral orbital walls.
When dissection of the masticator space is anticipated
(lateral to the pterygopalatine space), we have found it
STEP 7. After completion of the soft-tissue exposure,
expedient to perform preoperative angiographic coiling
osteotomies are performed as shown in Figure 43-8.
of the proximal internal maxillary artery. This minimizes
intraoperative hemorrhage and facilitates dissection of
this area when visualization is poor. CHSnyderman
STEP 8. Lateral osteotomies are performed along the
frontal and temporal processes of the zygoma.
STEP 9. Medial osteotomies are done along the frontal Total maxillectomy usually involves removal of the
process of the maxilla, and along the medial orbital wall entire maxillary bone including the palate and the
just below the frontoethmoidal suture, extending poste- orbital floor. Preservation of the orbital floor (subtotal
riorly to the level of the posterior ethmoidal foramen. maxillectomy), or the palate (suprastructure maxillec-
tomy) may be done if these structures are not involved
by tumor. Depending on the extent of the lesion, resec-
A further practice hint is to consider use of a 2- to tion may extend beyond the posterior wall to the ptery-
3-mm cutting burr instead of the osteotomes to gopalatine fossa and pterygoid plates. Perineural spread
complete the osteotomies. This can result in more of tumor along V2 may be resected by following the
control and less bleeding. JIrish nerve through the foramen rotundum and into Meckel’s
cave (Figure 43-9).
Specimen
FIGURE 43-7. The extended lateral rhinotomy allows adequate exposure for total
maxillectomy.
Osteotomy lines Osteotomy lines
A B
FIGURE 43-8. Total maxillectomy: osteotomies.

preservation is possible without compromising onco-

logic outcome. Orbital exenteration is usually indicated
when there is gross invasion of the periorbital fat, extra-
ocular muscles, or optic nerve. The presence of propto-
sis or diplopia may be due to displacement rather than
invasion of the intraorbital contents. Decreased visual
acuity or visual fields, or the presence of an afferent
pupillary defect, usually indicate gross invasion of the
Foramen rotundum Periorbita
orbit. Orbital invasion by perineural spread rather than
Infraorbital n.
direct extension may be missed unless careful examina-
Maxillary sinus tion of the cranial nerves especially VI and VII is done.
Detailed neuro-ophthalmologic examination should be
conducted on all patients with suspected or confirmed
orbital involvement by sinonasal or other skull base
tumors. If orbital exenteration is contemplated, always
make sure that the patient has useful vision in the con-
tralateral eye.
A When orbital exenteration is considered, preoperative

evaluation with ocular prosthetics can be helpful
Foramen rotundum V1 Trigeminal to allow for preoperative molds to be created and
ganglion allow for more accurate postoperative prosthetic
rehabilitation. JIrish
V2
V3
Unless there is tumor extension through the periorbita,
we attempt to preserve the orbit. The periorbita can
be resected to provide a margin and reconstructed
with a fascial graft. Titanium mesh reconstruction
Infraorbital n. of the inferior and medial orbital walls prevents
hypoglobus and postoperative diplopia. CHSnyderman
B
FIGURE 43-9. Transfacial dissection of foramen rotundum

In the absence of any ocular signs or symptoms,
and Meckel’s cave. A, Anterior visualization of drill. B, Sagittal
demonstration of drill placement.
however, evaluation of the extent of orbital involvement
relies mainly on imaging. High-resolution computed
tomography (CT) and magnetic resonance imaging
(MRI) are complementary and provide critical informa-
tion regarding the extent of orbital bony and soft-tissue
A “total” maxillectomy rarely requires removal of involvement, respectively. CT scans obtained at 1- to
the entire maxilla. Based on the extent of bone 3-mm slices with detailed bone windows are best for
involvement, an attempt is made to preserve a thin rim evaluating bony involvement of the orbital walls. MRI
of bone along the inferior orbital rim. This provides a is best used to evaluate the extent of soft-tissue invasion
superior cosmetic result and does not compromise the beyond the periorbita. MRI is also useful in detecting
exposure or resection. CHSnyderman perineural spread proximally beyond the orbital apex
and into the cavernous sinus or optic chiasm, which
compromises surgical margins, local disease control,
Management of the Orbit and survival, and as such is a contraindication for surgi-
When treating sinonasal malignancy, every effort should cal resection.
be made to preserve the eye as long as preservation does Even with the best imaging techniques, the definitive
not compromise the adequacy of oncologic resection. and most accurate assessment of the extent of orbital
Attempts at orbital preservation in the face of gross invasion and whether the eye could be preserved has to
residual disease, however, usually result in poor disease be made intraoperatively. This needs to be clearly dis-
control and ultimate loss of orbital function. cussed with the patient and family, and an informed
Most studies have shown that if orbital invasion is consent for possible exenteration needs to be obtained
limited to the bony orbit or the periorbita, orbital in high-risk cases.
If a decision is made to exenterate the orbit, supra-

and subciliary incisions are made around the upper and
lower eyelids, respectively. This allows for preservation
of the eyelids, which can be used to line the orbit. If
the eyelids are involved with cancer, they must be
included in the resection (Figure 43-10). The periorbita
is incised over the superior and lateral orbital rims. Dis-
section continues along the roof of the orbit and lateral
walls, until the superior orbital fissure and the optic
foramen are exposed. Lidocaine is injected around these
structures to block any autonomic-induced cardiac dys-
rhythmias. To prevent troublesome bleeding, the neuro-
vascular structures in the superior orbital fissure are
slowly and carefully isolated, ligated or clipped, and
transected. The optic nerve and the ophthalmic artery
are then managed in a similar fashion. The extraocular
muscles are transected at their origin in the orbital apex.
The medial and inferior orbits may be left attached to
the specimen if en-bloc resection of the eye in patients
with sinonasal cancer is indicated. Osteotomies are
FIGURE 43-10. Orbital exenteration.
done as previously described for total maxillectomy,
except that the orbital bony cuts are connected at the
orbital apex rather than the inferior orbital fissure.
Reconstruction of the orbital defect following orbital

exenteration is always suboptimal. Transposition of the
anterior half of the temporalis muscle through a lateral
orbital osteotomy helps fill the defect, provide
coverage of bone and hardware, and provide a
vascular base for a skin graft if the eyelids do not
provide adequate coverage. CHSnyderman
CHAPTER
Craniofacial Resection
44 Author Ehab Hanna
Commentary by Jonathan Irish and Timothy M. McCulloch
Indications Preoperative Evaluation

Surgical resection of the anterior cranial base is com-
and Surgical Planning
monly indicated for patients with sinonasal tumors High-resolution computed tomography (CT) scan with
involving the cribriform plate or fovea ethmoidalis. This both axial and coronal imaging is used for bony and
is done, by definition, for most cases of esthesioneuro- soft-tissue anatomic imaging.
blastoma, as well as carcinoma of the ethmoid or maxil-
lary sinuses approaching or involving the anterior
cranial base (Figure 44-1). Tumors transgress the crib- Contrast enhancement is also critical to allow
riform plate either by direct bony invasion or perineural for assessment of tumor vascularity and for
spread along the filaments of the olfactory nerves. The assessment of tumor relationship to major vascular
dura of the anterior cranial fossa forms a barrier that structures. JIrish
delays, to a certain extent, brain invasion. Dural resec-
tion in patients with intracranial but extradural disease
or patients with limited dural involvement often pro- High-resolution magnetic resonance imaging (MRI)
vides an adequate oncologic margin. In contrast, malig- is used for the extent of soft-tissue involvement as well
nant tumors that transgress the dural barrier and involve as for the potential existence and extent of perineural
the underlying brain parenchyma are usually associated involvement.
with poor prognosis. Although controversial, even in In most circumstances today, image guidance is used
some cases with limited frontal lobe involvement, ante- for both endoscopic and open craniofacial resection to
rior craniofacial resection may still be indicated for local ensure the safety and adequacy of excision of these
control of the disease. neoplasms.
Previously, tumors that involved brain parenchyma Image guidance is critical for most endoscopic
were viewed as not surgically treatable. Currently, resections. There is an increasing trend to also
involvement of the brain parenchyma and/or use real-time image acquisition with guidance
cavernous sinus is regarded as a relative and tracking, particularly to enable endoscopic
contraindication largely because of the poor approaches. JIrish
prognosis with tumors with this degree of local
disease extension. JIrish
Interdisciplinary evaluation and management is per-
formed by the skull base team. Involved members of
Resection of the floor of the middle cranial fossa is the team include (but are not limited to) the head-and-
sometimes performed in patients with sinonasal tumors neck/skull base surgeon, neurosurgeon, head-and-neck
to achieve tumor-free surgical margins for lesions radiologist, head-and-neck pathologist, dental oncolo-
extending to the roof of the infratemporal fossa or for gist, head-and-neck radiation therapist, head-and-neck
those tumors that exhibit perineural spread along the medical oncologist, and speech and swallowing rehabili-
branches of the trigeminal nerve to the gasserian gan- tative specialists.
glion, most commonly adenoid cystic carcinomas. In rare circumstances based on tumor extension or
Craniofacial approaches combine extracranial and vascular involvement, digital subtraction angiography
intracranial access to the anterior and lateral skull base. is used.
Extracranial approaches may include transfacial, subla- Tissue biopsy or pathologic confirmation is obtained
bial, or endonasal approaches as previously described on all patients with rare exceptions including presumed
(Figure 44-2). angiofibroma and paragangliomas.
427
A B
FIGURE 44-1. Tumor invading the anterior skull base.
Scalp incision
Osteotomy
Osteotomy Osteotomy
5
1
3
4
Endoscope
FIGURE 44-2. Extracranial approaches include transfacial, sublabial, or endoscopic

approaches.
CHAPTER 44 Craniofacial Resection 429
and deep layers of the temporalis fascia 1 to 1.5 cm

I would like to reiterate Dr. Hanna’s comments posterior to the superior orbital rim and extends pos
surrounding the preoperative evaluation and surgical teriorly parallel to the course of the zygomatic arch
timing of anterior skull base malignancies to (Figure 44-3C).
emphasize the importance of the multidisciplinary
team and pathologic confirmation of the tumor type
involved. Unlike other regions of the head and neck,
the anterior skull–based tumor pathologies are STEP 6. Dissection proceeds below the plane of the
extensively varied and the patient’s prognosis is deep layer of the temporalis fascia to preserve the
heavily influenced by the tumor pathology. The tumor frontal branch of the facial nerve, which is superficial to
pathology can dictate the timing and goals of surgical the fascia.
intervention and the anticipated sites of tumor spread
and may on occasion preclude the need for surgery as
in the case of lymphoma. In many cases well- STEP 7. The scalp flap is elevated anteriorly, exposing
established nonsurgical therapies are an essential part the superior orbital rims and the supraorbital nerves and
of the presurgical treatment paradigm or are used for posteriorly toward the vertex at least 2 cm.
improved survival in the postsurgical time frame.
TMMcCulloch
STEP 8. Pericranial incisions are made as far posteriorly
as necessary to provide adequate length for the pericra-
nial flap (Figure 44-3A and B).
Incision and Soft-Tissue Dissection
The pericranial flaps are released along the superior
temporal lines bilaterally.
STEP 1. Perioperatively, patients are predosed with
steroids and broad-spectrum antibiotics covering both
cutaneous and aerodigestive tract flora.
STEP 9. The pericranial flap is dissected free from the
DVT prophylaxis with low dose heparin is utilized as underlying bone and reflected anteriorly with the use of
well as sequential compression stockings. periosteal elevators (Figure 44-3D).
Careful dissection and preservation of the supraorbital

STEP 2. Following the induction of general anesthesia, neurovascular pedicles is necessary to provide a well-
a lumbar drain is placed in patients undergoing planned vascularized pericranial flap for reconstruction of the
transdural resection or dissection. cranial base defect.
STEP 3. The bicoronal incision starts in a preauricular This is an absolutely critical point. However, in some
crease anterior to the tragus. patients who have been treated with preoperative
radiation, it should be understood that the pericranial
The superficial temporal artery should be dissected and flap may not be usable. JIrish
preserved. The scalp incision is extended in the coronal
plane, staying behind the hairline along its entire course,
to the contralateral preauricular region. We prefer to The supraorbital nerves and vessels are located along
gently curve the incision anteriorly at the midline the medial one third of the superior orbital rim.
(Figure 44-3A and B).
STEP 10. Elevation of the supraorbital rim periosteum

This is also a technique preferred by our group but is begins laterally and proceeds medially, until the margin
not critical. JIrish of the supraorbital groove is carefully exposed with a
fine elevator.
STEP 4. The scalp flap is elevated in a subgaleal plane The nerve and vessels may exit the skull either through
superficial to the pericranium between the superior tem- a notch or a true foramen. If a notch is present, the
poral lines bilaterally with the use of electrocautery. nerve can be dissected free without difficulty. If a
foramen, rather than a notch is found, the floor of the
foramen is removed with a fine osteotome. This liberates
STEP 5. Lateral and inferior to the superior temporal the pedicle, and further elevation of the superior peri-
lines, an incision is made through both the superficial orbita is then achieved (see Figure 44-6A).
Scalp incision
Pericranial incision
Coronal suture
Coronal suture
Scalp incision
Squamosal Sagittal suture

suture
Facial n. Pericranial incision
A B
Scalp
(retracted)
Pericranial incision
Osteotomy
Facial n.
Pericranium Temporalis m.
C (retracted)
FIGURE 44-3. A though D, Bifrontal approach.

With regard to the incisions and soft-tissue dissection,

the description characterizes the standard steps
required for exposure of bony landmarks and
necessary for appropriate osteotomies, bone A
A. Frontal approach
mobilization, and then subsequent soft-tissue repair. B. Subfrontal (basal) approach
I would add that planning the coronal incision can
vary slightly from patient to patient depending on the
surgeon’s and patient’s preference. The use of a B
geometric broken line as opposed to a continuous
linear incision often heals better with less disruption of
hair growth along the incision line without unsightly
parts and scars. The lack of excessive cautery use
along the incision site can prevent future hair loss,
again leading to incision exposure as the patient
recovers. The management of the patient’s hair is also
a personal decision and can be left intact without
significant infection risks and can be completely
removed as part of the presurgical preparation.
However, I would caution against doing a simple strip
of hair removal along the incision line; I believe it is an
all-or-none decision. TMMcCulloch
Craniotomy
FIGURE 44-4. Improved exposure with subfrontal approach.
STEP 11. A frontal, temporal, or frontotemporal craniot-
omy is then performed to allow access to the floor of the
anterior or middle cranial fossa or both, respectively.
For a frontal craniotomy, bilateral burr holes are then

placed in the depression posterior to the frontal-
Subfrontal Approaches
zygomatic sutures (MacCarty’s keyhole), after reflection Subfrontal approaches have the advantage of minimiz-
of the temporalis muscle leaving a cuff of fascia at the ing brain retraction by providing wider and more
superior temporal line for reattaching the muscle during direct exposure of the floor of the anterior cranial fossa
closure (see Figure 44-6B). (Figure 44-4). This is especially helpful in more poste-
These anatomic keyholes provide access to the anteriorly located lesions such as those involving the planum
rior fossa dura and by inferior enlargement the perior- sphenoidale, clivus, orbital apex, and optic chiasm
bita, if needed. (Figure 44-5). The subfrontal approach is done by
adding osteotomies that allow incorporation of the
superior orbit and/or nasal bone to the craniotomy.
STEP 12. A burr hole is then placed on each side of the These skeletal elements may be removed in several
superior sagittal sinus (SSS), well anterior to the coronal subunits or as a single bone flap (Figure 44-6C).
suture, exposing the dura on both sides of the sinus.
STEP 1. Bilateral nasal osteotomies are done along

STEP 13. Through the burr holes, Penfield dural eleva- the lower border of the nasal bones and then along
tors are used in a stepwise fashion to safely elevate and the suture line between the nasal and lacrimal bones
protect the dura from the craniotomy saws with manu- (see Figure 44-6B).
factured dural protectors.
STEP 2. The osteotomies are connected across the

STEP 14. The bifrontal craniotomy is performed between
midline below the frontoethmoid suture line and in front
the burr holes (see Figure 44-6A).
of the anterior ethmoidal vessels.
The craniotomy may be extended inferiorly to the level This avoids injury to the cribriform plate and olfactory
of the frontonasal suture. nerves.
Application of small vascular clips is a good

alternative. JIrish
STEP 4. The lateral wall and roof of each orbit are

removed in separate orbital osteotomies (see Figure
44-6B).
STEP 5. Under direct visualization, taking care to protect

the periorbita and dura with the use of malleable and
orbital retractors, an anteroposterior cut is made at the
medial aspect of the orbital roof, staying lateral to the
ethmoid sinus.
STEP 6. A second anteroposterior cut is made at the

inferior aspect of the lateral orbital wall.
A
STEP 7. These cuts are connected posteriorly with pro-
tection of the tissues of the superior orbital fissure (SOF).
STEP 8. Using gentle periosteal reflection to ensure the

bone flap has no residual soft-tissue attachment, the
frontal bone, orbital roof, superolateral orbital rims, and
nasal bones can be removed for wide exposure of the
anterior skull base (see Figure 44-6C).
With regard to the craniotomies, the standard frontal

craniotomy does have significant limitations and, as
Dr. Hanna describes, in most cases is now performed
as a true subfrontal approach in which the frontal bar
is removed in conjunction with a portion of the frontal
bone or in a segmental fashion in which the frontal
craniotomy is subsequently followed by removal of the
subfrontal bar of bone. Depending on the need for
exposure, occasionally more limited craniotomies can
be performed including unilateral frontotemporal
craniotomies and/or a more central subfrontal
craniotomy in which the anterior table of the frontal
sinus is used as the landmarks for extent of subfrontal
craniotomy and is removed en bloc, followed by
piecemeal removal of the posterior table allowing
exposure to the central anterior cranial fossa. This
B approach is useful for limited and small tumors in the
FIGURE 44-5. A and B, Tumor (shaded) involves the nasal and anterior ethmoid region in which little dural
subfrontal skull base including the sphenoclival region. resection is required. TMMcCulloch
STEP 3. The dura and periorbita are carefully dissected

from the bone with the use of both Cottle and Freer Intracranial Dissection
elevators.
I prefer to use bipolar electrocautery to the defined STEP 15. After completing the craniotomy, brain “relax-
vasculator of the anterior and posterior ethmoidal ation” is achieved by opening the dura and allowing
arteries. release of cerebrospinal fluid (CSF) or by withdrawing
Osteotomy
Supraorbital Supraorbital
notch foramen
Supraorbital n.
Scalp
(retracted)
Temporalis m.
Sphenosquamous
suture
Osteotomy Key burr hole
Frontozygomatic suture
Sphenofrontal suture
Supraorbital
notch Osteotomy
Supraorbital
foramen
Osteotomy
FIGURE 44-6. A and B, Osteotomies for cranio-orbital (subfrontal) craniotomy.

Frontal bone
(resected)
Dura mater
Supraorbital n.
Scalp
(retracted)
Temporalis m.
FIGURE 44-4. Cont’d C, Osteotomies for cranio-orbital (subfrontal) craniotomy.
CSF from a lumbar subarachnoid drain described earlier, If the dura is involved by the tumor, intradural expo-
hypocapnea through controlled hyperventilation, man- sure is achieved and dura incisions are made around the
nitol diuresis, or steroids. tumor and the dissection proceeds in a subdural plane,
and the dura and even brain tissue if involved is resected
This also lessens the need for brain retraction, which along with the tumor.
minimizes postoperative brain edema.
STEP 19. With simultaneous exposure provided superi-

This is an important step to reduce postoperative
orly through the intracranial approach and inferiorly
morbidity. JIrish
through the extracranial approach, osteotomies of
the cranial floor around the tumor can be safely
completed.
STEP 16. The dura is carefully dissected along the floor
of the anterior cranial fossa to expose the crista galli and
Malleable retractors are used to protect the brain and
olfactory grooves.
the orbit as osteotomies are made. The placement of
osteotomies and the extent of resection are dictated
by the extent of tumor involvement, and tailored in
STEP 17. The olfactory nerves are bipolar cauterized at
each case.
a low setting and transected to expose the cribriform
Typically, however, osteotomies are made from the
plate.
planum sphenoidale, along the roof of the ethmoid,
and forward to the front of the cribriform plate
(Figure 44-7).
STEP 18. Dural elevation is continued to expose the
Frozen section control of the margins should be done
fovea ethmoidalis and orbital roofs.
to ensure the adequacy of resection.
Posteriorly, the planum sphenoidale and the base of the Prior to dural closure or pericranial flap inset, intra-
anterior clinoid process may be exposed as dictated by operative ultrasound is performed to evaluate for unap-
the extent of the tumor. preciated subdural hematoma or intracranial bleeding.
Tumor Crista galli

Pituitary
Scalp gland
Clivus bone
Pericranium
Excised cranial fossa

Crista galli
Lamina cribrosa
FIGURE 44-7. Tumor resection through intracranial (A) and extracranial (B) exposure.
With regard to the intracranial dissection, Dr. Hanna

again describes the classical intracranial dissection
technique, which is predicated on the tumor
Scalp Pericranium
involvement of intracranial structures. In essentially all
cases, the subfrontal dura will be removed along the
orbital roofs, olfactory grooves, and crista galli
depending on tumor involvement. Yet even without
obvious dural invasion, this can represent a free tumor
Area of excision
margin to ensure complete tumor extrication. When
tumor does penetrate the dura, small sections of Tacking
frontal lobe often are removed to again accomplish sutures
Drill holes
this free tumor margin.
The tumor extent defines the necessity for
extracranial or facial incisions. Smaller tumors are
easily managed with endoscopic approaches or
can be completely removed through the subfrontal
approach without additional exposure. Many tumors
do require secondary incisions to accomplish
FIGURE 44-8. Reconstruction of the anterior skull base with
removal of additional structure such as orbital content,
a pericranial flap.
involved skin, ethmoidal or maxillary bone. However,
it is our belief that secondary incisions are not
suturing should be meticulous in order to achieve a
necessary to ensure an en bloc resection of tumor.
watertight seal (Figure 44-8).
Tumor resection in a piecemeal fashion often is
Fibrin glue and tissue adhesives do not compensate
necessary in this approach and is not shown to
for an imperfect closure.
affect clinical outcomes as long as margin control
Lumbar subarachnoid drainage may be used for
is maintained. TMMcCulloch
several days postoperatively to reduce CSF pressure
and the possibility of a leak. Excessive lumbar drain-
age, however, may encourage the development of
Skull Base Reconstruction pneumocephalus.
STEP 20. Meticulous closure of all dural incisions

STEP 21. Occasionally more bulk is needed to recon-
is necessary. Larger defects of the dura should be
struct the surgical cavity and reduce dead space, such
repaired using temporalis fascia, pericranium, or fascia
as with extensive defects of the cranial base.
lata grafts.
Whenever the cranial and nasal cavities are joined by a Regional flaps, such as the temporalis muscle, are
surgical defect, as is the case with anterior craniofacial usually adequate for this purpose.
resection, watertight cranionasal separation is essential If the temporalis muscle bulk is inadequate, or if its
to reduce the risk of CSF leak, meningitis, and blood supply has been sacrificed, a microvascular free
pneumocephalus. flap is used.
Although bony reconstruction of the anterior skull Vascularized tissue may also be needed to protect the
base has been described using vascularized and nonvas- carotid artery if it is exposed to the surgical defect,
cularized bone grafts as well as bone cement, recon- especially in previously irradiated patients (or those
struction of the bone defect is not routinely necessary who will receive postoperative adjuvant radiation treat-
in most patients. ment). This is done to prevent desiccation of the arterial
wall and carotid artery blowout.
In patients who may require postoperative radiation,
one should avoid the use of nonvascularized bone With regard to skull base reconstruction, again Dr.
grafts as much as possible. The risk of in-treatment or Hanna provides an accurate description of the
post-treatment is increased in situations in which important steps of soft-tissue reconstruction including
nonvascularized tissue is used. JIrish watertight dural repair and dural grafting and the
placement and handling of an intact pericranial flap as
a primary separator of intracranial content from nasal
The vascularized pericranial flap is currently the facial spaces. I certainly agree with avoiding vascular
most frequently used flap for reconstructing defects of bone grafts for small defects. The careful use of
the floor of the anterior cranial fossa. Flap handling and
Lumbar subarachnoid drains are removed on the

lumbar subarachnoid drains and the occasional need
first postoperative day prior to transfer to normal post-
for additional soft-tissue reconstructions with local
operative care. Patients are encouraged to get up in a
tissues and commonly free tissue transfers that can
chair and begin to ambulate within their first 48 hours
support the dural repair replace facial tissues, cover
postoperatively.
cutaneous losses, eliminate dead space, and expedite
healing especially in previously radiated patients. It
should be noted that many patients require intranasal
packing material to diminish early postoperative Use of stool softeners is important in the
mucosal bleeding and aid in maintaining a clean and postoperative period to reduce straining and reduce
noninfected nasal cavity and occasionally to support CSF leak risk. This is particularly important because
the soft-tissue healing. TMMcCulloch patients are usually receiving narcotic analgesia, which
also contributes to constipation. JIrish
Most patients are intubated overnight and monitored in
an intensive care unit (ICU) setting during that period With regard to the postoperative management, I highly
of recovery. agree with the necessity for ICU monitoring, easy
Prior to extubating, a contrast-enhanced CT scan is postoperative imaging for the evaluation of potential
obtained to evaluate for intraoperative bleed and pneu- intracranial problems, and establishing baseline data
mocephalus. Patients remain on broad-spectrum periop- for comparison purposes if the need arises to
erative antibiotics for 48 hours unless prolonged CSF reevaluate mental status changes. TMMcCulloch
leakage is noted.
CHAPTER
Lateral and Subtotal Temporal
45 Bone Resection
Author Paul W. Gidley
Commentary by John P. Leonetti and Sam J. Marzo
Lateral Temporal Bone Resection (BAHA) at the time of the primary operation, but my
practice is to place a BAHA as a secondary procedure.
Indications
While this surgery produces a maximal conductive
This procedure is designed to remove the bony ear canal hearing loss, care should be exercised to avoid produc-
lateral to the facial nerve. The primary indication for ing a profound sensorineural hearing loss.
this procedure is to remove tumors of the ear canal en Diagnostic imaging may include either computed
bloc without tumor spillage. Lateral temporal bone tomography (CT) or magnetic resonance imaging (MRI).
resection (LTBR) alone may be sufficient surgery for
tumors with low potential for metastatic spread, such Radiographic imaging is important for proper
as basal cell carcinoma of the ear canal. However, this treatment planning but can underestimate tumor
procedure is often combined with parotidectomy and invasion/extension superiorly involving the middle
neck dissection to treat tumors that involve the ear canal fossa dura, and medially involving the middle ear and
and have the potential for metastatic spread. mastoid mucosa as well as the carotid canal (see
LTBR might be required for advanced tumors of the Leonetti et al, 1996). SJMarzo
periauricular skin, parotid, or temporal bone. When
advanced periauricular skin cancers encroach on the CT is perhaps more useful because fine cuts give exqui-
external ear canal, LTBR is performed to identify or site detail of the structures of the ear canal, eardrum,
achieve a negative medial tumor margin. When advanced ossicles, facial nerve, inner ear, and the vascular struc-
parotid tumors grow into the ear canal or temporoman- tures of the temporal bone. MRI has a distinct advan-
dibular joint (TMJ), LTBR is performed to achieve a tage over CT when assessing dural involvement around
negative posterior or deep margin. the temporal bone. MRI can give a good indication of
perineural spread in the facial nerve.
Make appropriate consultations with related spe
And/or to identify normal facial nerve proximal to the cialties:
stylomastoid foramen. JPLeonetti ❑ Neurotology for temporal bone surgery
❑ Head and neck surgery for neck dissection and
parotidectomy
When advanced temporal bone cancers are consid- ❑ Plastic and reconstructive surgery for flap
ered, LTBR is performed as a prelude to subtotal or total reconstruction
temporal bone resection. ❑ Neurosurgery if dural or intracranial extension is
identified
Preoperative Assessment
Patient Preparation
Preoperative assessment should include detailed clinical
examination of external auditory canal to determine The patient is taken to the operating room and placed
both lateral extension to the cartilaginous external audi- on the operating table in supine position. After sufficient
tory meatus and to or through the eardrum. Perform level of anesthetic, the patient is orally endotracheally
careful cranial nerve examination to determine facial intubated. The patient is then padded with the arms
nerve involvement, if any, as well as audiometric studies tucked in at the sides. At least three straps are placed
to determine hearing level in both ears. Consideration across the patient to allow the table to be tilted. The
can be given to placing a bone-anchored hearing aid operating table is then turned 180 degrees.
438
CHAPTER 45 Lateral and Subtotal Temporal Bone Resection 439
In selected cases in which a pedicled myocutaneous

latissimus flap is considered for wound closure, the
patient may be placed on the table on the side with
the treated ear upward. This avoids repositioning the
patient later in the case after the tumor is removed. It
is also important to prep out any other areas where
grafts may be taken such as the abdomen for a fat
graft or for a rectus abdominis flap, as well as the leg
if a sural nerve graft is anticipated. SJMarzo
Incision
Turning the table 180 degrees places the feet at the

anesthesia station. The head of the table is fully acces-
sible by members of the surgical team. This allows the
scrub nurse to be directly across the table from the
surgeon. While under the microscope, instruments can FIGURE 45-1. A C-shaped postauricular incision with a
be easily passed from nurse to surgeon. meatal incision allows the auricle to be preserved and gives
Facial nerve monitoring is used for all temporal bone access to the temporal bone, the parotid gland, and the
procedures. Electrodes for the facial nerve monitor are upper neck nodes.
placed in the orbicularis oculi and orbicularis oris
muscles. Patients must not be given long-acting paralyt-
ics for induction, and this fact must be communicated A reverse S-shaped incision helps preserve the
to the anesthesia team. anterosuperior circulation to the auricle JPLeonetti
When tumors are located only within the ear canal,

The type of defect reconstruction will determine what
an incision at the external auditory meatus lateral to the
other areas of the body will also be prepped in the
tumor is combined with a postauricular incision. The
operative field. JPLeonetti
postauricular incision is usually placed at the hairline or
about 2 fingerbreadths behind the postauricular sulcus.
The postauricular skin flap is raised in the loose fascial
Operative Steps plane superficial to the temporalis muscle, over the
mastoid periosteum, and superficial to the sternocleido-
mastoid muscle and parotid gland. The canal incision is
STEP 1. Incision planning is crucial for temporal bone encountered, the tragal cartilage is divided, and dissec-
procedures. tion continues in a plane superficial to the parotid gland
(Figure 45-1).
When planning to save the auricle, incisions must be
placed to avoid compromising blood flow to the auricle.
The lateral cartilaginous ear canal is oversewn to
The choice of incision is influenced by at least three
prevent tumor spillage. JPLeonetti
factors:
❑ Location and extent of tumor
❑ Location of previous incisions When tumors involve the pinna and extend into the
❑ History of previous radiation ear canal, total auriculectomy is usually required.
Two main incision types are used for temporal bone
surgery: If portions of the pinna are involved with the lesion it is
❑ Postauricular C-shaped incision better to counsel the patient preoperatively that the
❑ Anterior, pretragal incision entire pinna should be resected. Attempts to preserve
Both incisions are extended into the neck and/or tem- portions of the pinna usually result in pinna necrosis of
poral hairline as needed for either neck dissection or the preserved remnant as well as an unsatisfactory
temporalis muscle flap. cosmetic result. A good option for postoperative
reconstruction in patients requiring an auriculectomy is
a Vistafix implant with a silicone prosthesis with or
The C-shaped incision should be broad based to
without BAHA SJMarzo
avoid necrosis of the pinna. An alternative is a gentle
S-shaped incision that curves superiorly into the
temporal scalp. SJMarzo An incision that completely encircles the outer ear is
required, and it can be extended into the neck for neck
dissection and parotidectomy and into temporal hair-

An alternative would be a Y-shaped incision
line, as needed (Figure 45-2).
incorporating the parotid incision. In this instance the
If surgery is performed after radiation, the blood
back limb of the Y should curve posteriorly along the
supply to the auricle is already compromised. A postau-
bottom of the mastoid bone. The pinna can be
ricular incision, placed about 2 or 3 fingerbreadths
reflected superiorly. It is important to leave a broad-
above and behind the ear, is used to try to maintain the
based blood supply to the pinna superiorly to prevent
blood supply to the pinna. The flap is raised, cutting
necrosis. In cases in which the pinna is preserved it
across the ear canal, and developing a plane superficial
should be checked frequently during the case to make
to the parotid gland as described.
sure it is viable and has good capillary refill. SJMarzo
A preauricular incision can be performed and is
required when a parotidectomy scar already exists
(Figure 45-3). In this circumstance, the canal incision is
made to encompass the tragus and the external auditory In spite of every good intention and planning, some
meatus. The posterior-based flap is raised superficial to auricles do not survive the procedure. These ears are
the temporalis fascia and mastoid periosteum. Extend- either resected at the time of closure, or they necrose
ing the original incision into the hairline allows this and require excision and wound revision in a second-
posterior-based flap to be retracted sufficiently to stage operation. In preparation for such an outcome,
perform mastoidectomy and temporal bone resection every patient undergoing temporal bone resection must
(Figure 45-4). be made aware that loss of the pinna is a possibility and
recognized risk of the procedure.
Fortunately, the advent of the Vistafix implant system

with silicone prosthesis allows a satisfactory
reconstruction after completion of postoperative
radiotherapy. SJMarzo
The flaps are held in place with self-retaining or fish-

hook retractors (see Figure 45-4). After the flaps are
raised, ear canal margins are sent from the flap side for
frozen section analysis. The mastoid cortex is exposed
by raising a mastoid periosteal (Palva) flap and exposing
the mastoid cortex and root of the zygoma. The Palva
flap is a periosteal flap that is sewn over the ear canal
defect to prevent tumor spillage. The temporalis muscle
is elevated and retracted to identify the zygomatic root.
FIGURE 45-2. When the tumor involves the auricle, a The soft tissue of the TMJ is identified. The sterno-
circumferential incision is used to permit en-bloc resection of cleidomastoid muscle is elevated off the mastoid tip. The
the tumor, the lateral temporal bone, the parotid gland, and attachment of the digastric muscle in the posterior
neck nodes. digastric ridge is identified.
FIGURE 45-3. In cases in which a preauricular scar is

present, a meatal incision is made, and the existing
scar is incorporated. The auricle is raised along with
the surrounding skin as a posteriorly based flap.
Temporomandibular
joint capsule
Parotid gland
Temporalis m. Parotid gland
Ear canal Palva flap closed

over ear canal
Temporalis m.
Skull
FIGURE 45-4. A, A large C-shaped incision has been made, and the soft tissues, including
the auricle, have been raised. An incision across the membranous canal allows access to the
parotid gland. B, A mastoid periosteal flap, also called a Palva flap, is raised and sewn over
the membranous canal to avoid tumor spillage.
Temporomandibular
joint capsule
Parotid gland
Temporalis m.
Facial canal
Specimen
Horizontal
semicircular
canal
FIGURE 45-5. A complete
Sigmoid sinus mastoidectomy has been performed.
Dissection along the tegmen has been
Sternocleido-
mastoid m. completed, and the temporomandibular
remnant joint is exposed. The facial canal has
Mastoid air been delineated, and the mastoid tip has
cells been removed.
STEP 2: A complete mastoidectomy is performed. Much of this initial dissection can be safely and
quickly performed without magnification. Once the
The mastoid tegmen and sigmoid sinus are skeleton- mastoid antrum is opened, the microscope can be
inzed, and the antrum is opened. The mastoid tip air brought into the field to improve exposure for
cells are opened to identify the posterior portion of the dissection purposes. SJMarzo
digastric ridge (Figure 45-5).
Parotid gland
Specimen
STEP 4: Drill out the facial recess and identify the facial
nerve.
Temporalis m.
Under high-power magnification and using continuous
suction irrigation, the facial recess is drilled out (Figure
45-6). The middle ear is inspected. If the middle ear is
Facial canal free of disease, lateral temporal bone resection is suffi-
(opened)
cient. If tumor has breached the eardrum, a subtotal
temporal bone resection needs to be performed (see
Sternocleido- following).
mastoid m. The facial nerve is then identified at the tympanic
remnant
segment and in the floor of the facial recess and fol-
Mastoid air
cells lowed past the second genu into its mastoid portion.
Horizontal
Sigmoid
Follow the facial nerve along its mastoid portion to the
semicircular
canal sinus stylomastoid foramen. The stylomastoid foramen is
widened and the bone of the digastric ridge is removed.
FIGURE 45-6. The facial canal is further delineated by A trough is drilled lateral and anterior to the facial
extending the facial recess. nerve, extending the facial recess. This allows identifi
cation of the chorda tympani nerve, which is later
sacrificed.
Under the operative microscope, the antrum is
further widened, allowing the identification of the hori-
zontal semicircular canal and incus body. Drilling then STEP 5: Mastoid tip removal is performed in all cases to
continues lateral to the ossicular chain through the allow unobstructed dissection of the facial nerve in its
zygomatic air cells. extratemporal portions. Furthermore, removal of the
mastoid tip permits dissection at the skull base, medial
to the facial nerve.
The sigmoid sinus is identified and followed medial to
the stylomastoid foramen if tumor extends to the
Bone along the digastric ridge is drilled away to expose
jugular foramen JPLeonetti
the underlying muscle. Widening the stylomastoid
foramen naturally exposes the digastric muscle near the
facial nerve.
STEP 3: Perform the superior canal cut.
Drilling is performed through the bone inferior to
Drilling continues anteriorly through zygomatic air the ear canal and anterior and lateral to the facial nerve
cells, removing the bone between the ear canal and until soft tissue of the TMJ is reached. Doing so frees
middle fossa dura until the TMJ capsule is reached. the last bony attachment of the mastoid tip, having
Drilling is performed lateral to the ossicular chain. The already divided the bone posteriorly along and through
incus can be disarticulated to avoid transmitting drill the digastric ridge.
vibratory trauma to the inner ear. Care is taken to avoid The soft tissue attachments to the mastoid tip are
injury to the dura; occasionally the dural is very close divided beginning posteriorly.
to the ear canal bone. In this case, additional ear canal
bone is drilled away to avoid causing a cerebrospinal
fluid (CSF) leak. A helpful maneuver to avoid extratemporal facial nerve
The capsule here marks the anterosuperior extent of injury in this instance includes hugging the
the dissection. undersurface of the mastoid tip and elevating the tip
forward, sectioning the muscle attachments with a
Drilling is complete superiorly when the glenoid fossa sharp curved scissors. SJMarzo
is exposed from the tympanic annulus to the
zygomatic root. It is important to thoroughly inspect
the middle fossa dura for tumor invasion during this The mastoid tip is elevated laterally and dissection
portion of the dissection. If the dura is involved, a continues anteriorly. The facial nerve is held in the sty-
decision should be made in consultation with lomastoid foramen by its perineural and periosteal
neurosurgery about the feasibility of dural resection attachments and does not elevate with the mastoid tip.
with grafting. As stated, dural invasion may not The remaining soft tissue attachments of the mastoid tip
always be identified preoperatively on radiographic are divided until the mastoid tip is removed. No attempt
imaging. SJMarzo is made to identify the extratemporal portion of the
facial nerve prior to removal of the mastoid tip.
Temporomandibular
joint capsule
Parotid gland
Temporalis m.
Specimen Facial canal
(opened)
Horizontal FIGURE 45-7. The facial recess has
semicircular been extended, and bone between the
canal annulus and facial nerve has been
removed. The dissection continues
Sigmoid sinus Sternocleido- anteriorly and inferiorly until the soft
mastoid m. tissues of the temporomandibular joint
remnant
are reached. Thumb pressure on the
Mastoid air canal allows it to fracture along the
cells anterior tympanic ring.
STEP 6: Perform the inferior canal cut.

Care must be taken when drilling medial to the
The bone inferior to the ear canal is further drilled away, annulus because the artery can lie just below it (Figure
thinning the inferior aspect of the ear canal. Drilling is 45-7).
performed through the facial recess and bone is removed
between the facial nerve and the annulus. The annulus
is then followed inferiorly, and drilling is performed STEP 7: Mobilize the external bony canal.
through the hypotympanic air cells.
At this point, care must be taken to avoid having the At this point the ear canal is held principally by only a
shaft of the drill rest on the facial canal. The author has thin shell of bone anteriorly. The incus is disarticulated
found that some patients have either a deep annulus or and the incus bar is removed. The tensor tympani muscle
a superficial facial nerve, meaning that the facial nerve is divided.
lies in a plane higher than the level of the annulus. In Thumb pressure on the external auditory canal
this circumstance, drilling between the facial nerve and allows it to fracture off anteriorly (Figure 45-8).
the annulus must be done with great care to avoid
having the shaft of the drill rest on the facial nerve. If The specimen is left attached to the parotid if a
the shaft does rest on the facial nerve, the facial nerve parotidectomy is to be performed as part of the
can be burned by the drill’s shaft. The facial nerve oncologic resection. SJMarzo
monitor will not fire and there will be no warning to
the surgeon. Only constant vigilance and care can Using a Freer elevator, the surgeon can assure himself
prevent this type of injury to the facial nerve. that the canal is completely freed. Care must be exer-
The surgeon must also be cognizant of a high-riding cised not to use the facial canal as a fulcrum for the
jugular bulb and/or a high or dehiscent carotid artery. elevator. Occasionally the anterior bony annulus does
Preoperative CT imaging will alert the surgeon of these not fracture off in continuity with the canal and it can
anatomic variants. The high-riding jugular bulb should be drilled away.
be suspected when the sigmoid sinus is more anterior Others have described using osteotome to make the
and lateral than normal. Occasionally the jugular bulb superior and inferior canal cuts. The author has not
lies dehiscent just below the facial nerve. The dehiscent found this to be necessary and has avoided their use due
carotid artery is encountered and first noticed when to the potential for carotid artery injury.
drilling out hypotympanic air cells. A bulge in the ante-
rior hypotympanic air cells is a telltale sign. Adequate bony dissection above and below the
external auditory canal (EAC) will allow the thin
In this instance the carotid artery usually appears tympanic bone holding the specimen in place to easily
white and just below the promontory. SJMarzo fracture, avoiding use of the osteotome. SJMarzo
Specimen
Facial n.
Stapes
FIGURE 45-8. In cases in which parotidectomy is
not performed, soft tissues anterior and inferior to
the ear canal are dissected off the canal’s cartilage Temporal line
and bone, and the canal is liberated. The bone Horizontal
covering the facial nerve is removed, and the nerve semicircular
is traced into the extratemporal soft tissues. canal
If tumor is confined only to the ear canal and parot Some authors have written about creating an open
idectomy or neck dissection is not planned, the ear canal cavity covered by a split-thickness skin graft.
can be removed by developing a plane of dissection
between the parotid gland and the ear canal. Bridging I never do this, especially in cases of prior or future
blood vessels to the ear canal are cauterized with bipolar radiation. JPLeonetti
electrocautery. Blunt and sharp dissection staying close
to the bony ear canal allows the specimen to be removed
and facial nerve injury can be avoided. Such a cavity should be avoided because the patient
requires frequent debridement and the hearing is
usually poor as well due to radiation-induced
eustachian tube dysfunction. SJMarzo
STEP 8: Wound closure: The temporal bone defect can
be closed in a variety of ways, including temporalis
Skin graft is laid over the exposed bone and the
muscle flap and split-thickness skin graft to an open
cavity is packed with antibiotic impregnated gauze, as
cavity.
is done for chronic ear disease. This author has not used
The temporalis flap is commonly used to close the this technique because it can result in a chronic draining
defect. Its bulk allows protection of the temporal bone ear, especially after radiation therapy.
for radiation. Larger defects, as in the case of total auriculectomy,
might require free flap coverage, though these too can
be closed with temporalis flap and soft-tissue rotation.
Rotation of the temporalis muscle inferiorly creates a
depression above the pinna that some patients may
find cosmetically unappealing. Another option is to fill STEP 9: When necessary, decompress and mobilize the
in the mastoid defect with an abdominal fat graft. It is facial nerve.
important that the eustachian tube be obliterated with
muscle and the EAC closure be water-tight to prevent Many times the lateral temporal bone resection is
postoperative infection in the fat. SJMarzo combined with parotidectomy for advanced parotid
cancers. In this circumstance, the facial nerve can
be decompressed and mobilized in preparation for
The flap is measured, cut, and rotated into the defect. parotidectomy.
Removal of the posterior attachment of the zygomatic
arch helps free up the muscle and makes rotation easier. Anteriorly based tumors of the bony and cartilaginous
The flap is sewn to the mastoid periosteum, the sterno- ear canal are able to spread into the parotid gland via
cleidomastoid muscle, and the parotid fascia. The author preformed pathways. In most cases of EAC cancer, a
also placed sutures under the pinna to the temporalis superficial parotidectomy is indicated except possibly
muscle to suspend the outer ear and to avoid the inevi- in selected T1 cases. SJMarzo
table sag that happens without an ear canal.
Facial nerve decompression is required in three

I disagree. I would proceed with labyrinthectomy to
circumstances:
❑ When facial weakness is identified preoperatively,
obtain a negative (tumor-free) proximal facial nerve
margin. JPLeonetti
because this connotes facial nerve involvement by
tumor
❑ When tumor is located at the stylomastoid In such a circumstance, labyrinthectomy would be
foramen, and the nerve will need to be mobilized required to expose the next segment of the nerve. This
or sacrificed creates undue morbidity. These patients will be treated
❑ When scarring from previous parotidectomy is with postoperative radiotherapy, which should be suf-
suspected. ficient to control the positive margin on the nerve.
Facial nerve decompression has three purposes:
❑ Identify the facial nerve at an uninvolved segment
Unfortunately, due to perineural spread, it may be
❑ Obtain a negative margin on an infiltrated nerve
difficult to obtain a negative margin proximal margin
❑ Permit facial nerve grafting if facial nerve sacrifice
on the facial nerve. It is this author’s opinion that one
is required.
should not hesitate to take a facial nerve if it is
After the ear canal is mobilized, the ear canal can be
involved with tumor or the patient has preoperative
left attached to the soft tissue of the parotid and TMJ.
facial paralysis. If the tumor has eroded into the
The bone of the facial canal is removed with fine
cochlea and/or labyrinth, these structures can be
diamond burrs and continuous suction-irrigation. Bone
resected as well and it may be possible to obtain a
for 270 degrees around the nerve is removed until only
negative margin within the meatal segment of the
a thin layer remains. Fisch instruments or other suitable
nerve. Grafting with either a sural or median
raspatories are used to remove this last layer of bone.
antebrachial cutaneous nerve may be an option if
At the stylomastoid foramen the periosteal cover is
negative facial nerve margins are obtained. SJMarzo
opened, and the facial nerve is identified extratempo-
rally. Using a Jacobson hemostat and a No. 12 blade,
the soft tissue lateral to the facial nerve is identified. The Facial nerve grafting can be considered depending on
nerve is traced out until the pes anserinus is identified. the amount of remaining intratemporal and any extra-
Parotidectomy can then proceed. temporal branches.
Collagen tube wrap helps reduce scar ingrowth at the

At times neck dissection may be indicated for
level of the neurorrhaphy. JPLeonetti
treatment of palpable or radiographically suspicious
lymphadenopathy as well as neurovascular control.
SJMarzo
Postoperative Care
The decision for facial nerve sacrifice can be made Consider admitting patients to an intensive care unit if
based on inspection of the nerve. Frozen section pathol- there are preexisting medical problems or if a microvas-
ogy is required for this decision making. Facial nerve cular free flap has been performed.
sacrifice is performed in at least three circumstances: Eye care is important for patients with facial weak-
❑ There is obvious disease involving the nerve. ness or paralysis. Liberal use of eye moisturizers is nec-
❑ There is disease involving the tissue surrounding essary to prevent corneal drying and ulceration.
the nerve.
❑ There is preoperative facial nerve paralysis.
Ophthalmology consultation can be helpful in such
At a minimum, this indicates perineural spread along
cases as well. Gold weights, tarsorrhaphy and other
the nerve. Branch defects of the nerve might require only
oculoplastic procedures may be indicated as well.
one extratemporal branch to be sacrificed. This is
SJMarzo
covered in the chapter on parotidectomy.
When facial nerve sacrifice is performed, an initial
first cut in the nerve is performed just above the stylo- Hospitalization continues until the patient meets cri-
mastoid foramen. The nerve is marked and oriented for teria for dismissal. Patients are usually discharged after
the pathologist, and frozen section is performed to 2 or 3 days when uncomplicated surgery without free
determine the margin. Multiple segments of the nerve flap is performed. Patients who have required microvas-
can be sent until the margin is negative. In practice, cular free flaps usually stay 5 to 7 days after surgery.
if the margin is still positive with microscopic disease Due to removal of ear canal and/or rotation of the
at the geniculate ganglion, no further surgery is temporalis muscle, some patients develop difficulty with
performed. mouth opening. These patients should be instructed to
start mouth-opening stretching exercises about 10 days shown to produce any lengthening of disease-free
to 2 weeks following surgery. survival.
Decision making for advanced temporal bone tumors
is complicated. The most difficult decision is resectabil-
Suction drain usage eliminates the need for a
ity of the tumor. Criteria that prevent surgical therapy
compressive dressing, which could further
include the following:
compromise the auricular circulation. JPLeonetti
❑ Brain involvement (i.e., brain involvement beyond
microscopic disease or a few millimeters)
❑ Carotid encasement
Subtotal Temporal Bone Resection ❑ Treatment failure following LTBR and ra
diotherapy
Indications
❑ Distant metastatic disease
Subtotal temporal bone resection is required for tumors ❑ Moribund patient
that involve the mastoid, middle ear, inner ear, or lateral ❑ The challenge of intratemporal carotid artery
skull base (i.e., jugular foramen). The direction and disease
extent of dissection depend on the location of the tumor. Although carotid artery resection and bypass graft-
These tumors are often extensive, and a team approach ing have been described, these procedures are fraught
is necessary. Typically our team consists of neurotolo- with significant morbidity and mortality. In practice,
gist, neurosurgeon, head-and-neck surgeon, and plastic only tumor debulking is performed when the carotid is
reconstructive surgeon. When sacrifice of cranial nerves encased. In our philosophy, for malignant disease the
IX through XI is contemplated, a preoperative speech carotid artery is not sacrificed because this disease is far
and swallowing evaluation should be performed. advanced, and surgery cannot possibly remove all
In general, there seems to be four classes of tumors: disease. In this circumstance, quality of life outweighs
❑ Tumors that involve the middle ear and have any potential extension of life. For benign tumors the
limited mastoid disease carotid artery is not sacrificed because the potential risk
❑ Tumors that extend into the labyrinth. These of major stroke is not outweighed by any potential
tumors usually have replaced the mastoid com- benefit.
pletely prior to involving the labyrinth.
❑ Tumors that extend below the otic capsule into
the jugular foramen Carotid resection may be considered in younger
❑ Tumors that have replaced the otic capsule and patients who pass a balloon occlusion test and who
entered the cochlea. These tumors are the most have tumor invasion of the wall of the petrous portion
dangerous due to the involvement of the carotid of the internal carotid artery (ICA). JPLeonetti
artery.
Adequate preoperative evaluation must be performed
to determine the extent of carotid involvement. Surgery Subtotal temporal bone resection differs from lateral
is not offered to patients who have tumors that encase temporal bone resection in at least one of five ways:
the carotid artery. ❑ The posterior fossa plate is removed, exposing
the sigmoid sinus and posterior fossa dura.
❑ The labyrinth is removed, either partially or
Advanced disease involving the petrous carotid artery
totally.
is an ominous finding and even with extensive surgery
❑ The retrofacial air cell tract and jugular bulb
including carotid artery resection, the 5-year survival
region are exenterated, as a prelude to possible
rate is dismal at 0% to 11% (see Prasad and Janecka,
jugular bulb resection.
1994). If the decision is made to resect the carotid
❑ The cochlea is removed.
artery, the current trend is for carotid bypass in most
❑ The carotid artery is skeletonized.
cases because the risk of postoperative stroke
Consideration might be given to use of lumbar drain
approaches 25% or higher even in those patients
if dura resection is required. Temporary postoperative
undergoing successful balloon test occlusion with
lumbar drainage might be helpful if a large dural defect
cerebral blood flow studies (see Natarajan et al,
is created.
2009). SJMarzo
I never use a lumbar drain for temporal bone resection

En-bloc resection is not possible with these tumors.
(TBR). JPLeonetti
Some authors have described total temporal bone resec-
tion as an en-bloc procedure; however, in my opinion
the risks of this procedure far outweigh any potential Consideration must be made for reconstruction.
benefit. Furthermore, en-bloc resection has not been These procedures usually produce a large defect in the
skull base. The temporal bone defect communicates

with the neck. Abdominal fat graft might be sufficient
with smaller defects and uncomplicated cases. Free
microvascular flap reconstruction might be required for
closure of larger, complicated skull base defects.
Incision
Patient Preparation and Positioning
These procedures are performed with the patient
placed supine on the operating table. The head is fixed
in a Mayfield head holder, and positioned to allow
access to the temporal bone and neck. Rigid fixation
of the head is necessary for intraoperative stereotactic
guidance systems. Intraoperative stereotactic guidance
systems can be helpful in determining extent of
surgery.
FIGURE 45-9. A large postauricular C-shaped incision allows
The arms are tucked at the patient’s side, and the access to the temporal bone, the middle fossa, the parotid
patient is strapped to the table with three straps. A site gland, and the great vessels in the neck.
for abdominal fat graft harvest is exposed. Facial nerve
and laryngeal monitoring should be considered when
these nerves have normal preoperative function and an
attempt will be made to preserve their function. Neck Exposure
Rectus abdominis muscle is ideal for reconstruction of STEP 2: The neck exposure should precede the temporal
defect only while serratus muscle can be used for filler bone dissection.
and midface reanimation. JPLeonetti Once the lymphoareolar tissue of the level II and level
III are removed, the jugular vein, carotid artery, and
cranial nerves IX, X, and XI are identified. The great
vessels are then isolated with vessel loops (Figure 45-10).
This is performed in case of inadvertent injury to the
Operative Steps carotid or if the jugular bulb needs to be resected.
STEP 1: A large C-shaped incision that extends into the

STEP 3: Complete the temporal bone dissection.
neck is made (Figure 45-9). The skin flap is raised as
described earlier. Mastoidectomy is performed to identify the tegmen and
posterior fossa dura. The middle fossa and posterior
fossa dura are important landmarks to identify because
Same comment as earlier: the reverse S-shaped
they represent limits of resection.
incision helps preserve the anterosuperior blood
The external bony ear canal can be removed as
supply to the auricle. JPLeonetti
described earlier for lateral temporal bone resection.
Removal of the canal gives an unobscured view of the
The ear canal is closed. An incision is made in the disease in the middle ear.
ear canal medial to the bony-cartilaginous junction. Due to the extent of tumor in the mastoid, land-
Often for these more medially placed temporal bone marks can be difficult to find. The dura can be found in
tumors, ear canal skin is normal. If so, the canal skin an uninvolved area and followed inward to identify the
can be elevated and an incision made medial to the sigmoid sinus. The eustachian tube is an important
bony-cartilaginous junction. landmark for the carotid artery. The cochleariform
The tragal cartilage is elevated off the anterior tym- process, the horizontal semicircular canal, the digastric
panic ring, and the flap is raised superficial to the parotid ridge, and the chorda tympani nerve are important land-
gland. The skin of the external auditory meatus is marks for the facial nerve. Tumor is debulked as needed
undermined and everted and oversewn in a water-tight for exposure.
fashion. The Palva flap can be sewn to the tragal
cartilage to create a second layer of closure on the ear
STEP 4: Identify and manage the facial nerve.
canal.
The skin flap is held forward with self-retaining or Palpation for the ear canal, bony labyrinth, and/
fishhook retractors. or cochlea should be performed to identify these
Ear canal (transected)

Parotid gland
Common carotid a.
Vagus n.
Internal jugular v.
FIGURE 45-10. The membranous
Ear canal
canal is transected, and the great (transected)
vessels in the neck are exposed
Temporalis m.
and marked with vessel loops. The
soft tissues of the ear canal are Spinal
everted, and the ear canal is closed accessory n.
with the Palva flap as a second
layer of closure. Sternocleidomastoid m.
Facial n.
Vagus n.
Common carotid a.
Stapes Tumor Internal jugular v.
Horizontal semicircular canal
Temporalis m. Sternocleidomastoid m.
Spinal
Sigmoid sinus
accessory n.
FIGURE 45-11. After mastoidectomy, the sigmoid sinus is skeletonized, and the mastoid tip is
removed. The facial nerve is mobilized and transposed to permit access to the jugular
foramen.
structures. From these structures one can try to find the creates a bridge with the facial nerve protected within
facial nerve. Often these tumors have already produced the bone of its canal. Alternatively, the facial nerve can
facial paralysis, so facial nerve sacrifice is performed. be transposed by removing the bone surrounding the
When the facial nerve is intact preoperatively and nerve, dissecting the extratemporal portion of the nerve,
not involved by tumor, an attempt can be made to pre- and elevating the nerve out of its canal. The nerve is
serve its function. When the jugular bulb region is sewn to parotid fascia with a silk suture placed in
involved, the facial nerve can be left in its canal and the periosteal cuff from the stylomastoid foramen
drilling is performed medial and anterior to it. This (Figure 45-11).
STEP 5: Labyrinthectomy and/or cochlectomy is required

superior and inferior petrosal sinuses until these are
for disease involving the labyrinth, oval or round
packed off.
windows, or cochlea.
Care is taken to identify the cranial nerves IX through
The bone of the labyrinth is removed and the internal XI; however, in tumors at this location these nerves are
auditory canal (IAC) is identified. If the facial nerve is frequently involved and preservation is difficult.
being preserved, care must be taken not to disturb the
nerve in the internal auditory canal. If the IAC is
The lateral or anterior wall of the jugular bulb can be
involved, facial nerve sacrifice is undertaken.
the medial tumor margin in cases of temporal bone
cancer or advanced malignant parotid
tumors. JPLeonetti
STEP 6: Once the labyrinth is removed, dissection
around the carotid artery is undertaken.
STEP 8: Complete the reconstruction.
The carotid artery is readily identified in the temporal
bone by drilling in the floor of the eustachian tube The principal goal of reconstruction is to achieve a
(identifying the lateral wall of the carotid artery). Once water-tight closure. Small dural defects in the middle
the cochlea is removed, drilling can be performed pos- fossa might be closed with allografts. Temporalis fascia
terior and medial to the carotid artery. Disease around and abdominal fat graft are good choices for a limited
the carotid artery is removed in a piecemeal fashion. In posterior fossa and jugular foramen dural defect. The
our practice philosophy, no attempt is made to resect temporalis muscle flap can be rotated to cover the
the carotid artery. abdominal fat graft and create another layer of closure.
Larger defects, especially in the postradiation setting,
require microvascular tissue transfer.
STEP 7: Jugular bulb resection is performed to eradicate
disease.
Postoperative Care
The morbidity with jugular bulb resection includes These patients are always admitted to an intensive care
damage to cranial nerves IX through XI and the poten- unit for at least one night of close observation.
tial for increased intracranial pressure from venous Eye care is important for patients with facial weak-
outflow clamping. The patient must be made aware of ness or paralysis. Liberal use of eye moisturizers is nec-
these significant morbidities. Preoperative MRI is helpful essary to prevent corneal drying and ulceration.
to demonstrate contralateral sigmoid sinus flow. Voice and swallowing problems need to be diag-
Prior to sigmoid ligation, a retrosigmoid dural inci- nosed and addressed. Close cooperation with a speech
sion is made to evaluate for any intradural disease. The and swallowing therapist is essential. Modified barium
sigmoid sinus is doubly ligated, and the sinus divided swallow (MBS) can be performed when the patient’s
between these ligatures. condition permits. Patients who fail MBS need to have
a gastrostomy tube placed. Vocal fold augmentation or
A tumor that involves the sigmoid sinus may cause a medialization might be required to help with phonation
slow occlusion of the sinus, allowing the contralateral and protection from aspiration.
sinus and collateral circulation to develop. Care must Hospitalization continues until the patient meets cri-
be taken to make sure that the involved sinus is not teria for dismissal. Patients are usually discharged after
the dominant sinus because taking this structure can 7 to 10 days.
result in venous infarction of the brain. In many cases
of suspected venous and carotid artery involvement a Suggested Readings
preoperative angiogram can be helpful in delineating
the anatomy and venous drainage patterns. SJMarzo Leonetti JP, Smith PG, Kletzker GR, Izquierdo R: Invasion
patterns of advanced temporal bone malignancies. Am J
Otol 17:438-442, 1996.
The digastric muscle is divided and the upper jugular
Natarajan SK, Ghodke B, Sekhar LN: Cerebrovascular man-
vein is then ligated. Disease involving the jugular bulb agement in skull base tumors. In Hanna EY, Demonte F,
can then be removed. Tumor debulking in the region of editors: Comprehensive Management of Skull Base Tumors,
the jugular bulb is often very bloody. Extraluminal com- New York, 2009, Informa Healthcare.
pression of the sigmoid (or ligation of the sigmoid) Prasad S, Janecka IP. Efficacy of surgical treatments for squa-
followed by ligation of the jugular can help minimize mous cell carcinoma of the temporal bone: a literature
blood loss in this area. Bleeding continues through the review. Otolaryngol Head Neck Surg 110:270-280, 1994.
SECTION A Thyroid Operations
CHAPTER
Thyroid Lobectomy and Isthmusectomy
46 Author Gary L. Clayman
Commentary by Helmuth Goepfert, Ashok R. Shaha, and Randal S. Weber
Preoperative Considerations Preoperative evaluation of the neck in patients with

Ultrasound with fine needle aspiration cytology is a papillary or medullary thyroid carcinoma is very
requisite in all thyroid surgery. important. Paratracheal lymph nodes at levels VI and
VII are important to evaluate with ultrasound because
clinically these lymph nodes are not palpable. The
Not in all, but certainly in most, for a large goiter needs
jugular chain and lateral neck nodes should also be
no fine-needle aspiration or ultrasound. HGoepfert
evaluated with ultrasound and occasionally with
ultrasound-guided needle biopsy to confirm
Most thyroid lobectomies are performed as a result metastatic disease and help plan the appropriate
of cytologically benign neoplasms, small (less than neck dissection. ARShaha
1.5 cm) differentiated papillary thyroid carcinomas
in young patients, or follicular lesions that cannot Preoperative thyroid functions including analysis of
otherwise be further classified. These surgeries are thyroid-stimulating hormone (TSH) levels are needed in
performed for definitive pathologic diagnosis as well all patients. Biochemically hyperthyroid (suppressed
as treatment. TSH) patients should be diagnosed prior to thyroid
surgery and should be controlled and presented treat-
The evaluation of the thyroid nodule is an important ment options of surgery as well as radioactive iodine
diagnostic subject. Even though ultrasound has made therapy.
a major impact on ease and accuracy of diagnosis,
clinical evaluation is important if the thyroid nodule These patients would not have a lobectomy but a total
appears to be fixed to the central compartment or or almost total thyroidectomy, and fine-needle
hard or with reduced mobility. Ultrasound is helpful aspiration would not be needed. HGoepfert
in evaluating the possibility of malignancy, such
as irregular borders, peripheral halo, punctate
calcification, and hypervascularity. It is also helpful in Preoperative evaluation of vocal cord function and
evaluating the opposite lobe to identify nodules that laryngeal positioning (rotation) should be performed in
are not clinically apparent because treatment may all patients by either indirect or fiberoptic examination.
then need to include total thyroidectomy in selected
individuals. ARShaha Preoperative vocal cord evaluation is extremely
important and not commonly performed in every
institution by every thyroid surgeon. If one vocal
And hopefully there will be a cytologic molecular test
cord is paralyzed, the surgeon should be extremely
in the future that will make this surgery unnecessary.
concerned about the opposite vocal cord. Any injury
HGoepfert
to the opposite recurrent laryngeal nerve may lead
to airway-related issues. Such patients should be
Ultrasound of the lateral necks should be performed extubated carefully and observed for a period of
with all thyroid ultrasounds in the analysis of the lateral time. If there is any injury to the opposite vocal cord,
neck. Suspicious lymph nodes should be cytologically the patient may require reintubation or occasionally
analyzed independent of the thyroid mass size or cyto- tracheotomy. ARShaha
logic diagnosis.
453
454 UNIT VI Thyroid and Parathyroid
Subtle laryngeal dysfunction may require videostro-

boscopic examination to clarify functional laryngeal
issues. Normal functioning recurrent laryngeal nerves
rarely require sacrifice due to the presence of local
malignancy; however, knowledge of their function or
lack thereof may affect the approach to areas of invasive
thyroid malignancy.
Thyroid cartilage
Evaluation of the vocal cord is also important
because the patient’s voice may be normal with
a paralyzed vocal cord. A paralyzed vocal cord Trachea
invariably indicates invasive thyroid carcinoma.
Such patients should be evaluated more critically Incision
clinically, and occasionally radiologically with a
computed tomography (CT) scan to evaluate extent
of the disease. These are the patients in whom
Manubrium of
appropriate evaluation of the trachea is important sternum
to rule out tumor invading the tracheal wall or the
tracheal lumen. If the tumor invades the tracheal
lumen, either clinically with a tracheoscopy or FIGURE 46-1. Incision location and size to accommodate a
radiologically, appropriate arrangements are 2-cm or smaller mass within a normal-sized gland.
necessary for an extended thyroidectomy and
tracheal resection. ARShaha
Despite the paralysis of a unilateral recurrent laryn- it or around it. When healed the incision should rest
geal nerve preoperatively, transection of this paralyzed somewhere in the sulcus of the suprasternal notch area.
nerve should be discussed because the patient will fre- Incisions that eventually fall below the clavicle are less
quently experience a further diminution in the quality cosmetically acceptable than the well-placed cervical
of voice due to acute lack of vocal fold tone as well as incision.
the potential of loss of function of initially unaffected In general, the thyroid isthmus is located over the
arborized branches. cricoid cartilage. A more cephalad incision facilitates the
Although technically thyroid surgery can be per- dissection of the upper pole of the thyroid but may
formed without the assistance of magnification, magni- hinder more inferior dissection of the inferior paratra-
fied surgery of at least 2.5× facilitates safe surgery. cheals and superior mediastinum.
This provides early identification and protects the If the patient has a cervical crease(s), the incision
superior and recurrent laryngeal nerves and their arbo- should be strongly considered for this location. Marking
rized branches from injury and allows both identifica- the incision location with the patient sitting upright
tion and meticulous surgery of the adjacent parathyroid prior to general anesthesia can facilitate the surgeon in
glands. design. Often, some compromise between the cricoid
location, existing cervical creases, and the planned
suprasternal notch location of the cicatrix is required.
Operative Technique In younger patients, the absence of cervical creases
is the usual, and flexion of the neck may facilitate more
STEP 1. With a marking pen, mark the incision’s cepha- optimal incision location in a neck fold with this maneu-
locaudal location with the patient awake and in a seated ver. In younger patients, an incision location approxi-
position (Figure 46-1). mately 2 to 3 cm superior to the sternal notch should
be planned. A 4-0 silk suture strung with tension along
Despite the beautiful anatomic nature of thyroid surgery, this area nicely produces an indentation to mark the
the surgeon must be cognizant that the patient primarily area for incision. The incision length is generally 3.5 to
focuses on incision length, location, design, and healing 4 cm in overall length for open procedures when the
in the assessment of the overall quality of the surgery thyroid mass is 3 cm or less in size. For larger masses,
(barring complications). Optimally the incision should the incision length must be able to accommodate the
be adequate to provide access and visualization for the delivery of the mass and adequate superior and inferior
surgery and delivery of the thyroid and masses within gland visualization.
CHAPTER 46 Thyroid Lobectomy and Isthmusectomy 455
the head by moving the table about 2 feet away

Previously, incisions for thyroidectomy were up to
from the anesthesia machine.
10 cm in length and placed just above the sternum
and clavicles. Over time the incision length has been
reduced to 4 to 5 cm (usually the distance between
STEP 3. The chin is pointing upward toward the ceiling.
the medial edge of the sternocleidomastoid muscles)
for routine cases but may be longer for patients with
goiter or large nodules. By making the incision higher Positioning of the patient on the operating table is
than the suprasternal notch, usually between the crucial. The head should be on the head plate so that
lower edge of the cricoid muscle and the sternal it can be moved up and down as necessary. Three
notch, access to the upper pole and the pyramidal sheets placed in a stack are helpful under the
lobe is facilitated. RSWeber shoulder in the scapula. The scapula is a flat bone,
and a roll is generally not stable. The head should be
extended on the head plate with a mild reverse
Trendelenburg position of the body. Both hands
As the surgeon’s experience increases, thyroid inci-
should be tucked in so that the surgeon and the
sions may decrease in length. Incision length must be
assistant can easily move up and down without
based on several factors. First, it is imperative that
interference. A Foley catheter is rarely necessary
the surgeon have adequate visualization. In general, the
unless total thyroidectomy with neck dissection
incision must extend enough to adequately deliver the
is planned. ARShaha
thyroid itself. For example, a 4-cm thyroid mass requires
at least a 4-cm incision in order to deliver the mass
without spillage. Clearly, smaller thyroid masses can be
STEP 4. Field anesthetic is used with 0.5% mepivacaine
removed though shorter incisions to ultimately about
1 : 200,000 epinephrine.
2 cm (that of the video-assisted thyroidectomy).
This provides postoperative pain management and inci-
sion hemostasis without cautery.
It is important for the surgeon to spend extra time to
An anesthetic also allows postoperative pain man-
formulate the incision for a thyroidectomy. In young
agement with antiinflammatory medication only and
individuals, particularly in females, the thyroid incision
outpatient surgery facilitation.
should be much higher because through the years it is
likely to pull down. Any incision below the clavicle
does not look cosmetically good and may have a I have never used local anesthesia infiltration, except
higher likelihood of developing a hyperplastic scar or a when I did thyroidectomies under local anesthesia in
keloid. The best location is in a skin crease; however, the 1960s. HGoepfert
a skin crease may not be available in younger
patients. The length of the incision depends on the
size of the thyroid nodule; however, if the nodule is STEP 5. The incision is made with a scalpel through to
small, an incision less than 5 cm is appropriate. If the subcutaneous tissues.
the tumor is large or the patient requires a neck
Attention to detail in incising and handling skin reduces
dissection, an extended incision is necessary. If
cicatrix hypertrophy.
the patient is likely to require a neck dissection, a
higher incision in the region of the cricoid cartilage
is helpful to allow dissection of the lymph nodes Proper skin incision in thyroid surgery is critical,
starting at level II to level V. Even with a smaller keeping the knife blade perpendicular to the skin to
incision, thyroidectomy is not very difficult if the achieve satisfactory scaring. It is important to avoid
fascia is separated properly, including mobilization of any cautery burns to the surrounding skin or edges of
the strap muscles. ARShaha the skin. After making the skin incision with the knife
point, electrocautery should be used to cut the dermis
and subcutaneous tissue. However, once the
STEP 2. The patient is positioned with the back section subcutaneous tissue is cut, a flat electrocautery
of the table elevated to reduce venous congestion and should be used because the pointed cautery is likely
the table placed in Trendelenburg to facilitate superior to injure the anterior jugular veins and other important
pedicle visualization (a lounge chair position). veins in front of the thyroid gland. ARShaha
The legs are lowered and compression stockings placed

on all patients. The patient is slightly hyperextended Cutting electrocautery is not a bad option, unless you
in the neck. I leave the patient with the head toward use the “charring” setting. HGoepfert
the anesthesiologist and simply request space around
Thyroid
cartilage
Median raphe of
strap musculature
after Cooley
FIGURE 46-2. Gentle lifting and retraction of the sternothyroid muscle facilitates the rapid
avascular separation of the midline raphe (linea alba) of the strap musculature.
STEP 6. Electrocautery is used to incise the subcutane- STEP 8. The flaps are suspended with the use of 2-0 silk
ous tissues deep to the platysma to the fascia envelop- sutures placed at the very base of the elevated flap with
ing the strap musculature and the communicating a moistened sponge to keep from drying.
anterior jugular veins.
Although some individuals prefer self-retaining retrac-
Although skin flap elevation is generally immediate tors, I have not used them and prefer suture suspension
subplatysmal in neck dissections, in thyroid surgery, to anchored drapes on the patient.
especially in obese individuals (in the midline), elevating
at the level of the investing fascia eliminates the poten-
If the second assistant is available, retractors are very
tial for lipectomy and facilitates identification of the
helpful both in the upper and lower flap areas.
linea alba.
However, a self-retaining Mahorner retractor is useful
for thyroidectomy. If a Mahorner retractor is not
available, standard fish hooks are helpful. ARShaha
STEP 7. The flaps are elevated to the level immediately
above the thyroid notch, superiorly and the sternal
notch, inferiorly.
STEP 9. The linea alba is first identified inferiorly and
incised with the use of electrocautery along its entire
Skin rake tension on the flaps elevated primarily per-
length.
pendicular allows the plane above the anterior jugular
veins and strap musculature to be readily visualized and In most patients the linea alba or median raphe of the
opened with the electrocautery. strap musculature is self-evident. The linea alba is
unquestionably much easier to define first lower in the
neck. Gentle lateral tension of the sternothyroid muscle
with application of the electocautery on the raphe from
Some surgeons do not like to raise the flaps under the immediate suprasternal area to the thyroid notch is
the platysma, even though this is a standard practice. performed to separate these muscles (Figure 46-2).
Surgeons who do not raise the flaps generally cut Communicating branches of the anterior jugular
the strap muscles on either side for better veins may be encountered and controlled with suture
exposure. ARShaha ligatures or a Harmonic or similar type of ultrasonic
device.
procedure, in general, I prefer to address the takedown

Anterior jugular veins are generally asymmetric, or may
of the superior thyroid pedicle first.
be very close to each other in the midline, making
Takedown of a small portion of the sternothyroid
separation of the midline tricky. If there is any injury to
muscle can be performed if there is incomplete visualiza-
the anterior jugular vein, it should be carefully
tion of the pedicle with retraction only. The experienced
separated, clamped, and ligated after transecting the
surgeon will rapidly recognize the anatomic variations
main anterior jugular vein. Occasionally there are
of thyroid location and strap musculature insertions
H-type veins, both in the superior and inferior portions,
that suggest that this release is indicated.
which should be clamped or carefully ligated.
Electrocautery may not work satisfactorily on the
anterior jugular veins. Once the midline is incised, it is
most important to inspect and palpate the tumor In patients with thyroiditis the muscle may adherent
coming out of the thyroid gland and invading the to the surface of the thyroid lobe and elevation
surrounding soft tissues of the neck or sternothyroid must be carefully performed to avoid tearing the
muscle. If it looks like the tumor is adherent to the veins on the surface of the thyroid lobe. For patients
sternothyroid or sternohyoid muscles, these muscles with a large lobe or mass, exposure may be facilitated
should be generously sacrificed for sound oncologic by dividing the most superior and medial fibers of
margins. Once the midline fascia is incised, the best the sternothyroid muscle. This maneuver also
exposure of the thyroid gland is achieved by provides additional exposure to the upper pole
separating the fascia enveloping the thyroid and the vessels. RSWeber
strap muscles. Occasionally the fascia in front of the
sternomastoid may need to be incised, which will give
lateral mobility of the sternomastoid with excellent STEP 12. Gently lifting the superior-most portion of the
exposure of the thyroid gland. This is more important gland allows for identification of a fascial plane envelop-
with large goiters or substernal thyroid tumors. ing the superior vascular pedicle.
Understanding the extrathyroidal extension of the
tumor is necessary to reduce local recurrence and
achieve excellent oncologic margins. I generally like STEP 13. A mosquito hemostat is used to dissect the
to cut the sternothyroid muscle in the upper portion plane beneath the superior thyroid artery and vein and
for better exposure of the superior pole, which is the superior laryngeal nerve is identified deep to these
also helpful to avoid injury to the superior laryngeal structures.
nerve. ARShaha
A small right-angle clamp is my preferred tool.

STEP 10. The sternohyoid and sternothyroid strap HGoepfert
muscles are elevated off of the lateral surface of the
gland with the use of electrocautery.
As the muscles are laterally retracted with army-navy or Branches of the superior laryngeal nerve are frequently
small Richardson’s retractors, the muscles are separated arborized.
from the anterior and lateral surfaces of the thyroid If the superior laryngeal nerve is difficult to visualize,
gland. I prefer to take down the individual vessels of the supe-
In any circumstance when there is a question of strap rior aspect of the lobe in a stepwise fashion to spare
musculature invasion or effacement by the neoplasm, a variants of superior laryngeal nerve anatomy in contrast
“margin” of muscle should be obtained by resecting the to Step 14.
muscle in continuity with the thyroid mass (still attached).
Bipolar electrocautery and microclamps are helpful in I do not routinely attempt to identify the superior
dissection of the superior pole and rest of the thyroid. laryngeal nerve (SLN) but prefer to individually isolate
ARShaha the superior thyroid artery and vein and ligate them
separately as close to the superior pole as possible.
The exception is a very cephalad superior pole that
STEP 11. The superior vascular pedicle is visualized by places the SLN in jeopardy. In this instance I attempt
retraction of the sternothyroid and sternohyoid muscles to identify the SLN before ligating the vessels. Also I
both superiorly and laterally. remain vigilant for the superior parathyroid gland
that may be high up on the posterior aspect of the
Although I leave all patients and their neoplasm to superior pole. RSWeber
dictate the ultimate progression (order of events) in their
Superior
thyroid a./v.
Inferior
thyroid v.
after Cooley
after Cooley
FIGURE 46-3. The superior vascular pedicle is clamped and FIGURE 46-4. The superior pole and lateral surface of the
sectioned once the superior laryngeal nerve is identified deep gland have been mobilized. Here, the inferior thyroid vein is
to those structures. sectioned at the capsule of the inferior thyroid gland.
STEP 14. A small right-angle clamp allows both vessels

to be isolated, clamped, and then sectioned with elec- from the medial to lateral end just on the surface of
trocautery (Figure 46-3). the thyroid gland. This helps immensely in avoiding
injury to the superior laryngeal nerve. I generally like to
Most recently I have used Harmonic technology to
tie the superior thyroid vessels doubly because if the
perform thyroidectomy, thus avoiding suture ligatures.
first tie breaks, the superior thyroid vessels will be
I have always avoided the use of surgical clips in thy-
retracted high in the neck and identifying these
roidectomy and neck dissections due to their effect on
vessels and controlling the bleeding can be quite an
surveillance with both computerized axial tomography
undertaking. ARShaha
as well as ultrasound.
Even though there are a variety of different ways to STEP 15. With the superior vascular pedicle transected,
expose the superior thyroid pedicle and ligate the the superior lobe is mobilized in the capsular plane of
vessels individually, it is important to carefully expose the thyroid along its medial, lateral, and ventral surfaces
this area, avoid any bleeding from the minor vessels, such that the superior pole should be totally mobile.
and ligate the superior thyroid pedicle close to the
thyroid gland in an effort to avoid any injury to the
superior laryngeal nerve. The superior laryngeal nerve STEP 16. The lateral capsular surface of the gland con-
is a thin and small nerve that is not seen in almost tinues the dissection.
50% of thyroidectomies. The best approach is to
place a small blunt clamp on the superior pole of the Small capillaries and neovascularization are frequently
thyroid gland and pull the thyroid laterally and encountered and are controlled with bipolar electrocau-
inferiorly. This opens up a space medial to the tery or similar means.
superior thyroid vessels away from the constrictor
muscles of the pharynx. This is the Joll’s triangle,
which should be exposed. Once this triangle and STEP 17. The middle and inferior thyroid veins are usually
potential space are exposed, the dissection should be dominant and are transected along the gland’s capsule
done parallel to the superior thyroid vessels and not (Figure 46-4).
perpendicular to it. A blunt clamp should be used to
dissect this area. Once the superior thyroid vessels
are clearly identified, the clamp should be passed STEP 18. As the thyroid gland is dissected, it is mobilized
more medially, with the middle thyroid vein transected
Superior
parathyroid
gland
Inferior
thyroid a.
Middle
thyroid v. Inferior
parathyroid
gland
after Cooley
FIGURE 46-6. The right thyroid lobe is medialized with either

after Cooley a moistened sponge or vascular clamps to provide access for
visualizing the recurrent laryngeal nerve and inferior
parathyroid gland.
FIGURE 46-5. As the dissection of the thyroid transitions to a
more posterior lateral approach, the middle thyroid vein is
sectioned along the gland capsule.
along the posterior lateral surface of the gland

(Figure 46-5).
Carmalt forceps or moistened sponges help medialize

the gland and allow for adequate visualization of the
posterolateral component of the dissection. Meticulous
dissection and capsular excision technique facilitate
maintaining vascularity of the parathyroid glands.
Retraction of the thyroid lobe medially can be done

with the fingers, blunt hemostats, or tissue clamps
such as Ellis or Babcock clamps. The Kocher clamps Superior
are likely to traumatize the thyroid gland and cause parathyroid gland
bleeding from the surface of the gland. ARShaha
Inferior
thyroid a.
STEP 19. With the gland medialized, the inferior thyroid Inferior
parathyroid
artery and the inferior parathyroid gland can usually be gland
visualized (Figure 46-6).
STEP 20. Bipolar electrocautery and sharp dissection is

used to mobilize the parathyroid gland(s) on their vas-
cular pedicle(s) (Figure 46-7).
after Cooley
I prefer to use bipolar electrocautery on very small, fine
vessels at very low settings to minimize parathyroid FIGURE 46-7. This capsular-located inferior parathyroid
gland vascular compromise. gland is separated from the lateral thyroid lobe.
The recurrent laryngeal nerves arise from the vagus

Identification and preservation of the parathyroid
nerve, on both sides, and pass beneath the vessels that
glands are extremely important in patients undergoing
are derived from the primitive fourth aortic embryologic
thyroidectomy. This is most crucial in these patients
arch. Therefore the right recurrent laryngeal nerve passes
because the complication of permanent
beneath the right subclavian artery, whereas the left
hypoparathyroidism may be difficult to handle over a
recurs at the ligamentum arteriosum of the aortic arch.
long period and extremely distressing to the patient.
Both nerves then ascend toward the larynx in the approx-
Every effort should be made to preserve the
imate area of the tracheoesophageal groove. This under-
parathyroid glands that are identified with their
standing is critical in safe dissection in that the recurrent
own blood supply, avoiding any devascularization
laryngeal nerves are never at risk in the superior medias-
of the parathyroid glands. The incidence of
tinum in the dissection of structures lateral to the carot-
hypoparathyroidism is directly proportional to the
ids, aortic arch, innominate, or subclavian arteries.
extent of thyroidectomy and inversely proportional to
Due to their sites of recurrence (redirection), the left
the surgeon’s experience. The majority of parathyroid
recurrent laryngeal nerve assumes a course ascending
glands receive their blood supply from the inferior
relatively longitudinally parallel lateral to the border of
thyroid artery; however, the superior parathyroid gland
the trachea, whereas the right recurrent laryngeal nerve
may get its own blood supply through the superior
tends to be directed more angularly as it ascends medi-
thyroid vessels. Careful dissection should be done at
ally to the larynx. Depending on the lobe size and loca-
the superior pole, both to identify the superior
tion, the nerves may pass laterally or primarily beneath
parathyroid gland and to carefully preserve it with its
the lobes as they approach the cricothyroid membrane.
blood supply. Avoid electrocautery injury to the
In meticulous microdissection, the recurrent laryngeal
parathyroid glands and excessive irrigation. Suction
nerves, proximally, possess a wide range of arborized
may damage the glands by causing a surface
branches that may originate centimeters from the laryn-
hematoma, including excessive retraction of the soft
geal insertion. One or more of the medialized proximal
tissue of the neck and parathyroid glands. If for any
branches usually pass immediately posterior to the
reason the parathyroid gland appears to be
lateral suspensory ligament of the thyroid (Berry’s).
devascularized or changes color considerably,
Variability is the rule here, and instances of anterior
every effort should be made to autotransplant
branching of the recurrent laryngeal nerve as well as
the parathyroid gland. However, prior to
branches penetrating into thyroid parenchyma in the
autotransplantation, it is very important to send a
vicinity of the suspensory ligament can be present.
small piece of tissue to confirm the tissue is actually
the parathyroid gland and not metastatic thyroid
cancer or a lymph node. ARShaha The recurrent laryngeal nerve may be injured in the
tracheoesophageal groove, at the crossing of the
inferior thyroid artery, or near Berry’s ligament.
STEP 21. The recurrent laryngeal nerve is identified Extensive paratracheal dissection may lead to injury,
generally within the area of the inferior parathyroid either through traction or direct irritation of the
gland. recurrent laryngeal nerve during dissection in the
tracheoesophageal groove. The majority of the time
Its location, whether deep or superficial to the inferior the recurrent laryngeal nerve is behind the inferior
thyroid artery, is not constant or totally predictable. For thyroid artery; however, approximately 25% of the
practical purposes, the nerve may be identified caudal time the nerve is anterior to the inferior thyroid artery
to the inferior parathyroid gland but this may lead to a and anatomically more likely to be injured during
higher risk of compromise to the parathyroid gland’s dissection. The most common injury to the recurrent
vascular supply. I generally identify the nerve and its laryngeal nerve is near Berry’s ligament. This is most
arborized branches immediately in the vicinity of the likely due to traction, use of electrocautery, or bipolar
inferior parathyroid gland once it has been lateralized. cautery very close to the recurrent laryngeal nerve.
Most of the time the injury occurs in an effort to
The inferior parathyroid gland is usually in proximity to control bleeding from the branches of the inferior
the convexity of the inferior pole of the thyroid. Once thyroid artery near the Berry’s ligament. These vessels
identified it should be separated from the thyroid on may get retracted behind the recurrent laryngeal nerve
its superior surface and dissected off of the gland. and the nerve may be injured in an effort to control
Care must be taken to avoid the inferior aspect of the bleeding. Because the dissection is done in the
parathyroid gland because its blood supply enters in tracheoesophageal groove area, every effort should be
this location. In patients with thyroiditis, dissection and made to identify the recurrent laryngeal nerve. If for
preservation of the blood supply are difficult and if the any reason the recurrent laryngeal nerve is not
gland is devitalized it should be reimplanted. RSWeber identifiable in the tracheoesophageal groove, a diligent
search should be made for a nonrecurrent recurrent

laryngeal nerve, which may occur in less than 1% of
individuals. If the patient had a previous CT scan of
the chest, this should be evaluated to rule out arteria
lusoria. If the innominate artery is behind the
esophagus, invariably the patient will have a
nonrecurrent recurrent laryngeal nerve. Injury to this
nerve is best avoided by knowing the anatomy and
Berry’s ligament
careful dissection in the posterior portion of the
Sup.
thyroid gland near Berry’s ligament. ARShaha parathyroid
gland
Thyroid
Although great attention has been placed on the Recurrent
gland
relationship of the inferior thyroid artery to the recur- laryngeal n.
rent laryngeal nerve, basically the artery may present Inf. parathyroid
superficial, posterior, or branch in both locations sur- gland
rounding the recurrent laryngeal nerve. Independent of
the anatomic configuration, the recurrent laryngeal
nerve should be anatomically identified prior to transec-
tion of these vascular structures.
The nonrecurrent laryngeal nerve can only be found
on the right side and is present in about 1% of the
population. This occurs due to an anomalous right sub-
clavian artery that is retroesophageal. In such circum-
stances the right subclavian artery arises as the final
branch of the aortic arch, originating behind the esoph-
agus and terminating into the supraclavicular and axil-
FIGURE 46-8. The most anterior branch of the recurrent
lary regions. The right common carotid artery arises
laryngeal nerve has been preserved and a mosquito hemostat
directly from the aortic arch in these circumstances and
placed on the vascularized suspensory ligament prior to
therefore the nerve follows a direct course from the sectioning.
vagus, traversing posterior to the common carotid artery
and assuming a variable horizontally angulated course
beneath the thyroid lobe into the laryngeal inlet. The parathyroid glands frequently are situated along
The philosophy of protecting the nerve by solely dis- the course of the recurrent laryngeal nerves and preser-
secting on the thyroid capsule does not necessarily vation of their function is requisite by maintaining their
ensure protection of the nerve from injury. In some adequate lateral blood supply. The clear identification
circumstances, small anterior branches of the recurrent of the recurrent laryngeal nerves and distal dissection of
laryngeal nerves may penetrate the capsule especially in these nerves allow safe division of the longitudinally and
the vicinity of Berry’s ligament. medially directed vascular supply to these glands, which
is mandated for their normal function.
Generally the thyroid gland is pulled medially, both to
identify the recurrent laryngeal nerve and expose the
area of Berry’s ligament. Overpulling of the thyroid STEP 22. From a lateral to medial approach, the branches
gland may lead to stretch and traction on Berry’s of the recurrent nerve are identified and small vessels
ligament, where the nerve may become tented, are controlled with bipolar electrocautery and larger
causing traction injury to the nerve. ARShaha vessels are managed by ligatures (Figure 46-8).
Following lateralization of the inferior parathyroid Gentle cottonoid tracing of the nerve allows for atrau-
gland, I reflect the inferior pole of the thyroid gland matic dissection along the nervous sheath.
medially as I ligate the terminal branches of the inferior Thyroid tissue frequently invests into the area of the
thyroid artery and the draining veins. The gland is cricothyroid membrane laterally in the area of Berry’s
reflected superiorly and medially and the RLN is ligament, thus making complete removal of all thyroid
identified within 1 to 2 cm inferior to the Berry’s tissue unreasonable in some patients due to the inter-
ligament. One must be constantly vigilant for digitated nature of their recurrent laryngeal nerve
premature arborization of the RLN and all branches branches. In other instances, the ligament may be
are preserved. RSWeber bipolar cauterized or suture ligatured with minimal to
no thyroid tissue recognized in this area.
Generally in a patient undergoing thyroid lobectomy

the isthmus is cut with multiple clamps and suture
ligated or oversewn with Vicryl stitches. Recently the
Harmonic scalpel has been used to transect the
isthmus, which is quite helpful and avoids any
bleeding from the isthmic area. There are always small
vessels on the surface of the cricoid cartilage that
should be carefully identified, ligated, or cauterized
during the separation of the pyramidal lobe. The
pyramidal lobe may ascend high up in the neck, even
up to the hyoid. Generally the dissection is done up to
the thyroid notch and the remaining pyramidal lobe is
after Cooley
transected. ARShaha
Right thyroid
lobe and The availability of nerve monitoring has been a mixed
isthmus
blessing, and in 41 years of surgical practice I have
never used it. HGoepfert
I use the nerve integrity monitor (NIM) on reoperative

cases and for large goiters. The monitor is valuable for
FIGURE 46-9. The contralateral junction of the isthmus and establishing that the nerve is functioning from an
left thyroid lobe is demonstrated to be clamped and can then electrical standpoint at the completion of the
be oversewn. dissection. The NIM should not be used as a tool to
locate the nerve because this is an anatomic
dissection. At no time should any structure be
sacrificed until conclusively identified, regardless of
whether or not electrical stimulation is possible. If the
NIM has not been used and one wishes to assess the
RLN with stimulation, it may be accomplished in the
Tiny vessels near the recurrent laryngeal nerve may following manner: identify the RLN and place a finger
be ligated with dissolving sutures, such as Vicryl. behind the larynx and palpate the cricoarytenoid joint;
Dissection on the surface of the recurrent laryngeal with the disposable nerve stimulator set at 0.5 mA,
nerve should be done with the blunt end rather than touch the probe to the RLN and if the nerve is intact an
the tip of the clamp. The blunt belly of the clamp immediate twitch of the arytenoid will be palpable. This
should be used to dissect on the surface of the is highly sensitive to ascertain functional capacity of
recurrent laryngeal nerve. This will both avoid injury to the nerve to conduct electrical energy. RSWeber
the nerve and allow careful isolation of tiny vessels in
front of the recurrent laryngeal nerve. ARShaha
STEP 24. The pyramidal lobe and delphian lymph node
are mobilized with the thyroid isthmus (Figure 46-10).
STEP 23. The pretracheal fascia is entered and electro-
cautery (on a pure cutting setting) can be used to mobi- In large thyroid lobes or when there is a short neck it
lize the thyroid to the contralateral side of the isthmus might be helpful to first divide the isthmus of the
(Figure 46-9). gland, possibly including the pyramidal lobe, and
Once the medial-most branch of the recurrent (or non- elevating some of the thyroid lobe off the trachea from
recurrent nerve) is identified, the pretracheal fascia can medial to lateral, staying short of getting into the
be safely used as a dissection plane. tracheoesophageal groove. HGoepfert
The recurrent laryngeal nerve, if monitored, can be
stimulated with a minimal setting of 0.5 to up to 0.9 mA. The fascia and the thyroglossal remnant area are freed
Although I have not routinely used nerve monitoring, I with the use of electrocautery starting superiorly at the
have begun to use monitoring for resident and fellow inferior level of the hyoid bone and connecting inferi-
education. It has not, however, altered my surgical tech- orly to the isthmus dissection. In some instances, the
nique or discontinued completion of thyroid surgery tract and pyramidal remnants may be prominent and in
based on nerve stimulation criteria. other instances they may be vestigial.
Pyramidal lobe
of thyroid gland
Superior
parathyroid
gland
after Cooley
Recurrent
laryngeal n. Left lobe of
thyroid gland
Inferior
parathyroid
gland
FIGURE 46-10. The pyramidal lobe is removed even if only a

vestigial remnant is noted.
FIGURE 46-11. Postexcision surgical site with preservation of
superior and recurrent laryngeal nerves and their arborized
branches and both inferior and superior parathyroid glands.
The dissection should be done on the surface of the
cricothyroid membrane to identify the delphian node,
which is noted in approximately 25% of patients. If the
delphian node appears to be suspicious, it should be Even though the authors have suggested that wounds
sent for frozen section and if positive for metastatic should be thoroughly irrigated, I generally irrigate
thyroid carcinoma, then extended paratracheal minimally for fear of damaging the parathyroid glands
dissection should be considered, including dissection or their blood supply. Prior to closure of the wound,
of levels VI and VII. ARShaha after removal of the specimen, the Valsalva maneuver
should be undertaken to see if there is any minor
bleeding from vessels in the thyroid bed. The
STEP 25. The contralateral side of the isthmus is paratracheal area, the jugular node area, and the
transected. thymic and superior mediastinal areas should be
evaluated to see if there are any suspicious lymph
Prior to Harmonic surgical techniques, the contralateral
nodes. I generally like to use Avitene or Surgicel in the
side of the isthmus was clamped, cut with cautery, and
thyroid bed. Only a few stitches should be placed in
then oversewn for hemostasis with a running locked
the midline because if the midline is closed watertight,
absorbable suture. I have found that the Harmonic tech-
the hematoma may be contained under the strap
nology offers complete homeostasis with care to protect
muscles, leading to airway distress rather than
the tracheal structures from thermal injury by directing
allowing the blood to accumulate in the subcutaneous
the insulated portion to protect the airway.
area. At the time of closure make every effort to
avoid injury to the anterior jugular veins, which
In my opinion, if the cautery in cutting mode and are very close to the free border of the strap
bipolar is on hand, the oversewing of the isthmus is muscles. ARShaha
not needed. HGoepfert
STEP 27. The strap muscles are reapproximated in the

STEP 26. The specimen is removed, the wound is thor- midline with one or two interrupted absorbable sutures.
oughly irrigated with sterile water, and all areas are
inspected for homeostasis (Figure 46-11).
STEP 28. Meticulous closure of subcutaneous tissues
Bipolar electrocautery is used as required. The wounds
and skin is performed with fine attention to detail.
are not drained. The paratracheal area is inspected both
with cottonoid displacement as well as digital palpation I tend to use absorbable suture in a subcuticular fashion
for undiagnosed paratracheal pathology. and further apply adhesive and Steri-strips as well.
discharged on antiinflammatory pain medication, with

The platysma should be approximated very carefully,
narcotics only for breakthrough discomfort.
generally with absorbable sutures. This is the tissue
that will hold the skin together much better than skin
stitches or subcuticular stitches. ARShaha
At the time of extubation it is very important to
coordinate with the anesthesiologist to avoid bucking
In small incisions, 1 to 3 mm of traumatized skin can on the endotracheal tube. This may raise the
be excised to prevent cicatrix hypertrophy. intrathoracic pressure, causing bleeding. ARShaha
There are different ways to close the wound. It may

No laboratory studies are required. The patient’s
be closed with subcuticular dissolvable stitches such
first outpatient follow-up is at 1 week for pathology
as Vicryl or Monocryl, a subcutaneous nylon or
review, wound inspection, and further instruction on
Prolene stitch may be placed, which is generally
wound care.
removed in 3 to 4 days. Some surgeons prefer to use
small clips with removal of the clips in 2 to 3 days,
then applying Steri-strips. I generally prefer dissolvable
Monocryl sutures with skin approximated by When patients are seen during follow-up a week after
Steri-strips. ARShaha surgery, they are generally given advice regarding
wound care. Vitamin E may be applied 10 days after
surgery. Several other skin care preparations are
Postoperative Care available, such as Scar Guard and Mederma;
however, none of them has proven to be of greater
Thyroid lobectomies and isthmusectomies are per- benefit. ARShaha
formed as outpatient procedures. The patients are
CHAPTER
Subtotal and Total Thyroidectomy
Commentary by Maisie Shindo, Gregory W. Randolph, and Gianlorenzo Dionigi
Preoperative Considerations tumor smaller than 1.5 cm, patient younger than 45
Ultrasound with fine-needle aspiration cytology is a years of age), one could consider hemithyroidectomy,
requisite in all thyroid surgery. Subtotal thyroidectomy not subtotal. If a hemithyroidectomy is performed and
is largely for historical reference. Subtotal thyroidecto- the contralateral side has not been dissected, having
mies were primarily performed for cytologically benign to go back and do a completion thyroidectomy, should
neoplasms, small (less than 1.5 cm) differentiated papil- it be necessary, does not increase surgical risks
lary thyroid carcinomas in young patients, or follicular because the surgical field has not been violated.
lesions that cannot otherwise be further classified. These Also, if one is performing thyroidectomy for an
surgeries are performed for definitive pathologic diag- indeterminate follicular lesion, the procedure should be
nosis as well as treatment. The surgical management of hemithyroidectomy rather than subtotal thyroidectomy,
thyroid malignancies remains total thyroidectomy, and again for the previously stated reason. My statements
among low-risk patients possessing less than 1.5-cm are also supported by the most recent American
malignancies, hemithyroidectomy can be considered. Thyroid Association (ATA) Management Guidelines for
patients with thyroid nodules and cancer (see Cooper
et al, 2009). I think it would be better to perhaps
Generally we prefer to perform either lobectomy or
separate out the indications for total thyroidectomy
total thyroidectomy. Revision surgery, when it is
and subtotal thyroidectomy. MShindo
necessary, in a thyroid bed with thyroid tissue left in
place can be difficult. GWRandolph and GDionigi
Ultrasound of the lateral necks should be performed
with all thyroid ultrasounds in the analysis of the lateral
neck. Suspicious lymph nodes should be cytologically
In my opinion, there are only few indications for
analyzed independent of the thyroid mass size or cyto-
“subtotal” thyroidectomy. It can be performed in the
logic diagnosis.
rare situation of a benign compressive goiter with
bilateral nodules where the compressive side already
has vocal cord paralysis. In this setting, one would In patients with fine-needle aspiration–proven papillary
really want to minimize the risk of paralyzing the carcinoma, we prefer ultrasound and computed
functioning contralateral vocal cord, and therefore it tomography (CT) scan with contrast given the
would be justified to leave a significant volume of improved sensitivity of this preoperative radiographic
thyroid tissue to protect that nerve. Subtotal algorithm in the detection of central neck nodal
thyroidectomies should not be performed for any disease. GWRandolph and GDionigi
thyroid cancer or follicular neoplasm because if there
is any chance that one may have to subsequently Although I have rarely performed subtotal thyroi
administer radioactive iodine treatment, the amount of dectomies in the management of multinodular goiters,
thyroid tissue left behind will reduce the effectiveness in areas of the globe of underserved populations with
of the radioactive iodine. In other words, most of the limited medical and pharmaceutical access, the benefit
iodine administered will go to the residual thyroid of a small amount of retained functioning thyroid tissue
tissue rather than to metastatic site(s). With too much and easily maintained parathyroid functioning tissue
thyroid volume left, one may need to return for should not be underestimated.
completion thyroidectomy, which may significantly Preoperative thyroid functions including analysis of
increase complications because of scar tissue that thyroid-stimulating hormone (TSH) levels are needed
would have resulted in the surgical field on that side in all patients. Biochemically hyperthyroid (suppressed
from prior partial dissection. Therefore, in general, the TSH) patients should be diagnosed prior to thyroid
consensus for treatment of thyroid cancer is near-total surgery and should be controlled and presented treat-
or total thyroidectomy. In the low-risk patient (i.e., ment options of surgery as well as radioactive iodine
therapy.
465
TSH assessment is of course necessary prior to CT

scan and with contrast. GWRandolph and GDionigi
Preoperative evaluation of vocal cord function

and laryngeal positioning (rotation) should be per-
formed in all patients by either indirect or fiberoptic
examination.
Subtle laryngeal dysfunction may require videostro- Thyroid cartilage
issues. Normal functioning recurrent laryngeal nerves
rarely require sacrifice due to the presence of local Trachea
malignancy; however, knowledge of their function or
lack thereof may affect the approach to areas of invasive
Incision
thyroid malignancy.
Despite the paralysis of a unilateral recurrent laryn-
geal nerve preoperatively, transection of this paralyzed
nerve should be preoperatively discussed because the Manubrium of
patient will frequently experience a further diminution sternum
in the quality of voice due to acute lack of vocal fold
tone as well as the potential of loss of function of ini-
FIGURE 47-1. Location of incision.
tially unaffected arborized branches.
We absolutely agree with this statement. Often a nerve and delivery of the thyroid and masses within it or
associated with preoperative glottic paralysis may still around it. With time, the healed the incision should rest
retain some intraoperative electrical stimulability with somewhere in the sulcus of the suprasternal notch area.
neural monitoring assessment. The resection of such a Incisions that eventually fall below the clavicle are less
nerve often results in further decrease in voice and cosmetically acceptable than the well-placed cervical
swallowing function. GWRandolph and GDionigi incision.
In general, the thyroid isthmus is located over the
cricoid cartilage. A more cephalad incision facilitates the
Although technically thyroid surgery can be per- dissection of the upper pole of the thyroid but may
formed without the assistance of magnification, magni- hinder more inferior dissection of the inferior paratra-
fied surgery of at least 2.5× facilitates safe surgery. This cheal area and superior mediastinum.
provides early identification and protects the superior If the patient has a cervical crease(s), the incision
and recurrent laryngeal nerves and their arborized should be strongly considered for this location. Marking
branches from injury and allows both identification and the incision location with the patient sitting upright
meticulous surgery of the adjacent parathyroid glands. prior to general anesthesia can facilitate the incision
design.
We agree that magnification at surgery is
An incision placed in a cervical crease looks much
tremendously helpful. GWRandolph and GDionigi
better than one in the sulcus of the suprasternal
notch, even if it is placed higher. My approach to
incision placement is to determine if there is a
substernal component. If there is, the incision should
Operative Technique be placed in that sulcus of the suprasternal notch to
allow adequate access to the mediastinum. If there is
no substernal component, then determine where the
STEP 1. With a marking pen, mark the incision’s cepha-
patient’s isthmus is and look for a prominent crease at
locaudal location with the patient awake and in a seated
that level. If there is no visible prominent crease, go
position (Figure 47-1).
through the maneuvers that the author describes (i.e.,
Despite the beautiful nature of thyroid surgery, the flex neck) and place the incision as close to the
surgeon must be cognizant that patients primarily focus isthmus as possible. MShindo
on incision length, location, design, and healing in their
assessment of the overall quality of their surgery (barring Often some compromise between the cricoid loca-
complications). Optimally, the incision should be ade- tion, existing cervical creases, and the planned supra-
quate to provide access and visualization for the surgery sternal notch location of the well-healed incision site is
CHAPTER 47 Subtotal and Total Thyroidectomy 467
required. In younger patients, the absence of cervical

creases is usual, and flexion of the neck may facilitate
more optimal incision location in a neck fold with this
maneuver. In younger patients, an incision location
approximately 2 to 3 cm superior to the sternal notch
1:200,000 epinephrine.
should be planned.
This provides both postoperative pain management and
incision hemostasis without cautery.
This is because the incision may migrate inferiorly
Anesthetic also allows postoperative pain manage-
below the suprasternal notch as the patient ages.
ment with antiinflammatory medication only and out-
MShindo
patient surgery facilitation.
A 4-0 silk suture strung with tension along this area

nicely produces an indentation to mark the area for STEP 5. The incision is made with a scalpel through to
incision. The incision length is generally 3.5 to 4 cm in the subcutaneous tissues.
overall length for open procedures when the thyroid
mass is 3 cm or less in size. For larger masses, the inci- Attention to detail in incising and handling skin reduces
sion length must be able to accommodate the delivery cicatrix hypertrophy.
of the mass and have adequate superior and inferior
gland visualization.
STEP 6. Electrocautery is used to incise the subcutane-
In general we like to avoid placing the scar in an ous tissues deep to the platysma to the fascia envelop-
indented, scaphoid suprasternal notch, fearing ing the strap musculature and the communicating
widening of the scar in this area. An overarching issue anterior jugular veins.
of importance in incision placement is that the scar
be placed in or parallel to a normal skin crease Although skin flap elevation is generally immediate sub-
line. GWRandolph and GDionigi platysmal in neck dissections, in thyroid surgery, espe-
cially in obese individuals, (in the midline) elevating at
Incision length must be based on several factors. the level of the investing fascia eliminates the potential
First, it is imperative that the surgeon have adequate for lipectomy or searching for the linea alba.
visualization. In general, the incision must extend
enough to adequately deliver the thyroid itself. For
example, a 4-cm thyroid mass would require at least a STEP 7. The flaps are elevated to the level immediately
4-cm incision in order to deliver the mass without spill- above the thyroid notch superiorly, and the sternal notch
age. Clearly, smaller thyroid masses can be removed inferiorly.
though shorter incision lengths to ultimately about 2 cm
(that of the video-assisted thyroidectomy). Skin rake tension on the flaps elevated primarily per-
veins and strap musculature to be readily visualized and
STEP 2. The patient is positioned with the back section opened with the electrocautery.
of the table elevated to reduce venous congestion and
the table placed in Trendelenburg to facilitate superior
pedicle visualization (a lounge chair position). STEP 8. The flaps are suspended with the use of 2-0 silk
sutures placed at the very base of the elevated flap with
The legs are lowered and compression stockings placed a moistened sponge to keep from drying.
on all patients. The patient is slightly hyperextended in
the neck. I leave the patient with the head toward the Although some individuals prefer self-retaining retrac-
anesthesiologist and simply request space around the tors, I have not used them and prefer suture suspension
head by moving the table about 2 feet away from to anchored drapes on the patient.
the typical bed or anesthesia room configuration.
We agree with all of these important points regarding STEP 9. The linea alba is identified inferiorly and incised
patient positioning. It is essential that both the with the use of electrocautery.
surgeon and anesthesiologist jointly assess that
the patient’s head is adequately supported after In most patients, the linea alba or median raphe of the
the positioning. GWRandolph and GDionigi strap musculature is self-evident. The linea alba is
STEP 11. The superior vascular pedicle is visualized by

retraction of the sternothyroid and sternohyoid muscles
both superiorly and laterally.
Although I leave each patient and his or her neoplasm

to dictate the ultimate progression (order of events) in
their procedure, in general, I prefer to address the take-
down of the superior thyroid pedicle first.
Takedown of a small portion of the sternothyroid
muscle can be performed if there is incomplete visualiza-
tion of the pedicle with retraction only. The experienced
surgeon will rapidly recognize the anatomic variations
Median raphe of of thyroid location and strap musculature insertions
strap musculature that suggest that this release is indicated.
We generally prefer to leave the superior pole as a last

after resort in thyroid surgery. We think the more fully
Cooley mobilized thyroid lobe can be downwardly displaced,
more effectively allowing the dissection of the superior
pole vessels away from the external branch of the
superior laryngeal nerve. This maneuver is performed
FIGURE 47-2. Gentle lifting and retraction of the after the superior parathyroid gland is reflected off of
sternothyroid muscle facilitates the rapid avascular separation the thyroid’s superior pole. GWRandolph and GDionigi
of the midline raphe (linea alba) of the strap musculature.
neck. Gentle lateral tension of the sternothyroid muscle STEP 12. Gently lifting the superior-most portion of the
with application of the electrocautery on the raphe from gland allows for identification of a fascial plane envelop-
the immediate suprasternal area to the thyroid notch is ing the superior vascular pedicle.
performed to separate these muscles (Figure 47-2).
Communicating branches of the anterior jugular
veins may be encountered and controlled with suture
STEP 13. A mosquito hemostat is used to dissect the
ligatures or a Harmonic or similar type of ultrasonic
plane beneath the superior thyroid artery and vein, and
device.
the superior laryngeal nerve is identified deep to these
structures.
STEP 10. The sternohyoid and sternothyroid strap Branches of the superior laryngeal nerve are frequently
muscles are elevated off of the lateral surface of the quite arborized.
thyroid gland bilaterally with the use of electrocautery. If the superior laryngeal nerve is difficult to visualize,
I prefer to take down the individual vessels of the supe-
As the muscles are laterally retracted with army-navy or rior aspect of the lobe in a stepwise fashion to spare
small Richardson’s retractors, the muscles are separated variants of superior laryngeal nerve anatomy in contrast
from the anterior and lateral surfaces of the thyroid to Step 14.
gland.
In any circumstance when there is even a question
of strap musculature invasion or effacement by the neo- Neural stimulation is very helpful in identifying the
plasm, a “margin” of muscle should be obtained by external branch of the superior laryngeal nerve. The
resecting the muscle in continuity with the thyroid mass nerve stimulator can be run across the inferior
(still attached). Depending on the mass location, usually constrictor at the level of the superior pole to identify
a portion of the sternothyroid muscle can be easily left electrically the external branch of the superior
in continuity with the thyroid mass. laryngeal nerve. When stimulated, this nerve results in
The strap muscles are much easier to elevate off of a discrete contraction of the cricothyroid muscle and
the gland toward the opposite side that the surgeon is typically gives a laryngeal electromyographic waveform
standing. To facilitate the ipsilateral elevation of these of small amplitude and short latency. GWRandolph
muscles, the bed can be temporarily rotated toward the and GDionigi
primary surgeon.
Superior
thyroid a./v.
after Inferior
Cooley thyroid v.
after
Cooley
FIGURE 47-3. The superior vascular pedicle is clamped and FIGURE 47-4. As the dissection of the thyroid transitions to a
sectioned once the superior laryngeal nerve is identified deep more inferior and then posterior lateral approach, the inferior
to those structures. thyroid vein is sectioned along the gland capsule.
STEP 14. A small right-angle clamp allows both vessels muscle. The distal course of the recurrently laryngeal
to be isolated, clamped, and then sectioned with elec- is in proximity to this area. Therefore, at this point, go
trocautery (Figure 47-3). laterally as described in the next step and identify the
recurrent nerve. MShindo
Suture ligature or Harmonic control of these vessels is
equivalent. Harmonic instrumentation allows rapid and
efficient control of these vessels but must be carefully
STEP 16. The lateral capsular surface of the gland con-
oriented to place the insulated portion toward the supe-
tinues the dissection.
rior laryngeal nerve.
I have always avoided the use of surgical clips in Small capillaries and neovascularization are frequently
thyroidectomy and neck dissections due to their effect encountered and are controlled with bipolar electrocau-
on surveillance with both computerized axial tomogra- tery or similar means.
phy as well as ultrasound.
STEP 17. The middle and inferior thyroid veins are usually
STEP 15. With the superior vascular pedicle transected, dominant and are transected along the gland’s capsule
the superior lobe is mobilized in the capsular plane of (Figure 47-4).
the thyroid along its medial, lateral, and ventral surfaces
such that the superior pole should be totally mobile.
We do not rely on the Harmonic scissors to control
the middle thyroid vein if it is of significant caliber.
The superior parathyroid gland may be located along
GWRandolph and GDionigi
the thyroid gland fascia and care should be used in
preserving these glands if they are in this location.
STEP 18. As the thyroid gland is dissected, it is mobilized
more medially, with the middle thyroid vein transected
Regarding mobilization of superior pole, when along the posterior lateral surface of the gland.
dissecting inferiorly along the medial aspect of the
superior pole, dissection should stop as one Carmalt retractors or moistened sponges help medialize
approaches the inferior border of the cricothyroid the gland and allow for adequate visualization of the
posterolateral component of the dissection.
Meticulous dissection and capsular excision tech-

nique facilitates maintaining vascularity of the parathy-
roid glands.
The hand retracting the thyroid lobe, providing cranial

retraction to some degree as well as rotation over the
trachea medially, grasps the thyroid with a unfolded
sponge to improve traction. This medial retraction of
the gland opposes the lateral strap muscle retraction
and serves to open up the lateral thyroid region.
Recurrent Thyroid
laryngeal n. gland
Inf. parathyroid
STEP 19. With the gland medialized, the inferior thyroid gland
artery and the inferior parathyroid gland can usually be
visualized.
I tend to medialize the gland with a moistened sponge

and countertraction. Vascular Carmalt clamps are
another alternative as well as Kocher clamps.
STEP 20. Bipolar electrocautery and sharp dissection FIGURE 47-5. The right recurrent laryngeal has been
are used to mobilize the parathyroid gland(s) on their identified and a stepwise dissection of the nerve along its
vascular pedicle(s). most medial branches is ensued. The right superior and
inferior parathyroid glands are laterally dissected and
I like to use bipolar electrocautery on very small, fine displaced from the thyroid gland.
vessels at very low settings to minimize parathyroid
gland vascular compromise.
left recurs beneath the ligamentum arteriosum of the
aortic arch. Both nerves then ascend toward the larynx
STEP 21. The recurrent laryngeal nerve is identified gen- in the approximate area of the tracheoesophageal
erally within the area of the inferior parathyroid gland groove. This understanding is critical in safe dissection
(Figure 47-5). in that the recurrent laryngeal nerves are never at risk
in the superior mediastinum in the dissection of struc-
Its location, whether deep to or superficial to the infe- tures lateral to the carotids, aortic arch, innominate, or
rior thyroid artery, is not constant or totally predictable. subclavian arteries.
For practical purposes, the nerve may be identified Due to their sites of recurrence (redirection), the left
caudal to the inferior parathyroid gland, but this may recurrent laryngeal nerve assumes a course ascending
lead to a higher risk of compromise to the parathyroid relatively longitudinally parallel lateral to the border of
gland’s vascular supply. I generally identify the nerve the trachea, whereas the right recurrent laryngeal nerve
and its arborized branches immediately beneath the tends to be directed more angularly as it ascends medi-
gland once the inferior parathyroid gland has been ally to the larynx. Depending on the lobe size and loca-
lateralized. tion, the nerves may pass laterally or primarily beneath
the lobes as they approach the cricothyroid membrane.
In meticulous microdissection, the recurrent laryngeal
We agree with this approach. The inferior gland being nerves, proximally, possess a wide range of arborized
more ventral than the nerve is best reflected prior to branches that may originate centimeters from the laryn-
identification of the nerve. GWRandolph and GDionigi geal insertion. One or more of the medialized proximal
branches usually pass immediately posterior to the
lateral suspensory ligament of the thyroid (Berry’s).
The recurrent laryngeal nerves arise from the vagus Variability is the rule here and instances of anterior
nerve, on both sides, and pass beneath the vessels that branches penetrating thyroid tissue in the ligament can
are derived from the primitive fourth aortic embryologic be present. In these circumstances, total thyroidectomy
arch. Therefore the right recurrent laryngeal nerve still results in a tiny remnant of thyroid tissue that can
passes beneath the right subclavian artery, whereas the be ablated if so indicated.
We agree that the relationship of the recurrent

laryngeal nerve branches to the ligament of Berry
varies. Branches of the nerve containing motor fibers
at this level may therefore be tethered or banded by
the ligament of Berry as the thyroid gland is retracted.
Under these circumstances, the mobilized lobe’s
retraction is conveyed to the nerve through the
posterior ligament of Berry attachments. One must
Berry’s ligament
therefore always keep the nerve in view as one
Sup.
retracts the thyroid and dissects the ligament of parathyroid
Berry. GWRandolph and GDionigi gland
Thyroid
Recurrent
gland
Although great attention has been placed on the laryngeal n.
relationship of the inferior thyroid artery to the recur- Inf. parathyroid
rent laryngeal nerve, basically the artery may present gland
superficial, posterior, or branch in both locations sur-
rounding the recurrent laryngeal nerve. Independent
of the anatomic configuration, the recurrent laryngeal
nerve should be anatomically identified prior to transec-
tion of these vascular structures.
The nonrecurrent laryngeal nerve can only be found
on the right side and is present in about 1% of the
population. This occurs due to an anomalous right sub-
clavian artery that is retroesophageal. In such circum-
stances, the right subclavian artery arises as the final
branch of the aortic arch, originating behind the esoph-
FIGURE 47-6. The most anterior branch of the recurrent
agus and terminating into the supraclavicular and axil-
laryngeal nerve has been preserved and a mosquito hemostat
lary regions. The right common carotid artery arises
placed on the vascularized suspensory ligament prior to
directly from the aortic arch in these circumstances and sectioning.
therefore the nerve follows a direct course from the
vagus, traversing posterior to the common carotid artery
and assuming a variable horizontally angulated course Thyroid tissue frequently invests into the area of the
beneath the thyroid lobe into the laryngeal inlet. cricothyroid membrane laterally in the area of Berry’s
The philosophy of protecting the nerve by solely dis- ligament, thus making complete removal of all thyroid
secting on the thyroid capsule does not necessarily tissue unreasonable in some patients due to the inter-
ensure protection of the nerve from injury. In some digitated nature of their recurrent laryngeal nerve
circumstances, small anterior branches of the recurrent branches. In other instances, the ligament and small
laryngeal nerves may penetrate the capsule especially in vasculature may be bipolar cauterized or suture liga-
the vicinity of the suspensory ligament. tured with minimal to no thyroid tissue recognized in
The parathyroid glands frequently are situated along this area (Figure 47-6).
the course of the recurrent laryngeal nerves and preser- If paratracheal pathology is identified and pathologi-
vation of their function is requisite by maintaining their cally confirmed, a standard level VI and VII dissection
adequate lateral blood supply. The clear identification should be performed during this procedure.
of the recurrent laryngeal nerves and distal dissection of
these nerves allow safe division of the longitudinally and
medially directed vascular supply to these glands, which STEP 23. The pretracheal fascia is entered and elec
is mandated for their normal function. trocautery (on a pure cutting setting) can be used to
mobilize the thyroid to the contralateral side of the
isthmus.
STEP 22. From a lateral to medial approach, the branches
of the recurrent nerve are identified and small vessels Once the medial-most branch of the recurrent (or non-
are controlled with bipolar electrocautery and larger recurrent nerve) is identified, the pretracheal fascia can
vessels are managed by ligatures. be safely used as a dissection plane.
The recurrent laryngeal nerve, if monitored, can be
Gentle cottonoid tracing of the nerve allows for atrau- stimulated with a minimal setting of 0.5 to 0.9 mA. I
matic dissection along the nervous sheath. have not adopted practice of stimulating the dissected
nerve and do not alter surgical procedure based on such however, the gland remains tethered contralaterally on
findings. the undissected side.
Although I have not routinely used nerve monitor-
ing, I currently use monitoring for resident and fellow
education. It has not, however, altered my surgical tech-
Completing a Total Thyroidectomy
nique or discontinued completion of thyroid surgery
based on nerve stimulation criteria. STEP 26. Completion of the total thyroidectomy is
performed essentially identically as described on the
primary side of the surgery in the preceding steps.
Neural monitoring has many applications, particularly
in education. Neural monitoring allows for rapid
I prefer to ligate the middle and inferior thyroid veins
identification of the nerve (i.e., neural mapping prior to
prior to the more superior dissection of the superior
actual nerve visualization), allows for intermittent
thyroid pedicle, at this time.
confirmation of neural integrity and neural identification
The surgeon should focus on meticulously preserving
during nerve dissection, and, possibly most important,
every parathyroid gland unless clinically involved with
allows for postdissection testing of the nerve to ensure
suspected malignancy.
postoperative function prior to contralateral dissection.
Any devascularized parathyroid tissue should be
One may reduce the risk of bilateral cord paralysis by
removed immediately, a small portion sent for frozen
acknowledging the accuracy of this information.
section pathologic confirmation of parathyroid tissue,
and then autotransplanted.
Devascularized glands should be finely minced imme-
diately to provide oxygen and nutrients to the cellular
STEP 24. The pyramidal lobe and delphian lymph node
suspension in a timely fashion.
are mobilized with the thyroid isthmus.
If left devascularized for a prolonged period without
The fascia and the thyroglossal remnant area are freed creating a cellular suspension, irreversible anoxic
with the use of electrocautery starting superiorly at the damage occurs to the majority of the gland except
inferior level of the hyoid bone and connecting inferi- the surface levels, which will be maintained due to
orly to the isthmus dissection. In some instances the diffusion.
tract and pyramidal remnants may be very prominent I perform autotransplantation using an injection
and in other instances they may be vestigial technique except in circumstances of multiple endocrine
Delphian nodes and tissue in the area of the neoplasia type I or II. In the latter, I transplant into a
cricothyroid muscle and membrane should be skele defined pocket that is marked for localization if required
tonized to their fascia in surgical management of in the future.
malignancies.
In cases unlikely to subsequently develop parathyroid

Care must be taken during pyramidal lobe and
adenomatous change, we prefer to mince the resected
delphian lymph node dissection not to injure the
normal parathyroid into small individual pieces and
delicate, thin, wafer-like cricothyroid muscles on the
place them into three separate muscle pockets in the
anterior surface of the lower larynx. GWRandolph and
ipsilateral sternocleidomastoid muscle. GWRandolph
GDionigi
and GDionigi
STEP 25. The clean plane between the thyroid gland and
tracheal fascia continues to be elevated with the use of STEP 27. The paratracheal areas—both homolateral and
electrocautery toward the contralateral lobe. contralateral—are inspected for metastatic disease.
As the surgeon becomes increasingly comfortable with For patients with differentiated thyroid cancers, the
thyroidectomy, the elevation of the isthmus and contra- common carotid artery is dissected along its anterior
lateral thyroid lobe from the pretracheal fascia greatly and medial surfaces from the superior thyroid artery
facilitates the rapidity of the procedure. takeoff to the subclavian artery on the right and the
The pretracheal elevation toward the already dis- innominate artery on the left.
sected lateral aspect of the gland can safely proceed For patients with T4- and T3-differentiated thyroid
toward the area of the lateral dissection inferiorly and malignancies, the homolateral paratracheal lymphatics
more superiorly approaching the suspensory ligament have already been significantly dissected and exposed
area (but not to the suspensory ligament). during the course of the thyroidectomy.
Larger thyroid glands can be delivered outside of the The recurrent laryngeal nerve is identified inferiorly
incision at this time to reduce ultimate incision length; within each paratracheal basin.
A cottonoid pledget is used to displace the paratra-

cheal lymphatics medial and lateral to the recurrent
laryngeal nerves.
Visual and digital examination is used. Small, but
rounded nodules or lymph nodes are removed and sent
for frozen section analysis. Lymph nodes that are clearly
enlarged, indurated, or possess a blue or purple hue are
removed and sent for frozen section analysis.
For patients with positive frozen section analysis for
thyroid malignancy, a paratracheal and superior medi- Sup.
parathyroid
astinal dissection (levels VI and VII) is performed (see gland
paratracheal and superior mediastinal dissection in
Recurrent
Chapter 50). laryngeal n.
Inferior parathyroid glands, clearly distinct from
malignancy, should be pathologically confirmed and Thyroid gland
Inf. parathyroid remnant
autotransplanted. For patients younger than 45 years of gland
age with minimal homolateral disease, I thoroughly
inspect the contralateral paratracheal lymphatics and
perform a more limited paratracheal dissection of the
contents medial to the recurrent laryngeal nerve. The
lateral to nerve paratracheal contents are not removed
in these select patients unless disease is suggested during after
Cooley
the dissection.
FIGURE 47-7. Artist’s representation of a subtotal

We titrate paratracheal dissection lymph node surgery
thyroidectomy surgical bed. The right recurrent and superior
to objective data obtained on preoperative radiographic
laryngeal nerves and both superior and inferior parathyroid
mapping including ultrasound and CT scan. If there is
glands have been visualized and spared on the right. On the
clearly identifiable disease on these preoperative left, a remnant of normal thyroid tissue remains from the level
studies, the paratracheal region affected is dissected at of the middle thyroid vein to anterior of the suspensory
surgery. If these modalities are negative, we visualize ligament area.
and palpate the paratracheal region, and if that
assessment is negative, we do not perform
paratracheal dissection. If preoperative imaging and STEP 28. The superior pole is left intact and the inferior
intraoperative assessment are negative, such and middle thyroid veins are ligated.
dissection would at most yield microscopic disease.
We think that the patient’s risk factor for nodal disease
is less important in the determination of nodal surgery STEP 29. The gland is sectioned with the use of electro-
than the objective individual preoperative radiographic cautery in the location of the already separated plane
data for that patient. GWRandolph and GDionigi between the thyroid gland and the trachea (pretracheal
fascia) (Figure 47-7).
In pediatric and adolescent patients, enthusiasm to Bipolar electrocautery can be used to control vessels
remove all disease must be tempered with preserving that bleed within the retained thyroid tissue.
parathyroid function.
Closure of Subtotal and
Completing a Subtotal Thyroidectomy Total Thyroidectomies
The amount of gland to be retained varies based on the
surgeon’s experience, location of nodules or irregulari- STEP 30. The removed specimen is thoroughly inspected.
ties within the remnant area, and patient anatomic
variations. Any suspected parathyroid tissue is separated and a
small specimen sent for frozen section analysis and the
Should one perform a subtotal thyroidectomy, one remainder finely minced and placed in autologous serum
must be cautious that the recurrent laryngeal nerve’s or tissue solvent for transplantation.
course relative to the posterior thyroid lobe remnant is Any suspicious lymph nodes are separated and ana-
completely understood before dividing the lobe. lyzed utilizing frozen section to determine whether para-
GWRandolph and GDionigi tracheal dissection (and completion of thyroidectomy)
is indicated.
STEP 31. Bipolar electrocautery is used as required For a parathyroid hormone level (PTH) greater than
during the very meticulous inspection and control of very 14 pg/mL, calcium supplementation only is given. For
small vessels that may ooze in the wound. The wounds a PTH 10 to 14 pg/mL, patients are supplemented with
do not require drainage tubes except in instances of calcitriol 0.25 mcg daily and 1 g of elemental calcium
large goitrous glands for evacuation of dead space. twice daily for the first week only. Patients with PTH
less than 10 pg/mL are replaced with 0.25 mcg of cal-
citriol twice daily and 2 g of elemental calcium three
We like to reexamine the operative space in all its times daily (patients greater than 70 kg or with PTH
interstices with anesthesia providing intermittent less than 1 pg/mL are replaced with 0.5 mcg calcitriol
Valsalva maneuver during ventilation to facilitate twice daily). For patients with PTH less than 10 pg/mL,
venous oozing during this examination. GWRandolph a repeat PTH and serum calcium, magnesium, and phos-
and GDionigi phorus is obtained prior to discharge, and if normalized,
no further testing is required.
The patient’s first outpatient follow-up is at 1 week
STEP 32. The strap muscles are reapproximated in the for pathology review, wound inspection, and further
midline with one or two interrupted absorbable sutures. instruction on wound care and follow-up. Laboratory
analysis of parathyroid hormone level and serum
calcium is obtained at the first follow-up for patients
with PTH less than 10 pg/mL.
I tend to use absorbable suture in a subcuticular fashion

Suggested Readings
and further apply adhesive and Steri-strips as well.
Berlin D: Recurrent laryngeal nerves in total ablation of the
normal thyroid gland. Surg Gynecol Obstet 60:19, 1935.
Postoperative Care American Thyroid Association (ATA) Guidelines Taskforce
Subtotal and total thyroidectomies are generally per- on Thyroid Nodules and Differentiated Thyroid Cancer,
formed as 23-hour observation procedures. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL,
Mandel SJ, et al. Revised American Thyroid Association
The patients are discharged on antiinflammatory
management guidelines for patients with thyroid nodules
pain medication with narcotics only for breakthrough and differentiated thyroid cancer. Thyroid 19:1167-1214,
discomfort. Patients are discharged on liothyronine 2009.
(Cytomel), 25 mcg twice daily until final pathologic Lennquist S, Cahlin C, Smeds S: The superior laryngeal nerve
review. in thyroid surgery. J Surg 102:999, 1987.
An intact parathyroid hormone level is obtained Wang CA: Anatomic basis of parathyroid surgery. Ann Surg
immediately on arrival to the recovery room. 183:271, 1976.
CHAPTER
Video-Assisted Thyroidectomy
Commentary by Paolo Miccoli, David J. Terris, and Ralph P. Tufano
Over the past 10 years techniques and technology have surgical personnel on appropriately staged monitors,
advanced to provide surgical approaches to both thyroid and decreased surgeon fatigue and neck strain because
and parathyroid surgery that allow minimal incision the scopes provide visualization. Because the gland is
size and, in some circumstances, more remote incisions essentially nearly always normal in size other than in
including axillary and chest approaches to surgery the presence of the thyroid nodule/mass, the procedure
within and about the thyroid bed. is performed almost identically in every instance. This
The onus of responsibility in developing these video- allows a standard approach and rhythm to be estab-
assisted approaches was to provide equal or improved lished for the surgeon as well as the operative team as
operative outcomes to “open” approaches including a whole.
cosmetics, safety, complication rates, operator fatigue, A high-quality ultrasound is critically important in
as well as efficiency both in time and adequacy of the the planning of video-assisted surgery. Analysis of the
surgery. Some of these factors have been investigated cervical lymphatics is mandatory and fine-needle aspira-
with varying levels of evidence supporting these tion cytology should be performed on lymph nodes
approaches. suggestive of metastatic disease because in this author’s
In particular, two evidence-based reviews are avail- opinion, this procedure should not be entertained in
able in the literature: Sgourakisg and associates (2008) those circumstances.
and Miccoli and colleagues (2008). Among the out-
comes measured were:
I agree that a formal central neck dissection as
n Adverse event (hypoparathyroidism, recurrent nerve
described in the recently published American Thyroid
damage, major bleeding)
Association consensus statement on central neck
n Cosmetic outcome
dissection (see Suggested Readings) cannot be
n Postoperative pain and distress
adequately performed with this technique. RPTufano
Regarding adverse effects, the published series were

Adequate determination of gland size and the loca-
not able to reach any statistically significant difference
tion, size, and extent of thyroid nodules is imperative
between the examined procedures. As far as the
as well.
cosmetic outcome and postoperative pain are
concerned, both demonstrated a statistical
significance in favor of video-assisted thyroidectomy. This point should be highlighted. A posteriorly based
PMiccoli nodule that may approximate the recurrent laryngeal
nerve, trachea, or esophagus may be more difficult
to resect with this technique. General relative
The patient benefits of video-assisted thyroid
contraindications include nodule or tumor greater
and parathyroid surgery are clearly improved cosmetic
than 3 cm, thyroid volume more than 25 mL,
results and minimization of postoperative discomfort
Hashimoto’s thyroiditis, and central neck
without compromise in quality and efficacy of the sur
lymphadenopathy. RPTufano
gical procedure itself compared with standard open
approaches. To the surgeon, however, there are also
other significant benefits including far superior visual- Because the thyroid mass is frequently subclinical,
ization (17- to 20-fold magnification) in contrast to the ultrasound should be reexamined preoperatively to
loupe magnification of only a fraction of what the tele- verify the size and the location of the thyroid mass and
scope affords. The other significant benefit is decreased the absence of suspicious lymphadenopathy. The patient
surgeon fatigue. should be site-marked to define the location of the
Further benefits of the procedure are consistency of thyroid abnormality at the time of the ultrasound review.
the surgical approach, ability to educate other surgeons Although the technique for both video-assisted
because the surgical procedure can be visualized by all thyroid and parathyroid surgery is not complex (once
475
TABLE 48-1 Video-Assisted Thyroidectomy and Patient Positioning

Parathyroidectomy Instrumentation
One of the patient comforts of this procedure is the
Telescope lens (KS): 30- and 70-degree wide angle/7 mm × absence of hyperextension while positioning the patient.
25 cm
A soft gel head donut is used with the chin in the
Dissector optical with large fenestrated spatula
Suction elevator Miccoli: blunt extended position without the use of a shoulder roll.
Elevator Miccoli: blunt 2 mm If you specifically ask your patients about this issue,
Elevator Miccoli: blunt 4 mm the absence of posterior neck discomfort will become
Hook Hermann self-evident as compared with the frequently discovered
Scissor Belucci: straight 7 mm 5.4 inches discomfort in “standard” hyperextended neck thyroid-
Forceps grasp: serrated/rough jaw 1 mm × 5.75 inches ectomy approaches.
Rake small: 3-prong/sharp
Retractor Miccoli: double end 45 mm/21 mm × 10 mm
Retractor Miccoli: double end 35 mm/21 mm × 10 mm The lack of extension has the added benefit of
Retractor army-navy maintaining the recurrent laryngeal nerve in a
Clamp micro-Halsted mosquito: curved 5 inches
serpentine configuration, more easily distinguishable
Clamp micro-Sawtell: curved 6 inches
Clamp Carmalt: 7.5 inches
from an artery. DJTerris
learned), a self-taught approach may be fraught with a Recurrent laryngeal nerve monitoring can be used in
higher than acceptable complication rate as well as this procedure as similarly discussed in open thyroid
undue physician strain. In this light, this brief introduc- surgery chapters. Verification of monitoring tube elec-
tion to these techniques must recognize my generously trodes position between the vocal folds and intact moni-
provided introduction to these approaches by Drs. toring is required for effective monitoring.
Paolo Miccoli and Piero Berti of the Ospedale Santa
Chiara (Pisa, Italy) and my subsequent adaptation of
This is a natural complement to minimal access
their approach to a totally video-assisted approach.
surgery with its necessarily reduced surgical
aperture. DJTerris
Instrumentation
The basic instruments are included in Table 48-1. This When initially using the video-assisted procedure,
special instrumentation is critical for adequate visualiza- it is highly recommended that the surgeon be first-
tion and safety. The 7-mm, 30-degree, wide-angle and second-assisted. The operative table remains in a
telescope (Storz Instruments Madison, NJ), ACE Har- straight position with the primary surgeon to the right
monic instrument (Ethicon Endomechanical, Johnson of the patient. Monitors are placed on both sides of
& Johnson Cincinnati, OH), and Miccoli suction and the patient so that the assistants can appreciate the
blunt dissectors are the workhorses of the procedure. adequacy of the retraction and maximally facilitate
visualization.
We personally prefer the CS 14 Harmonic: although its The ventilation tubing must be in low profile passing
power is inferior to ACE in most if not all cases, its over the top of the head and then below the table level
hemostatic effect is enough to coagulate and divide to the ventilation apparatus. Place the table approxi-
the superior pedicle of thyroid since the patients mately 2 feet away from the standard anesthesia posi-
eligible for this procedure show small size glands tion to allow for an assistant to stand directly at the
with limited vascularization (see Miccoli, Berti, and head of the bed.
Ambrosini, 2008). PMiccoli
The patient may also be rotated to 180 degrees from
the anesthesiologist, which provides ample room for
An alternative to the Storz set is the Medtronic
the endoscopic tower, nerve monitor, and Harmonic
thyroidectomy instrument set that incorporates a
generator. DJTerris
nerve-friendly suction, specially angled nonreflective
retractors, and a unique peanut-holder design.
DJTerris
Do not try to use the same endoscopes that you

Draping
would use for sinus surgery. Those scopes are too short Two U-shaped disposable adhesive drapes are placed in
and create conflict with the instruments the primary a cephalad and then caudad opposing position such that
surgeon is using for dissection and delivery of the the cervical area is the only area exposed. It is rapidly
thyroid gland. and easily applied.
CHAPTER 48 Video-Assisted Thyroidectomy 477
Who Does What?

In general, as in with any surgery, this surgery is best
performed by an experienced team. The primary surgeon
must position the retractors for the second assistant.
The second assistant is best positioned directly at the
head of the table.
The first assistant should drive the scope and be
Hyoid bone
familiar with the surgery. In my experience, because I
am involved in the training of fellows and residents and
they are frequently unfamiliar with the procedure, I may
position the scope for the first assistant and then trans- Thyroid cartilage
fer his or her hands to the scope before proceeding with
the surgery.
As primary surgeon, your hands are generally occu-
pied with the dissection and Harmonic instruments. If Incision
the first assistant is having difficulty providing adequate
visualization because of the experience level with scopes Trachea
or the surgery itself, the primary surgeon can drive the
scope but the procedure will be slightly prolonged
because of transfer of instruments. FIGURE 48-1. Ideal location and approximate size of incision
Careful attention to the orientation of the Harmonic for video-assisted thyroidectomy (and parathyroidectomy).
device is critical. The insulated portion of the instru-
ment is always oriented toward all critical structures
such as the superior and recurrent laryngeal nerves, Although a 2-cm wound is to be considered the ideal
trachea, great vessels, and esophagus. length of the incision, we generally start with a 1.5-cm
incision because in some patients, particularly older
In addition, with the ACE product (I prefer the adults, there is a tendency to a slight enlargement
ACE23E) the distal shaft gets hot enough to burn the under the retraction so that the final length of incision
skin edge, and this risk must be managed. DJTerris will be around 2 cm. PMiccoli
This is an important point, and at all times we confirm As with any thyroid incision, an incision placed too
on the monitor that the insulated side is against critical inferiorly impairs access to the superior dissection and
structures before turning on the Harmonic. We have pyramidal lobe and produces a less desirable cosmetic
the second assistant monitor that we are not result. I tend to caution the patient that initially the
approximating the skin with the Harmonic shaft as well incision location will appear higher in the neck, but
so that we avoid any thermal injury to skin and the ultimately its location will settle into the manubrial
Harmonic is not turned on until this is confirmed. What notch area.
may also be of help is to apply Opsite to the skin or
clear drape that adheres to the skin so that the skin My preference is to mark the incision with the patient
edges are protected better. RPTufano sitting up in the holding area. Therefore the location
is determined while in the upright position, as is the
case when the patient is in most public situations,
Operative Technique and optimal positioning of the incision can be ensured.
DJTerris
STEP 1. The horizontal incision is drawn at a level
approximating the first tracheal ring (Figure 48-1).
The video assistance allows for exposure of the more
Incision length is usually 2 to 2.5 cm but must be ade- difficult to reach superior pole even from a lower
quate to deliver the thyroid gland (which is distensible) incision. In a thin neck, the placement of the incision
but more important, the thyroid mass itself. The inci- at this level may be projected anteriorly by the
sion size, location, and orientation (horizontal) are akin laryngotracheal complex. The incision location should
to that of a tracheotomy. Despite your operative experi- be marked preoperatively with the patient in an upright
ence, I generally recommend that surgeons early in their position to determine the optimal location and should
video-assisted experiences plan slightly larger incisions be shown to the patient. RPTufano
until their comfort level has been attained.
STEP 2. The incision is locally infiltrated with 0.5%

bupivacaine (Marcaine) 1:100,000 epinephrine in a field
block approach.
This is not an essential step if one is using a 1.5- to

2.5-cm incision. RPTufano
STEP 3. The skin is incised and the skin, subplatysmal,

and subcutaneous flaps are elevated superiorly to the Pyramidal lobe
of thyroid gland
level of the hyoid and inferiorly to the sternal notch.
In contrast to open thyroidectomies, however, the flaps

need only be elevated primarily in the midline overlying
the median raphe of the strap musculature. This there-
fore avoids creation of significant dead space as well as
being time efficient.
I have not found it necessary to elevate a superior

and inferior skin flap beyond a distance of 1 cm for
this procedure. It is often difficult to raise flaps to
the hyoid and sternal notch with this limited incision.
RPTufano
As with open thyroidectomy, it is critically important FIGURE 48-2. Lateral and superior retraction of the
for the flaps to be elevated in the immediate prevascular sternothyroid and sternohyoid from the fascial envelope of the
anterior jugular chain as opposed to the immediate sub- lateral surface of the thyroid gland.
platysmal plane as commonly suggested in cervical flaps
for other neck procedures.
STEP 5. The straps are separated with electrocautery
We no longer raise these flaps; after the incision is along the median raphe (linea alba) and then elevated
made and carried down to the strap muscles, the off the anterior and lateral surfaces of the thyroid gland
muscles are separated superiorly to the thyroid notch with monopolar electrocautery technique and standard
and inferiorly to the sternal notch. DJTerris optics (loupe magnification) (Figure 48-2).
The linea alba, as in open thyroidectomy, is usually

easier to identify and separate more inferiorly in the
The small centrally located incision usually does not
neck. Occasionally the anterior jugular vein has collat-
permit visualization of the platysma so elevation of the
eral branches crossing the linea alba and these are
skin flaps may be accomplished in the prevascular
readily separated with the Harmonic instrumentation.
plane. RPTufano
I use the rubber sleeve available for covering the neck
of the Harmonic instrument to protect the skin edges
from inadvertent thermal injury.
STEP 4. The flaps are secured with a single 2-0 silk
suture to the drapes themselves.
One can also fashion a piece of Jackson-Pratt drain
Securing the flaps only holds the skin slightly out of the
tubing over the Harmonic shaft to avoid thermal
way. The major access to the surgery is provided by
injury. RPTufano
specialized retractors used for both traction and coun-
tertraction to create the necessary space for visualization
and instrumentation. Once the gland has been skeletonized laterally, the
7-mm, 30-degree, wide-angle telescope is used through-
out the remainder of the procedure. Depending on the
The retraction of the skin should be accomplished ultimate location of the incision and gland anatomy, the
with the specialized retractors. RPTufano 70-degree scope may be used more inferiorly in the dis-
section later in the procedure.
Sternohyoid m.
Sternothyroid m.
Pyramidal lobe
of thyroid gland
Thyroid cartilage
Common carotid a. FIGURE 48-3. Retractors are shown with superior

lateral retraction of the sternothyroid and sternohyoid
muscles with simultaneous medial retraction of the
superior pole of the thyroid. The scope view shows
the Miccoli dissector along the long axis of the
superior thyroid vessels.
This placement of a retractor directly on the

thyroid gland itself is not intuitive, but is
essential to creating the optical pocket.
DJTerris
STEP 7. Gentle dissection of the superior thyroid vascu-

We use a 5-mm laparoscope, which provides lar pedicle is initiated along the long axis of these vessels.
adequate visualization, and may provide additional
space compared with a 7-mm scope. DJTerris I tend to pick up the lateral aspect of the superior pole
with a DeBakey forceps during the vascular dissection
with the combination Miccoli dissecting and suction
instrument.
A Freer elevator is particularly helpful in dissecting
Too heavy of retraction laterally of the muscles or
the lateral aspect of the strap muscles to allow for
medially of the gland places these vessels under undo
identification of the carotid artery, which is a critical
tension; therefore adjusting the pull of the retractors
landmark in the video-assisted technique. RPTufano
may greatly facilitate vessel mobilization.
STEP 8. The superior laryngeal nerve is identified prior

STEP 6. Retractors are placed, retracting the strap mus-
to transecting the superior vascular pedicle vessels
culature laterally and the upper pole of the thyroid gland
(Figure 48-4).
medially (Figure 48-3).
Independent of whether a thyroid lobectomy or total As the fascia is gently teased apart along the long axis
thyroidectomy is going to be performed via a video- of the superior thyroid artery and vein, the superior
assisted method, I initiate the procedure on the side of laryngeal nerve is generally readily identified.
the ultrasonically defined mass. This traction and coun- Gentle dissection with the blunt Miccoli dissector
tertraction technique is critical in creating the space for creates planes between the vessels and the fascia cover-
visualization as well as instrumentation. ing the thyroid gland and surrounding fascial envelope
of the superior laryngeal nerve. I transect each vessel
independently rather than in combination.
I first use the video endoscope to assist with
identifying and dissecting the carotid artery from the Once the superior laryngeal nerve is visualized and the
inferior pole to superior pole of the thyroid lobe. It may cricothyroid muscle is dissected away from the
be helpful to first perform ligation of the middle thyroid superior pole, I use the Harmonic on the “slow
vein to facilitate the medial retraction of the thyroid sealing” mode with the insulated end against the
lobe with the retractor. I then address the superior cricothyroid muscle to take down the superior pole in
pole. RPTufano one or two applications of the Harmonic. RPTufano
As a rule, I avoid the use of surgical clips due to their

production of diagnostic imaging artifacts in patient
follow-up.
Sup. laryngeal n.
I think this is important for those who do a lot of
revision or reoperative surgery as well. Clips make it
very difficult to perform a reoperation. RPTufano
Sup. laryngeal a./v.

In spite of possible artifacts, we retain the 2-mm
vascular titanium clips as a precious tool when
operating in proximity to the recurrent nerve. In fact in
Common carotid a. several cases the surgeon can be coping with tiny
vessels crossing this nerve: their coagulation or even a
ligature might jeopardize the structure more than small
clips, which can be applied via the disposable
dispenser with a very gentle and soft touch. PMiccoli
STEP 9. The Harmonic is then used to free the medial

aspect of the superior pole followed by the pyramidal
lobe (Figure 48-5).
The upper pole needs to be completely mobilized. I

perform this in an immediate capsular fashion, carefully
recognizing the potential location of the superior para-
FIGURE 48-4. The superior pole vasculature is skeletonized
thyroid gland and lateral mobilization of this gland with
along the long axis and the deeper fascial envelop along the
its vasculature whenever feasible.
superior pole opened to visualize the superior laryngeal nerve
and its branches (scope view).
I agree that before ligating the entire superior pole, the

superior parathyroid gland should be visualized,
Using surrounding fascia does provide more bulk to making sure that it is not incorporated in the thyroid
facilitate seal of the vessels with the Harmonic instru- resection. RPTufano
ment. For “named vessels,” I use the slow sealing Har-
monic setting, whereas for small vessels, the rapid
setting is efficient and effective. The superior pole can be safely mobilized inferiorly as
far as the lower edge of the cricothyroid muscle
without fear of placing the recurrent laryngeal nerve
We prefer to ligate the entire upper pedicle in a single at risk. DJTerris
bundle close to the capsule after mobilizing the medial
cleft between the superior pole of the thyroid and the
larynx. This technique has the advantages of vessel As with any thyroid surgery, every parathyroid gland
ligation farther from the superior laryngeal nerve, should be handled as if it were the last gland. Devascu-
ligation of the terminal branches of the superior pole larized glands should be pathologically confirmed and
vessels instead of the trunks, and incorporation of the transplanted.
protein associated with the capsule, which facilitates So as not to compete with retractors and the scope
coagulation. This maneuver is faster and easier than within the field, a longer fine-tipped gently curved dis-
conventional vessel ligation in this location. DJTerris sector frees the medial triangle of the upper lobe. The
fascia is generally readily freed and the Harmonic can
be used. If space is limited, cautery can be used.
If the vessels are ineffectively sealed, they will bleed Depending on patient anatomy, the sternothyroid
at this time and not postoperatively. The Harmonic can may have been released earlier or at this time, along this
be used to reseal if this happens. Alternative backup medial extent. If the middle thyroid vein is encountered
approaches including bipolar and suture ligature can be during this superior lateral dissection, it is harmonically
performed if necessary. sealed in a capsular fashion along the gland.
Sup. laryngeal n.
Pyramidal lobe
FIGURE 48-5. The pyramidal lobe is freed
of thyroid gland
from its superior-most infrahyoid attachment.
The superior pole has been mobilized and the
transected superior vascular vessels are shown
(scope view).
STEP 10. The pyramidal lobe is freed via a lateral

approach first and then superiorly from its infrahyoid The identification and dissection of the recurrent
tract (see Figure 48-5). laryngeal nerve (RLN) require a technique different
from what is used for open surgery. The Miccoli
As the medial superior triangle of the superior pole is dissectors are spread in a perpendicular fashion as
mobilized, the retractors are replaced along the sepa- opposed to parallel along the expected course of the
rated linea alba and the pyramidal lobe and delphian nerve. Remember, the patient is not hyperextended,
lymphatic basins cleaned and mobilized to the superior so the nerve will not be stretched with this method.
aspect of the isthmus. In fact, the nerve appears more physiologic with a
wormlike, curvy appearance as opposed to the
I think that the isthmus should be transected next as tense bowstring appearance one may see with
long as the pathology is not located there. This allows hyperextension. RPTufano
for complete mobilization of the superior pole and
better mobility as you prepare to protract the gland
anteriorly. RPTufano
STEP 12. Dissection along the long axis of the carotid
sheath allows inspection of the paratracheal lymphatics
STEP 11. The inferior and lateral aspects of the thyroid and the initial visualization of the recurrent laryngeal
are mobilized. nerve (Figure 48-7).
The retraction is then transitioned to more inferiorly If paratracheal pathology is identified, again, the proce-
along the strap musculature and again the gland is dure should be converted to a more standard open
retracted medially but along the inferior third of the approach with level VI dissection (although some video-
gland (Figure 48-6A). assisted surgeons are now using video assistance for
I prefer to continue the use of the 30-degree scope paratracheal dissections as well).
here but in some patients, a 70-degree scope is required
to visualize adequately inferiorly and laterally.
The middle thyroid vein is transected with the Har-
monic instrument and the inferior parathyroid gland is This is controversial and beyond the scope of this
usually visualized and dissected laterally and maintained atlas. RPTufano
on its vascular supply (see Figure 48-6B).
Superior pole
of thyroid gland
Pyramidal lobe
of thyroid gland
0.5-mL scope Inf. parathyroid

gland
A B
FIGURE 48-6. A, Retraction and placement of instruments for left lateral lobe dissection. The
Miccoli retractors are laterally displacing the strap muscles and medially retracting the thyroid
gland. Dissection takes place along the medial aspect of the carotid sheath and the 7-mm
scope is directed toward a more inferior gaze. B, The scope view of the initial identification of
the recurrent laryngeal nerve. The fascia overlying the nerve is teased with the Miccoli
dissector to identify its course and arborization. Cottonoids can be used to facilitate
mobilization of the nerve along its more proximal course.
Actually we tend to induce surgeons to use the option the nerve. Once the lymphatic tissue has been freed
of operating also on the central (level VI) compartment laterally it can be easily lifted up and retrieved from
during the same procedure. This allows surgeons to the incision; it will be then separated from the trachea
recruit a greater number of patients, including among by simply detaching it with Harmonic on the avascular
the eligible, patients presenting small papillary plane constituted by the anterior aspect of the trachea
carcinomas or RET gene mutation carriers who, (see Berti et al, 2007). PMiccoli
according to some, do need a routine prophylactic
level VI lymph node dissection. In fact not all agree
about this necessity (see Mazzaferri et al, 2009) for Gentle fascial dissection with the Miccoli dissector
“low-risk” papillary carcinoma, whereas it is mandatory along the medial aspect of the carotid in the cephalo-
in RET gene mutation carriers with a calcitonin caudal direction (along the long axis of the nerve) allows
elevation. The technique to perform such a clearance for its identification as well and may equally help iden-
is simple: we change the position of the endoscope, tify the inferior parathyroid gland.
moving it from the left side of the patient to the head.
A 0- or 30-degree scope is ideal for the procedure. Unlike classic teaching (in which this and other nerves
The RLN is traced on both sides until the innominate are identified by spreading parallel to the anticipated
artery is reached separating all the fat an lymphatic direction of the nerve) it is easier and faster to find the
tissue off the nerve, using clips or Harmonic according nerve by dissecting perpendicular to the anticipated
to the distance between the vessels to be divided and direction, using blunt elevators. DJTerris
Thyroid gland
Middle thyroid v.
Recurrent
laryngeal n.
Inf. parathyroid
gland
FIGURE 48-7. Scope view of the mobilization of the inferior and lateral glands. The Harmonic
is shown transecting the middle thyroid vein. Stepwise mobilization of the thyroid medially and
simultaneously, the inferior parathyroid gland laterally (keeping insulated space away from the
recurrent laryngeal nerve) is performed.
STEP 13. Once the nerve has been identified, the STEP 15. The Harmonic transects the isthmus and
entire inferior and lateral mobilization of the gland connects superiorly to the pyramidal component of the
is stepwise performed along the gland capsule (see gland already mobilized (Figure 48-8).
Figure 48-7).
The Harmonic is placed in the identical position as has
The inferior thyroid vein is frequently encountered here just been used with the mosquito hemostat.
and separated with the Harmonic. The pretracheal fascia is the level of dissection. It is
Medial mobilization of the gland and stepwise a bloodless plane. The isthmus is transected in a step-
cautery or Harmonic is performed. wise fashion with the Harmonic insulation continuing
to protect the trachea.
STEP 14. Along the side of the isthmus contralateral to

the lobe that is being dissected, the isthmus is tran- STEP 16. Monopolar cautery is used to elevate the
sected such that a total thyroidectomy specimen will be already transected isthmus from the pretracheal fascia.
delivered in two components.
As the surgeon feels increasingly comfortable with the
The strap muscles are retracted laterally along the linea procedure, this elevation of the isthmus toward the
alba. lateral thyroid lobe greatly facilitates the rapidity of
I like to use a mosquito hemostat to open the fascia the procedure.
immediately inferior to the thyroid isthmus fascia. The pretracheal elevation toward the already dis-
This area is usually rich with inferior draining thyroid sected lateral lobe can safely proceed toward the area
veins. The mosquito hemostat is positioned with its of the lateral dissection inferiorly and more superiorly
tip in a cephalad direction and the pretracheal fascia approaching the suspensory ligament area (but not to
dissected open. the suspensory ligament).
gentle rotation of the pole conveniently allows half of

the gland to be pulled out of the incision and the remain-
der of the thyroid will follow more easily.
STEP 18. The thyroidectomy is completed via an inferior

lateral approach with optics focusing on the recurrent
laryngeal nerve and gland fascia (see Figure 48-9B).
Or you can proceed as you would with open

Thyroid isthmus thyroidectomy. RPTufano
The superior parathyroid gland should be visualized

lateral to the area of dissection.
The inferior parathyroid gland should be visualized
and mobilized laterally with its vascular pedicle lateral
to the nerve. I tend to use both the bipolar and cot
tonoids medial to the inferior gland to further mobilize
and lateralize the parathyroid glands.
FIGURE 48-8. The isthmus is transected along its shortest The visualized recurrent laryngeal nerve is dissected
cepahalocaudal dimension along the junction of the toward its entry into the laryngeal inlet. Anatomic vari-
contralateral lobe (from the dissection). The pretracheal fascia ants of the nerve, branching and nonrecurrent nerves,
is opened and dissected with a Sawtell clamp and then the are unquestionably routinely encountered.
Harmonic inserted with the insulated portion protecting the
trachea as illustrated.
That’s why the RLN should be carefully followed into
its insertion site so that every extralaryngeal branch
STEP 17. Once the isthmus and more lateral lobe have can be identified and preserved. RPTufano
been elevated, a Carmalt or Kocher clamp is placed to
traction the delivering thyroid gland medially out of the
incision site (Figure 48-9A). STEP 19. A stepwise connection of the lateral aspect of
the dissection with the already more medially mobilized
Multiple clamps may be used on the superior pole (to gland is ensued with the nerve in complete scope
distribute the tension), which serves as the handle by visualization.
which the gland is retrieved. DJTerris
In those circumstances in which the suspensory ligament
is not filled with thyroid tissue integrated between
In smaller incisions the scope is removed and the gland recurrent laryngeal nerve branches or there is adequate
compressed to deliver it through the incision site. space between the ligament and the most medial
The gland is then compressed and delivered external branches of the nerve, the Harmonic can be used for
to the incision site to create space for the final aspects safe separation of the suspensory (Berry’s ligament)
of the dissection and thyroid lobectomy completion. (Figure 48-10).
When using the Harmonic instrument around the
nerve, it is imperative that the insulated portion of the
Identification of the RLN and dissection superiorly
instrument be placed facing the nerve’s long axis. This
along its course can be accomplished with video
usually requires placement of the instrument and rota-
assistance but the final dissection over its last 1 cm to
tion of the instrument along its long axis to parallel the
its distal insertion point should be accomplished much
nerve. The Harmonic should also be gently lifted to
like open surgery once the lobe has been exteriorized
create an “air space” between it and all critical struc-
over the skin. RPTufano
tures (nerves, parathyroids, great vessels, trachea, and
esophagus).
A maneuver that, in our opinion, greatly facilitates In most circumstances, in order to provide an
the delivery of the gland through the incision site is the excellent and safe removal of thyroid tissue in the area
grabbing of the upper pole of the gland at the site of of the ligament, I prefer a stepwise bipolar technique of
the superior pedicle vessels previously divided. They can the thyroid attachment, combined with fine tenotomy
be easily recognized and a mosquito clamp can be scissors and cottonoids for lateral mobilization of
applied at the site of their emergence from the gland: a the nerve.
Middle thyroid v.
Inf. parathyroid gland
FIGURE 48-9. A, Macroscopic view of the dissection of the

Inf. parathyroid gland distal arborization of the recurrent laryngeal nerve with the
6-inch Sawtell clamp. The thyroid has been delivered through
the incision with the Carmalt clamp. B, The scope view of the
deep lateral lobe and recurrent laryngeal nerve dissection
proximal to the suspensory ligament. The inferior parathyroid
gland is lateralized with its vascular pedicle and the recurrent
laryngeal nerve stepwise dissected more distally toward its
B laryngeal insertion.
Thyroid
gland
Sup. parathyroid
gland
Recurrent
laryngeal n.
FIGURE 48-10. The scope view of the most
distal portion of the dissection. The inferior and
superior parathyroid glands have been dissected
with their vascular pedicles laterally. The most
distal branching of the recurrent laryngeal nerve
is performed with magnification and if adequate Inf. parathyroid
space between nerve and Harmonic is present, gland
Harmonic instrumentation can be used.
Otherwise, stepwise bipolar and sharp dissection
is used.
STEP 20. For those patients undergoing a total thyroid-

ectomy, the thyroid excision is always performed in two One may also use Surgicel, which tends to layer nicely
pieces. The contralateral lobe is similarly excised via a in this area. RPTufano
capsular or subcapsular approach depending on the
surgeon’s comfort with these approaches.
On the contralateral side, elevate the isthmus laterally It is important to note that the strap muscles should
first off of the pretracheal fascia and then proceed with be closed only in a single location using a figure-eight
the superior and then lateral approach as described 3-0 Vicryl (or similar) suture, rather than the classical
earlier. top-to-bottom running closure for both video-assisted
and conventional thyroidectomy. This permits egress
of blood in the event of postoperative oozing,
STEP 21. The wound is irrigated, and meticulous hemo- minimizing the likelihood of lymphatic and venous
stasis verified. outflow obstruction, which may cause supraglottic
edema and airway obstruction. DJTerris
Alternatively, half of a large sheet of Surgicel may be
placed in each thyroid compartment. DJTerris
STEP 22. The wound is closed with a subcutaneous
Vicryl suture and Dermabond or a subcuticular absorb-
No drains are required. Inspect viability of all identified
able suture.
parathyroid glands. Vascular compromised glands
should be pathologically confirmed and at least partially Due to traction trauma to wound edges of these very
autotransplanted. small incisions, I have adopted approaches to freshen
Compressed Gelfoam about the size of the removed 1 to 2 mm of the incision edges prior to closing to
thyroid lobe(s) is placed in the surgical site. minimize the risk of hypertrophic wound healing.
This is an important point and the wound edges have The concepts of appropriate patient selection,
to be carefully inspected to determine whether this a steep learning curve and the advantage of expert
step is necessary. It usually is due to the significant guided rather than self-taught learning at the
retraction used during this surgery. RPTufano outset cannot be overemphasized. Although a
background in both open thyroid surgery and
video-assisted soft tissue surgery may be helpful
in preparation for this technique, neither will allow
Postoperative Care for its safe performance without some hands-on
Because limited dissection and space have been created, guidance. JICohen
discharge is anticipated following adequate postopera-
tive observation and instruction. In total thryoidectomy
patients, discharge can also be safely commenced once
a rapid parathyroid hormone level (intact PTH) verifies
adequate parathyroid function. Suggested Readings
Despite adequate parathyroid hormone levels, I
American Thyroid Association Professional Guidelines. Avail-
maintain patients on 1 g of elemental calcium supple-
able at http://thyroidguidelines.net.
mentation for overall bone and physical health. Asao T, Kuwano H, Yamaguchi S, Uchida N, Yanagita Y:
In total thyroidectomy patients, if rapid parathyroid Videoscopic thyroidectomy with fine needle-type appara-
hormone levels are not obtainable, a postoperative tuses: an approach that does not leave a scar on the neck
serum sample for PTH can be obtained and the patient or anterior chest. Surg Laparosc Endosc Percutan Tech
supplemented with calcitriol 0.5 mcg twice daily, and 15:339-344, 2005.
1.5 g of elemental calcium three times daily is initiated. Lombardi CP, Raffaelli M, Princi P, De Crea C, Bellantone R:
This approach provides adequate replacement in the Video-assisted thyroidectomy: report on the experience of a
rare hypoparathyroid patient and the short-term risk of single center in more than four hundred cases. World J Surg
hypercalcemia is essentially nonexistent for the first 3 30:794-800, 2006.
to 4 days until the parathyroid hormone levels can be Lombardi CP, Raffaelli M, Princi P, Lulli P, Rossi ED, Fadda
G, et al: Safety of video-assisted thyroidectomy versus con-
verified (and then calcitriol discontinued and calcium
ventional surgery. Head Neck 27:58-64, 2005.
supplementation initiated). Mazzaferri EL, Doherty GM, Steward DL: The pros and cons
of prophylactic central compartment lymph node dissection
Summary for papillary thyroid carcinomas. Thyroid 19:683-689,
2009.
Video-assisted surgery of the thyroid and parathyroid Miccoli P, Berti P, Materazzi G, Minuto M, Barellini L: Mini-
glands is as safe and effective as conventional open mally invasive video-assisted thyroidectomy: five years of
methods. Nevertheless, the techniques require some experience. J Am Coll Surg 199:243-248, 2004.
additional training or instruction prior to adding them Miccoli P, Berti P, Ambrosini CE: Perspective and lessons
to the surgeon’s armamentarium. Patient benefits include learned after a decade of MIVAT. ORL J Otorhinolayngol
decreased postoperative discomfort and improved Relat Spec 70:282-286, 2008.
Miccoli P, Elisei R, Donatini G, Materazzi G, Berti P: Video
cosmetic results. Physician benefits include decreased
assisted central compartment lymphadenectomy in patients
surgeon fatigue and improved visualization over con- with positive RET proto-oncogene: initial experience. Surg
ventional magnification. Endosc 21:120-123, 2007.
Miccoli P, Minuto MN, Ugolini C, Pisano R, Fosso A, Berti
EDITORIAL COMMENT: Although this technique P: Minimally invasive video-assisted thyroidectomy for
is in its relative infancy in North America, benign thyroid disease: an evidence based review. World J
Surg 32:1333-1340, 2008.
considerable experience has been developed over
Miccoli P, Pinchera A, Materazzi G, Biagini A, Berti P, Faviana
a longer time in Europe. This chapter provides the
P, et al: Surgical treatment of low- and intermediate-risk
combined wisdom of one of the European papillary thyroid cancer with minimally invasive video-
“fathers” of the technique and three individuals assisted thyroidectomy. J Clin Endocrinol Metab 94:1618-
who have pioneered its introduction into the 1622, 2009.
United States. Each of the authors has his own Sgourakis G, Sotiropoulos GC, Neuhäuser M, Musholt TJ,
pearls and nuances that make it work well for Karaliotas C, Lang H: Comparison between minimally
them; however, what is comforting is the fact that invasive video-assisted thyroidectomy and conventional
the fundamental principles are the same for all. thyroidectomy: is there any evidence-based information?
Thyroid 18:721-727, 2008.
CHAPTER
Robotic Thyroidectomy: Surgical Technique
49 for Lobectomy via Axillary Incision Without
Carbon Dioxide Insufflation
Authors F. Christopher Holsinger, Mark E. Zafereo, and Woong Youn Chung
Commentary by Emad Kandil, Ronald B. Kuppersmith, and Nancy D. Perrier
Attempting a total thyroidectomy through a unilat-

Preoperative Considerations eral transaxillary incision requires significant robotic
Patients with tumors of indeterminate pathology requir- experience because it can be difficult to identify the
ing unilateral thyroid lobectomy are optimal candidates contralateral recurrent laryngeal nerve from a medial to
for robotic thyroidectomy. Contraindications include lateral approach. Extreme caution should be taken in
tumors greater than 5 cm in size, retropharyngeal goiter, using the transaxillary approach for lesions that extend
and lesions located at the posterior capsule in the tra- to the posterior aspect of the thyroid adjacent to the
cheoesophageal groove. tracheoesophageal groove because there is increased
risk for injury to the trachea, esophagus, and recurrent
Additionally, the presence of Hashimoto’s thyroiditis or laryngeal nerve.
Graves’ disease makes robotic surgery much more
challenging. RBKuppersmith
We believe that a vast experience in performing
thyroidectomy is the most important qualification for
Lesions of 5 cm or larger might be considered relative this operation. Familiarity with the axilla, pectoralis
contraindications. The authors advocate a very muscle, sternocleidomastoid muscle (SCM), and lateral
cautious approach for many surgeons new to the approach to the central neck are key elements to
technique. However, with experience it is possible to success. We support a systematic and safe approach
perform robotic thyroidectomy for larger lesions up to to learning the technique, which should include a team
8 cm. EKandil of individuals with experience in open thyroid
lobectomy. This maximizes troubleshooting and
The role of robotic thyroidectomy for malignancy is offers a shared learning curve. Observing a live
controversial. For experienced surgeons this approach procedure with particular attention to setup is most
may be well suited for micropapillary cancers, but its helpful. NDPerrier
role for more advanced stage disease is uncertain but
clearly contraindicated for patients with extrathyroidal
tumor extension, tracheal invasion, and multiple lateral
metastases.
Many groups reported the safety of performing Considerations
video-assisted surgery for low-risk papillary thyroid
Robotic thyroidectomy facilitates endoscopic neck
carcinoma. However, more studies are needed to
surgery while maintaining three-point or three-
further study the role of robotic thyroidectomy for
instrument approach. In other words, the surgeon can
malignancy. EKandil
retract, view target surgical anatomy, and still have
two arms to operate, while maintaining traction-
Patients requiring thyroidectomy for a thyroid cyst or countertraction. Thus similar to open surgery, this tech-
unilateral “hot” thyroid nodule that is refractory to nique uses a retractor and two operative instruments.
medical management could also be candidates for this The ProGrasp retractor is used to provide traction and
procedure. The ideal patient has a small body frame, countertraction, allowing the surgeon to operate with
is nonobese, and has the ability to adequately two additional instruments. By placing the camera
hyperextend the neck. NDPerrier through the axillary incision and using an endoscope
with 30-degree down orientation, principles from open
488
CHAPTER 49 Robotic Thyroidectomy 489
TABLE 49-1 Equipment for Robotic Thyroid

surgeon preference and comfort with the procedure.
Lobectomy The patient cart is covered with sterile drapes and
positioned on the contralateral side of the operating
Robotic Instrumentation table. The patient cart is initially kept away from the
• 5-mm Maryland
operating table during the development of the working
• 8-mm ProGrasp with substernal port
• 5-mm curved Harmonic shears
space because the surgical assistant(s) will work across
• 30-degree endoscope (used in the rotated down the table to retract during the transaxillary approach.
position) (If the operating room is small we prefer to then
Standard Instrumentation add another layer of sheets over the robot to prevent
• Regular and extended-tip electrocautery knife inadvertent breach of sterile technique and start the
• Army-navy retractor × 2 case.)
• Sauerbruch retractors × 2 (7.3 × 1.9 cm; V-Mueller J09
CH800)
• Breast lighted retractor × 2 (8 to 15 cm in length) Surgical Technique
• Curved gently hemostatic forceps × 2
• Vascular Debakey forceps (extended length × 2)
• Mayo scissors (extended length) STEP 1. Patient positioning.
Other
• Chung’s retractor (see Figure 49-1) The patient is placed in the supine position. After general
• Table mount and suspension device (BioRobotics
anesthesia is induced, the arm ipsilateral to the thyroid
Seoul, Korea, or Marina Medical, Sunrise, FL)
• Ethicon Endopath graspers and forceps
mass is gently rotated nearly 180 degrees cephalad,
• Ethicon Endopath suction irrigator placed on an armboard, and padded (Figure 49-2A).
• Laparoscopic clip appliers for hemostasis.
• ENDO PEANUT 5-mm device (23 cm in length)
• Nurse prepares rolled Raytec 4 × 4s wrapped in two Appropriate padding is necessary at all pressure
places by silk sutures to pass with forceps into the field points. Having the peripheral intravenous catheter in
(measuring 1.5 to 2 cm in length). (See Gholami et al for the contralateral arm is also important to prevent
a description of this technique.)
kinking of the catheter. If a female patient has a
Robotic Configuration (for Right Thyroid Lobectomy)
generous breast size, we recommend taping the
• Arm 1—Maryland bipolar (5 mm)
• Arm 2—Harmonic shear (5 mm) pendulous breast caudally to avoid the bulge of
• Arm 3—ProGrasp (8 mm) the upper breast parenchyma in the operative
• Endoscope—30-degree rotated down field. NDPerrier
We have used this positioning without upper extrem-

ity neurovascular or orthopedic injury. However, an
surgery can be applied safely to this endoscopic environ- alternative position is that described by Ikeda (see
ment (Table 49-1 and Figure 49-1). Figure 49-2B).
The setup and placement of the Chung retractor is We prefer the alternative position as described by
critical to a successful procedure. We recommend Ikeda. Additionally, we routinely perform monitoring for
practicing the equipment setup several times prior to the median and ulnar nerves to avoid neuropraxia.
performing the operation. Understanding the proper This technology is used also by other thoracic
positioning of the nuts and bolts to achieve maximum surgeons and neurosurgeons to avoid neuropraxia.
elevation of the operative space can be difficult. EKandil
Positioning the blade in the space beneath the strap
muscles is important to allow for necessary torque for
gland exposure. NDPerrier I prefer a modified version of the Ikeda position. The
patient is placed on a small shoulder roll, and an
armboard is attached to the table from the side
contralateral to the incision. The armboard is centered
Room Setup and Anesthetic over the patient’s forehead and the arm is generously
Considerations padded and fixed to the armboard. This position is
compact and efficient and allows the patient-side cart
The operating table is positioned with the anesthesiolo- of the robot to be brought into the operative field
gist at the head of the bed. An endotracheal tube with without restriction. RBKuppersmith
a laryngeal nerve monitor may be used depending on
B
FIGURE 49-1. A and B, Chung’s retractor.
Whether using Chung’s (see Figure 49-2A) or Ikeda’s

We also use transparent split-sheet sterile drapes (3M
approach (see Figure 49-2B), this positioning rotates the
Steri-Drape long U drape) to provide better access to
clavicle superiorly, diminishing the distance between the
the surgical field and to keep the endotracheal tube
axilla and the midline thyroid bed. Proper positioning
under direct visualization by both the surgical and
is essential for surgical exposure, and patients who have
anesthesia teams during the entire operation. EKandil
limited shoulder or cervical range of motion require
careful consideration and may not be candidates for this
approach. Padding the forearm and especially the elbow
is essential to prevent neurapraxia and stretch injury. We prefer the use of a “thyroid” pillow, which pro-
The arm and shoulder should be at the same vertical vides support not only of the neck and shoulder but the
height, further minimizing risk for neurapraxia. upper back and scapula.
Incision
Arm 1: Maryland bipolar

Camera
Arm 2: Harmonic shear
Arm 3: ProGrasp
FIGURE 49-2. A, Patient positioning. B, Alternate patient positioning, as described by Ikeda.

C, Arm and instrument placement.
Although conventional training is to position the

patient on a shoulder roll or “thyroid pillow,” this step STEP 2. Skin Incisions
has proven to be unnecessary by many authors. We
rarely use it during this approach. We found that The patient should be marked preoperatively, ideally in
easier access to the superior pole can be provided the upright position, while still in the holding area. This
better by avoiding the need for placing a thyroid practice allows to surgeon to ensure the patient that the
pillow. We use a thyroid pillow in cases in which incision will be well camouflaged. The location of this
substernal goiter is present or when we plan to incision is determined by drawing a transverse line from
perform a central lymph node dissection. For patients the sternal notch laterally to the axilla. This marks the
who require thyroidectomy for substernal goiter, inferior limit of the incision. Then an oblique line 60
although it is still sometimes quite challenging, the degrees from the midline is drawn from the thyrohyoid
transaxillary approach provides a safe access to the membrane to the axilla. This marks the superior limit
substernal portions of substernal goiters, without a of the incision.
need for median sternotomy, and this provides great A 5-cm skin incision is made in the axilla just lateral
relief to the patient. EKandil to the anterior transaxillary fold at the posterior border
of the pectoralis major muscle.
to be modified to ensure that the port placement will

I typically mark the patient after anesthesia is induced
allow the instrument to reach the working space. This
and the patient is intubated, and prior to putting the
second incision is generally not made until the thyroid
arm into position. I make a 5-cm line in the axilla that
lobe is exposed and the retractor apparatus is suspended
is parallel and posterior to the lateral edge of the
because this allows the surgeon to better appreciate the
pectoralis major muscle. The arm is then placed back
optimal location for port placement. The trocar cannula
into its natural position to ensure that the incision will
should be advanced.
be hidden. When patients have large breasts, the
breasts are retracted medially to ensure the incision
will remain hidden. RBKuppersmith
STEP 3. Establishing the working space: the skin is
incised.
The inferior limit of the incision is directed posteriorly

A subcutaneous plane is developed superficial to the
toward the patient’s back to ensure that the incision
pectoralis major muscle fascia in a superomedial direc-
is well camouflaged. Otherwise, if a straight line is
tion toward the clavicle (Figure 49-3). The electrocau-
drawn, the inferior limit of the incision can be seen on
tery knife is generally used after the skin incision, and
the anterior chest. For that reason, preoperative
in order to prevent bleeding and muscle injury, the plane
markings in the holding area are preferred. Also, this
is superficial to the fascia of the pectoralis major muscle
approach can be offered safely to patients with breast
at all times.
implants. EKandil
We use a wound protector (Alexis wound retractor
Depending on patient anatomy and body habitus, a system from Applied Medical, CA), which is placed to
gentle-taper or even an S-shaped incision can be consid- protect the axillary wound edges from any heat
ered in order to accommodate the incision into the generated by the electrocautery or harmonic scalpel.
relaxed skin tension lines of this region. The Maryland EKandil
dissector, the 30-degree endoscope, and the harmonic
shears will be placed through the axillary incision (see Progressively longer retractors are used by the assis-
Figure 49-2C). tant: three-prong skin rakes, army-navy retractors, then
Initially we used second 0.8-cm skin incision, which Sauerbruch retractors. Because the incision is developed
can be made on the anterior chest wall, 6 to 8 cm medial medially, an extended-tip Bovie is needed. Suction evac-
and 2 cm superior to the patient’s nipple. (However, uation of smoke is very helpful. Obese patients create
these measurements vary based on the patient’s body additional challenges retracting and exposing adequate
habitus and body mass index). A trocar is used to estab- working space. If the distance between the axillary inci-
lish the tract. The third robotic arm can be docked to sion and midline is greater than 18 cm, the surgeon will
the cannula, and this arm can be used for thyroid retrac- at least encounter fatigue and difficulty, if not the impos-
tion in the midline with the ProGrasp retractor. However, sibility, of developing adequate exposure.
with experience, it is possible to place all instruments
through a single axillary incision, although we empha- Because creating the working space creates a deep
size that the surgeon should use this technique only after surgical tunnel with large vessels at its apex, I have
adequate experience and training. several “contingency” instruments present in the
operating room just in case significant bleeding
Surgeons should be familiar with the technique of occurs. These instruments include adequate suction,
placing the third instrument through a chest incision in long clamps, long surgical clip appliers, a laparoscopic
case it is difficult to arrange all of the instrumentation Harmonic scalpel, and a laparoscopic clip applier.
through a single axillary incision. With proper RBKuppersmith
development of the working space and familiarity with
spatial relationships between the robotic arms, the Because the tunnel is developed lateral to medial,
single axillary incision technique can be reproducibly two lighted breast retractors are used to maintain proper
performed. RBKuppersmith visualization.
A headlamp is preferred to maintain proper

To accomplish the procedure via a single incision,
visualization. We stopped using lighted breast
precise positioning of the instruments is necessary to
retractors and currently use Haney right-angle
ensure adequate mobility. NDPerrier
retractors. In addition, endoscopic exposure with a
5-mm, 30-degree-angled camera can be used to
Because of differences in patient body habitus or provide endoscopic dissection. EKandil
breast size, the location of the second incision may need
Sternocleidomastoid
muscle (SCM)
FIGURE 49-3. Identification of the sternal and clavicular heads of the sternocleidomastoid
muscle.
Next, the clavicle is identified and followed medially.

Using the Harmonic scalpel helps to develop a
By following the clavicle, this dissection leads naturally
reasonable space to place the Chung retractor later in
to the SCM.
the triangulated division between the sternal and
clavicular heads. EKandil
This can be challenging in obese patients, so paying
attention to the medial aspect of the dissection using
the Harmonic scalpel (Ethicon, Somerville, NJ) will help Exposure of the great vessels can make the surgery
with dissection and identification of the SCM. EKandil technically more challenging. In addition to
incorporating too much of the SCM, surgeon-
performed preoperative ultrasonography can be
The surgeon should then identify the triangulated
helpful to evaluate the caliber of the internal jugular
division between the medial (sternal) head of the SCM
vein, and the relative location of the great vessels to
and the lateral (clavicular) head of the SCM. The natural
the thyroid in the anteroposterior plane. If most of the
boundary between these two muscle bellies varies. In
thyroid is anterior to the great vessels, exposure and
some patients the division is quite clear; for other
dissection in the tracheoesophageal groove will be
patients, the surgeon will need to “find” this natural
easier and the great vessels will most likely not be
division. In general, I estimate that the sternal head
seen. If most of the thyroid is posterior to the great
constitutes the anterior third of the SCM; the clavicular
vessels, exposure will be difficult throughout the case
head the posterior two thirds. If the surgeon has diffi-
and great care will need to be exercised to retract the
culty locating this landmark, later exposure is compro-
vessels and to avoid injury. Care must be taken to
mised. If too much of the SCM is incorporated during
avoid inadvertent contact between the active blade of
the creation of the working space, the great vessels are
the Harmonic shears and the internal jugular vein in
exposed throughout the entire case. If too little of the
these cases. RBKuppersmith
SCM is incorporated, then the surgeon struggles to
work about this bulk when approaching the thyroid bed
and paratracheal groove. Once the SCM is found, the surgeon should develop
wide (cephalocaudad) access from the axilla to the
This can be the most challenging aspect of the midline neck. When elevating this skin, keep in mind
dissection. Keen observation of the pulse of the that the platysma is dehiscent over most of the posterior
carotid can offer insight because the dissection is triangle. The surgeon can avoid “buttonholes” into the
medial to its medial border. NDPerrier skin by having an assistant tent up or pull the skin away
from the tunnel. If a lighted breast retractor is used, the
surgeon can also dissect just deep and lateral to the

Placing the chest wall trocar after placing the Chung
retractor and thus minimize risk of skin injury. In
retractor will confirm the proper positioning of the
general, the working space should be developed from
chest wall retractor below the Chung retractor under
the clavicular head to just above the omohyoid muscle.
visualization. However, by placing the chest wall trocar
Usually the omohyoid muscle correlates nicely with the
prior to placing the Chung retractor, one would risk
superior pole of the thyroid lobe.
covering the entry of the chest wall retractor under the
The Chung retractor is then introduced under the
Chung retractor. EKandil
sternal head of the SCM and sternohyoid musculature.
Once these muscles are elevated, the surgeon will then
find the thyroid lobe, usually covered by the adherent
STEP 4. The da Vinci surgical robot is docked: instru-
sternothyroid muscle. As in open surgery, the uppermost
ments are introduced.
fibers of the sternothyroid muscle must also be dissected
off the superior pole of the gland. The 5-mm Harmonic curved shears are placed in the
robot arm corresponding to the surgeon’s dominant
hand. Chung recommends always having the Harmonic
The use of the Harmonic scalpel will help with the
in the patient’s “right hand” position, regardless of the
dissection of the strap muscles off the thyroid gland
side of the surgery; however, this may vary when using
and keep a nice avascular dissection plane. Division of
the “single-port” incision (see Figure 49-2C).
strap muscles is required while dealing with large
goiters or nodules larger than 4 cm. EKandil
In cases with large nodules, we still prefer using 8-mm
instruments through the axillary incision. This provides
Performing this maneuver now is important so that
the opportunity to switch the Harmonic scalpel to the
the surgeon can create an ideal working space. The
chest wall trocar to perform division of the isthmus.
working space should extend from just above the cla-
EKandil
vicular head to just above the omohyoid, in the cepha-
locaudad plane. From lateral to medial, it should be
developed from the axilla until well past the midline: in
Because the Harmonic shears do not have the same
other words, deep to and lateral to the mid- or lateral
freedom of motion as the other robotic instruments,
portion of the contralateral sternohyoid muscle. Then,
during the case, I will move the Harmonic shears
as the breast retractor is removed, the Chung retractor
between hands if that improves visualization or my
is inserted and suspended.
angle of approach. Typically, surgery from the
patient’s right hand side is more difficult and requires
In most cases the retractor can be placed under the this maneuver, more often than surgery from the left
strap muscles from the sternal notch and inferior to side. RBKuppersmith
the omohyoid muscle. This retracts the omohyoid
superiorly. In some cases the omohyoid may need
to be divided to obtain adequate exposure. The angles of the camera and instrument deserve
RBKuppersmith special attention to allow optimal visualization and
avoid instrument collisions in the wound. The camera
should be positioned low outside the wound and high
We often use the Chung retractor immediately after inside the wound, so that it can look down at a 30-degree
identifying and separating the sternal and clavicular angle onto the thyroid bed. The instruments should enter
heads of the SCM. Attaching suction to the retractor is high in the wound and angle down to a lower position
also useful. NDPerrier so that they are in a plane lower than the camera.
The dissection toward the mid- to lateral portion of the We systematically insert, align, and then deploy the
contralateral thyroid lobe is essential, not only while instruments under direct visualization to efficiently and
performing total thyroidectomies but also during strategically place them in positions that allow for
thyroid lobectomies. EKandil maximum mobility. NDPerrier
The anesthesiologist should reconfirm that the neck

and shoulders are adequately padded after suspending I use bariatric trocars for each instrument. This
the retractor apparatus. At this point the second chest allows the robotic arms to be spaced farther apart,
wall incision can be made. The trocar is inserted into making the docking of the instruments technically
the working space under direct visualization with the easier. RBKuppersmith
endoscope.
Strap muscles
retracted
Cricothyroid
muscle
Right superior
parathyroid gland
Thyroid
FIGURE 49-4. Delineation of the superior thyroid pole.
STEP 5: Thyroid dissection: the cricothyroid muscle and

superior thyroid pole are delineated (Figure 49-4). suction, and clips if necessary. An assistant with
an understanding of the steps of the operation
The superior thyroid pole is retracting both inferiorly and good communication with the console surgeon
and out of the upper aspect of the tracheoesophageal is imperative. NDPerrier
groove, using the 8-mm ProGrasp retractor. The supe-
rior thyroid vessels are then identified and coagulated
close to the gland using the Harmonic scalpel (Figure Before dissecting more deeply I recommend that the
49-5). Often the external branch of the superior laryn- robotic surgeon direct the dissection now inferiorly.
geal nerve can be readily seen. As the pedicle is mobi- Mediastinal veins and the inferior thyroid vessels are
lized, the superior parathyroid gland may be identified then ligated, and the inferior aspect of the gland is
along the superior and deep posterolateral aspect of the mobilized. The trachea is palpated to determine the
gland. midline. Identification of the trachea is an important
maneuver because it permits the surgeon to understand
the relationship of the thyroid gland to the tracheo-
Laparoscopic or robotic clip appliers should be esophageal groove and thus estimate the course of the
available in case the superior pole vessels are large, recurrent laryngeal nerve. In open surgery the percep-
or if the Harmonic shears fail to seal the vessel. tion of depth is intuitive; however, during robotic
RBKuppersmith surgery, experience is required to better delineate these
three-dimensional relationships. By clearly defining the
level of the trachea within the wound, the surgeon can
The bedside assistant can provide traction in the precisely estimate the tracheoesophageal groove and
tracheoesophageal groove to facilitate easy begin the search for the recurrent laryngeal nerve.
identification of the recurrent laryngeal nerve as it The inferior parathyroid gland is often identified
courses cranially. The role of the bedside assistant is after dividing the middle and inferior thyroid veins.
important to success by providing countertraction, Ligating the middle and inferior thyroid veins immedi-
ately adjacent to the gland minimizes risk of injury to
FIGURE 49-5. Division of the superior thyroid vessels.
the inferior parathyroid gland. The thyroid gland is then

provide suction in the field. The curve of the Yankauer
retracted medially and suspended using the ProGrasp
suction facilitates its placement into the field. A
retractor.
laparoscopic suction-irrigator can be helpful to remove
Use of the ProGrasp retractor to suspend the thyroid
blood from the field and improve visualization during
gland medially facilitates a two-handed dissection using
the case. An extended stimulator probe, designed for
the Maryland retractor and the Harmonic scalpel. As
spine surgery, can be used to stimulate the nerve
opposed to standard insufflating endoscopic thyroidec-
intraoperatively, if desired. RBKuppersmith
tomy, here robotic thyroidectomy facilitates the funda-
mental surgical principle of “traction-countertraction.”
The inferior thyroid artery and the recurrent laryn- As the dissection along the recurrent laryngeal nerve
geal nerve are identified. The inferior thyroid artery is proceeds superiorly, the superior parathyroid gland is
controlled once the recurrent nerve has been identified often identified. The branch of the inferior thyroid
and its course through the tracheoesophageal groove is artery that supplies the superior parathyroid gland
traced (Figure 49-6). should be preserved. The mechanics of the Harmonic
scalpel require that it is a non-wristed instrument, with
limited degrees of freedom. In addition, the tip of the
Routine nerve stimulation is performed via a special Harmonic scalpel becomes quite hot (80° to 100° C)
designed probe introduced into the field through the during activation. Therefore extreme caution should be
axillary incision by the assisting surgeon. EKandil used when this instrument is in proximity to the recur-
rent laryngeal nerve to minimize the risk of thermal
injury and resulting neurapraxia. We recommend allow-
ing 3 to 5 seconds to elapse between activating the
Having the bedside assistant retract the great vessels Harmonic scalpel and allowing this instrument to come
and deep tissue posteriorly can be helpful when trying within 5 to 10 mm of the recurrent laryngeal nerve
to identify the recurrent laryngeal nerve. My assistant (RLN). In addition, the surgeon can “cool” the acti-
uses a Yankauer suction to perform this retraction and vated blade by resting it on a 2-cm radiopaque sponge
placed within the wound by the bedside assistant.
Recurrent
laryngeal
nerve
FIGURE 49-6. Release of the thyroid lobe from the recurrent laryngeal nerve.
Facility and experience with the ultrasonic scissors and

We place the drain through a separate incision
Harmonic scalpel are crucial for safe and effective
posterior to the axillary incision. We think that this
robotic thyroidectomy.
provides better healing for the axillary incision. EKandil
The posterior suspensory ligament of Berry is released
from the trachea as the nerve is mobilized and swept
away from the gland.
Postoperative management is similar to open thyroid
Nerve stimulation is a critical step here, too. EKandil surgery. The drain can usually be removed on postop-
erative day 1 or 2. Patients are generally kept overnight
and discharged from the hospital the morning following
By using the 5-mm Maryland dissector and enhanced surgery. Because of larger working space, the risk of
microscopic visualization, it is often possible to remove postoperative airway compression from hematoma is
completely all thyroid tissue along the ligament. lower than with conventional open surgery, and it is also
Once released laterally, the isthmus is then divided reasonable to discharge patients on the same day of
using the Harmonic scalpel, and the resected thyroid surgery.
lobe is removed from the axillary incision. If there is a
concern for malignancy, a plastic “endo” bag can be Motivated patients can be discharged the same day of
used to deliver the specimen to minimize tumor spillage. surgery. We usually recommend an advanced cold
For smaller glands, sometimes the isthmus can be and compression regimen system that can help
divided earlier to facilitate the dissection. reduce pain and swelling. Many patients do not
A closed suction drain is placed through one end of require any pain medication in their postoperative
the axillary incision and the wounds closed with meticu- recovery. EKandil
lous cutaneous approximation.
malignancies using a gasless transaxillary approach. J Am

We observe all patients overnight. Many have Coll Surg 209:e1-e7, 2009.
higher pain medication thresholds in the immediate Kang SW, Jeong JJ, Yun JS, Sung TY, Lee SC, Lee YS, et al:
postoperative period from “vague discomfort” from Gasless endoscopic thyroidectomy using trans-axillary
the stretched muscles of the neck and anterior chest approach; surgical outcome of 581 patients. Endocr J
wall. NDPerrier 56:361-369, 2009.
Kang SW, Jeong JJ, Yun JS, Sung TY, Lee SC, Lee YS, et al:
Robot-assisted endoscopic surgery for thyroid cancer: expe-
rience with the first 100 patients. Surg Endosc 23:2399-
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CHAPTER
Paratracheal and Superior Mediastinal
50 Dissection (Transcervical)
Author Gary L. Clayman
Commentary by Jeremy L. Freeman, Gregory W. Randolph, Gianlorenzo Dionigi,
Ashok R. Shaha, and Randal S. Weber
Preoperative Evaluation Preoperative vocal cord examination is required in all

and Surgical Planning patients undergoing thyroid and thyroid cancer
All patients with recurrent or residual regionally meta- surgery. Vocal cord paralysis more sensitively
static papillary thyroid carcinoma should be demon- identifies extrathyroidal and/or extranodal disease
strated by ultrasound and confirmed by fine-needle than does high-resolution computed tomography (CT)
aspiration biopsy and cytology whenever feasible. scan imaging. Preoperative vocal cord paralysis in
recurrent thyroid cancer patients may be completely
asymptomatic. GWRandolph and GDionigi
At times, biopsy proof is not feasible but other

evidence is so compelling for malignancy that surgery
is justified (e.g., rising thyroglobulin and strong
With preoperative unilateral paralysis, it is of utmost
ultrasound evidence for a metastatic node such as
importance to discuss bilateral paralysis with the
hypervascularity or microcalcification). JLFreeman
patient and all its inherent problems should the
opposite nerve be injured during the procedure.
JLFreeman
Preoperative thyroid functions including analysis of
thyroid-stimulating hormone levels are needed in all
patients. Preoperative evaluation of vocal cord function
and laryngeal positioning (rotation) should be per- Patients presenting with recurrent central compartment
formed in all patients by either indirect or fiberoptic disease or recurrent thyroid cancer require an initial
examination. risk assessment of their previous thyroid cancer. It is
Subtle laryngeal dysfunction may require videostro- important to evaluate the extent of initial surgery and
boscopic examination to clarify functional laryngeal analyze the patient’s risk group. Most of these
issues. Normal-functioning recurrent laryngeal nerves patients probably had locally aggressive thyroid
rarely require sacrifice because of the presence of local cancer with extrathyroidal extension, large size, or
malignancy; however, knowledge of their function or previous paratracheal lymph node metastasis or lateral
lack thereof may affect the approach to areas of invasive nodal disease. Recurrent laryngeal nerve function is
thyroid malignancy. also very important, especially if the patient had a
Despite the preexisting paralysis of a unilateral temporary paralysis of the recurrent laryngeal nerve
recurrent laryngeal nerve preoperatively, transection of during initial surgery, which would place the patient in
a paralyzed nerve should be preoperatively discussed the high-risk category for reoperative surgery.
because the patient frequently experiences a further Parathyroid function and temporary severe
diminution in the quality of voice due to acute lack of hypoparathyroidism are also important considerations
vocal fold tone as well as the potential of loss of func- for reoperative thyroid surgery. ARShaha
tion of initially unaffected arborized branches.
499
Among younger patients (younger than 45 years and Subfascial recurrent disease in the laryngeal inlet and
especially those younger than 40 years of age), my cricothyroid membrane area can be easily surgically
general approach is to educate both the patient and the missed without appropriate preoperative appreciation
family members and observe patients with nonbulky and intraoperative verification of the completeness of
disease (less than 8 mm in size) and establish progressing surgery.
disease prior to recommending surgical intervention. Positron-emission tomography (PET) or CT scan-
ning has been used over the past decade. I have found
Increasingly there is a shift in thinking in endocrine
that PET can be useful in patients with dedifferentiated
oncology circles that small metastatic disease from
as well as differentiated cancers. It can be effective in
well-differentiated tumors may be observed without
discerning disease that may be otherwise difficult to
intervening, for evidence of aggressive biologic activity
visualize or assess with contrast-enhanced CT or ultra-
with a view to contemplating surgery should the latter
sound. I have generally found it to be very complemen-
declare itself. JLFreeman
tary to the other studies.
A surgical planning map, amalgamating the preop-
erative localization studies, is used to minimize the risk
High-resolution ultrasound and CT (at least 1.1-mm for persistent disease.
increments) imaging of the thyroid and conventional CT
of the chest should be obtained in the evaluation of
This is of paramount importance for proper planning
these patients. High-resolution ultrasound offers detec-
and to mitigate against recurrence. JLFreeman
tion limits as small as 2- to 3-mm metastatic or recurrent
deposits. The ultrasound encompasses both the central
compartment and lateral necks in a comprehensive
fashion. It is very important to review the localization studies
The thyroid CT scan is obtained from the skull base and know the exact extent of disease in the
to the midthoracic area in 1.1-mm increments. Both paratracheal or mediastinal area, which may be very
high-resolution ultrasound and the thyroid CT scan difficult to visualize with routine ultrasounds. Cross-
imaging are amalgamated in order to create the surgical sectional imaging can be very helpful in this situation.
plan. CT scan imaging is generally used for surgical It is also important to discuss the location of recurrent
planning in identification of disease in unpredicted or disease with the radiologist. The size of the recurrent
difficult to access areas including the parapharyngeal disease is also important because tumors smaller than
and lateral retropharyngeal spaces and subclavian and 1 cm may be extremely difficult to identify during
superior mediastinal locations. surgical exploration. Critical areas, such as the region
behind the jugular vein and near the carotid artery,
may be difficult to image and appropriate attention
I have on occasion seen CT imaging demonstrate should be paid during surgery. Disease smaller than
contralateral metastatic disease not appreciated on 1 cm may be observed, as it may be difficult to find
physical examination or ultrasound. JLFreeman during surgical exploration. Metastatic lymph nodes
that are PET positive are unlikely to respond to
radioactive iodine ablation and may be a definitive
High-resolution magnetic resonance imaging (MRI) indication for surgical resection. ARShaha
with contrast is an option for anatomic imaging of the
neck and mediastinum. Advantages are the avoidance
of iodinated contrast. Disadvantages include motion
degradation of the images if the patient swallows Patients who present with recurrent nodal disease or
during image acquisition. RSWeber central compartment disease need to understand
certain specific issues: (1) thyroglobulin levels may not
come down because the levels drop in only 30% to
Intraoperative ultrasonographic localization during 50% of patients; (2) the patient may present with
surgery is occasionally required when CT scanning fails additional lymph nodes, either in the same side of the
to reveal pathologically confirmed metastatic disease. neck, thyroid bed, or in the contralateral neck; (3) at
the time of surgery it may be difficult to find the
Our experience with intraoperative ultrasonography subcentimeter lymph node. It is not uncommon to
has not been favorable. We advise that unless have a situation in which neck nodes are “missing.”
preoperative imaging, including ultrasound and fine-cut These issues are important for patients to appreciate
CT scan with contrast, can localize disease, that because they may lead to considerable frustration
surgery not be performed. GWRandolph and GDionigi after surgery. ARShaha
CHAPTER 50 Paratracheal and Superior Mediastinal Dissection (Transcervical) 501
Operative Technique more rational and intelligently directed subsequent

dissection. It can also be used as an aid in dissection
In the majority of instances these procedures are per-
once the nerve is identified, similar to how nerve
formed for recurrent or “persistent” disease. For the
stimulation is used in tracing the facial nerve through
remainder of this chapter, only the differences between
a difficult parotid. It is important to note that neural
patients with a previously untreated thyroid malignancy
monitoring may be used through vagal stimulation
as compared with those with recurrent or persistent
to ensure that the system is working well at the
disease will be mentioned when they separate these two
beginning of surgery and to effectively prognosticate
entities.
nerve function postoperatively at the end of surgery.
All surgery is performed with a minimum of three-
This nerve testing function at the completion of
fold loupe magnification. In more extensive disease, dis-
surgery should be appreciated within the context
sections may advance to fivefold or binocular microscopic
of the currently available alternate test, which is
dissection. Although I use recurrent laryngeal monitor-
simple visual inspection of the nerve and has been
ing primarily for educational issues, the monitor is not
shown to identify only 1 out of every 10 injured
used for nerve localization or decision making in patient
nerves. GWRandolph and GDionigi
intraoperative management.
I have not found monitoring of particular use. It is no

substitute for a solid knowledge of anatomy and good
Preoperative localization is very important in patients
surgical technique. JLFreeman
undergoing surgery for both central compartment and
lateral neck dissection. It is important to identify the
For hemostasis, both bipolar electrocautery and vas- disease and its exact location. The preoperative
cular suture ligation are used. Surgical clips are not cross-sectional imaging studies should be reviewed
recommended in patients because imaging, particularly with the radiologist, including an ultrasound or CT
any cross-sectional CT or MRI techniques in follow-up, scan. It is important for the surgeon to know the exact
will be plagued with scatter artifact and make these location of the recurrent disease in relation to the
monitoring strategies suboptimal. surrounding normal structures such as cricoid cartilage
or the tracheal rings. If arrangements can be made,
a preoperative ultrasound on the day of surgery may
I underscore this statement. JLFreeman
be of help. If the lymph node is subcentimeter, a
preoperative transcutaneous injection with a blue dye
Recurrent laryngeal nerve monitoring is helpful, even or charcoal may be helpful. Needle localization with a
though it is rarely necessary in primary surgical curved needle placed percutaneously may be of help,
procedures. Even though one tries to find the just like needle localization of the breast. Intraoperative
recurrent laryngeal nerve in the inferior portion where localization may be difficult and intraoperative
there was no previous dissection, it is not uncommon ultrasound has been difficult; however, it is difficult
to find the recurrent laryngeal nerve entangled in the to localize recurrent disease when the neck is
scar tissue, where it may be extremely difficult to open. ARShaha
localize or dissection may traumatize the branches of
the nerve. Recurrent laryngeal nerve monitoring is also
helpful if the patient has unilateral vocal cord paralysis, STEP 1. With a marking pen, mark the incision’s cepha-
to monitor the other side. It is also helpful if there is locaudal location with the patient awake and in a seated
substantial injury to one side, then a limited dissection position.
may be performed on the other side in an effort to
avoid bilateral vocal cord paralysis. The technical In those patients with recurrent or persistent disease
pitfalls of recurrent laryngeal nerve monitoring circumstances, the incision designed is usually dictated
should be corrected before the surgery begins. by the patient’s prior surgical procedure(s). Unless the
Intraoperatively, vagal stimulation identifies whether incision location is far outside of reason for this
the nerve monitoring system is working well. ARShaha approach, even a cephalad-located thyroid incision can
be extended laterally in a cosmetic fashion to allow for
adequate flap elevation and visualization. In general, the
There is no question that intraoperative neural incision can be reexcised (for cosmetic optimization or
monitoring is helpful in both primary and revision if prior contamination is a concern) and extended in the
surgery. It can be helpful to map out the nerve through lower neck creases to the midpoint of the sternocleido-
a difficult scarred paratracheal region allowing for mastoid muscle continuing in the same cephalocaudal
direction as the thyroidectomy incision.
head by moving the table about 2 feet away from the

Generally, revision thyroid cancer surgery can be
anesthesia machine.
performed without reexcision of the scar unless scar
revision is part of the plan procedure. GWRandolph
and GDionigi I prefer following intubation to rotate the operating
table 180 degrees with the patient’s feet at the
anesthesiologist. This permits the second assistant to
A detailed description of location and design of the
stand at the patient’s head and facilitate retraction
thyroid incision is found in Chapter 47. The incision
without interfering with the surgeon’s access to the
length for total thyroidectomy and concomitant central
patient. Also this orientation allows the surgeon to
compartment dissection of 4 to 5 cm adequately pro-
stand at the head of the bed while the first and
vides access and visualization for this procedure in pre-
second assistants are at the patient’s side. The
viously unoperated patients. Further extension laterally
surgeon’s position at the head of the bed facilitates
can be used for those patients requiring an anterolateral
the lower cervical and upper mediastinal dissection.
level II through V dissection as well.
RSWeber
The incision is designed in a collar approach approx-
imately 2 to 3 cm above the sternal notch extending
from midsternocleidomastoid muscles bilaterally unless Positioning the patient on the operating table is
a comprehensive lateral neck dissection is required. The crucial. Generally I prefer both hands to be tucked in
incision should approximate the level of the cricoid because this is helpful for the surgeon and the
cartilage. The incision appears slightly “high” in the assistant on both sides to keep the arm out of the
patient’s neck initially, but healing and time place it way. The head should be on the head plate of the
more inferiorly in the vicinity of the suprasternal notch table so that the plate can be moved up and down as
depression. necessary. I generally do not prefer a shoulder roll
because the shoulders can become unstable. I prefer
In patients who have had previous surgery, obviously three sheets stacked on each other. Because the
one is bound by the position of the previous scar. scapula is a flat bone, stacked sheets are very helpful.
JLFreeman We do prefer a transparent drape on the chin area so
that the endotracheal tube can be visualized at all
times during surgery. ARShaha
In lateral neck dissections I have not found the need
to release the incision except by extending the incision
more laterally, paralleling the collar line into level V.
In individuals with particularly long necks it may be

necessary to curve the incision toward the ear for STEP 4. Field anesthetic is used with 0.5% mepivacaine
exposure. JLFreeman 1 : 200,000 epinephrine.
This provides both postoperative pain management and

Vertical release of the incision is cosmetically inferior incision hemostasis without cautery. Anesthetic also
and prone to hypertrophic scar generation. facilitates postoperative pain management.
I have deliberately discouraged this maneuver for two

STEP 2. The patient is initially positioned with the back
reasons. First, I think that some patients may have
section of the table elevated to reduce venous conges-
“rebound” vasodilatation after the epinephrine effect
tion and the table placed in Trendelenburg to facilitate
wears off and this may predispose to hemorrhage.
the initial flap elevation of the surgery (a lounge chair
Second, novice anesthetists who have tried to help
position).
minimize pain by performing this but without
knowledge of anatomy have inadvertently temporarily
paralyzed the recurrent nerve or phrenic or brachial
I prefer reverse Trendelenburg to facilitate venous
plexus. JLFreeman
drainage and minimize bleeding. JLFreeman
STEP 5. The incision is made with a scalpel through to

the subcutaneous tissues.
the neck. I leave the patient with the head toward the Attention to detail in incising and handling skin reduces
anesthesiologist and simply request space around the cicatrix hypertrophy.
STEP 6. Electrocautery is used to incise the subcutane- anterior jugular vein may not work because it slips off
ous tissues deep to the platysma to the fascia envelop- and the patient may have bleeding in the recovery
ing the strap musculature and the communicating room, especially when the patient coughs or
anterior jugular veins. bucks. ARShaha
Although skin flap elevation is generally immediate sub-
platysmal in neck dissections, in thyroid surgery, espe-
cially in obese individuals (in the midline), elevating at
STEP 9. The anterior fascia over the medial third of the
the level of the investing fascia of the anterior jugular
sternocleidomastoid muscle is skeletonized with elec-
veins eliminates the potential need for lipectomy.
trocautery dissection from the level of the hyoid to its
The site of previous incision is excised through to
sternal insertion bilaterally.
the subplatysmal level and sent for routine pathologic
analysis.
STEP 10. The sternocleidomastoid muscle is laterally
STEP 7. The flaps are elevated to the hyoid bone supe- retracted with a five-prong rake and its medial and
riorly and at least 3 cm below the level of the sternal ventral surface skeletonized, exposing the anterior
notch and clavicles more laterally. surface of the internal jugular vein.
Once the medial surface begins to mobilize, I prefer

I do not elevate as high as the hyoid for a pure Richardson retractors to limit trauma to the ster
central compartment dissection because I very nocleidomastoid.
rarely encounter metastatic nodes above the cricoids.
JLFreeman
At this point I think that optimal exposure is mandatory
so I divide all the straps horizontally midway between
the cricoid cartilage and the sternal notch. This
facilitates subsequent identification of critical anatomy.
I then reflect the cut ends of the straps cephalad and
opened with the electrocautery.
caudad. These can easily be reapproximated at the
Do not limit your visualization inferiorly by inade-
end of the procedure. JLFreeman
quate elevation and retraction of the inferior flaps.
In previously dissected necks, the internal jugular

STEP 8. The flaps are suspended with the use of 2-0 silk
vein can be found surprisingly superficial within the
neck and may be significantly adherent to the ventral
a moistened sponge to keep from drying.
surface of the sternocleidomastoid muscle. This is
Although some individuals prefer self-retaining retrac- nevertheless an indication for meticulous technique and
tors, I have not used them and prefer suture suspension not vein sacrifice.
to anchored drapes on the patient. The internal jugular vein is identified as the most
lateral point of the dissection unless lateral compart-
I have tried many different types of flap retraction, ment disease has been preoperatively identified (high-
including self-retaining ones and dural hooks, and find resolution ultrasound or CT scan) and thus requires
simple suturing works best. JLFreeman level II through V dissection. Note that carotid/vertebral
lymphadenopathy is frequently a site of metastases in
thyroid malignancies but may be misinterpreted by
A Mahorner, a self-retaining retractor, is very helpful ultrasound as central compartment disease.
in thyroidectomy. However, generally an incision has
to be larger than 2 inches to place the Mahorner
retractor, otherwise the transverse diameter decreases I agree that this is an often ignored area that if not
considerably. The usual standard retraction with a rake attended to may result in undetected and untreated
retractor or army-navy retractor is helpful. Fish hooks metastatic disease. JLFreeman
may be used to retract the skin superiorly and
inferiorly. ARShaha
Dissection of the carotid/vertebral locations requires
a comprehensive anterior level V and IV dissection. This
If the anterior jugular veins are injured, they should be site is well visualized on cross-sectional imaging but
ligated superiorly and inferiorly. The usual tie on the infrequently dissected in the standard aerodigestive tract
“modified neck dissection.”
These points are important in individually strategizing STEP 13. In those patients previously unoperated on, the
the approach to dissection. JLFreeman ventral surfaces of the strap musculature are skeleton-
ized via a midline approach to the lateral surface of
these muscles.
Even though traditionally we use the term modified
Although there is no difference in the dissection tech-
neck dissection for neck dissection, there are a variety
nique, in those circumstances in which the paratracheal
of different terms used. Radical neck dissection is
pathology is identified with the initial thyroidectomy
rarely used for thyroid cancer; however, preserving
procedure, the strap musculature has not been violated
the lymphoid tissue or the internal jugular vein,
in a prior surgical procedure and has not been “theoreti-
sternomastoid muscle, and accessory nerve are
cally seeded” and therefore these muscles need not be
referred to as modified neck dissection. Several other
removed.
terms, such as selective nodal dissection or
compartment oriented neck dissection, are also used.
The best nomenclature, however, is to describe the “Seeding” with true muscle invasion is a rare event,
surgical procedure—what was removed and what was but the surgeon should be cognizant of this possibility
retained. Every attempt should be made to preserve and be prepared to take the necessary extirpative
the accessory nerve because it has a major functional steps. JLFreeman
effect on the patient. ARShaha
However, adequate retraction of these muscles is

In revision lateral neck dissection the carotid artery
necessary, and they may also be released inferiorly and
generally offers a reliable plane. However, the
reapproximated if so desired. Otherwise the dissection
previously operated-on jugular vein can be adherent to
is carried out identically.
surrounding postsurgical scar. It is especially
In recurrent or persistent cases, the strap muscles
important to avoid jugular entry in the neck base
may be implanted, and pathologically disease has been
adjacent to the clavicle. GWRandolph and GDionigi
found between muscles and lateral to muscles indicating
disease outside of predicted locations; thus in recurrent
cases, especially in patients greater than 45 years of age
or those which have undergone more than one surgical
STEP 11. The common carotid artery is identified more
procedure in this area, these muscles are most frequently
medially along its anterior surface.
sacrificed.
Generally speaking, working in areas more distant from
the prior dissection are pursued to safely identify neural I rarely sacrifice the straps except for invasive disease
and vascular structures and then safely transitioned into but in the event that this is done, reconstruction
the previously surgically managed areas. of the midline straps is done using a portion of the
sternomastoid muscle as described in Figure 50-1.
JLFreeman
STEP 12. The common carotid artery is dissected along
its anterior surface from the level of the digastric to the
innominate artery (left) and the subclavian artery (right). In the event that the straps have been sacrificed, I
Based on patient age, cervical flexibility, and general believe that it is important to cover the trachea
anatomic differences, this dissection may reach signifi- anteriorly with muscle, again to prevent tethering with
cantly inferior to these vessels. speech and swallowing. This can be easily done by
re-creating bilateral straps by longitudinally dissecting
and separating the medial aspect of both
I believe that the key to anatomy identification in this
sternomastoid muscles thereby creating bilateral
operation is comprehensive dissection of the common
inferiorly based muscle flaps that may be
carotid artery. The vessel anatomy is constant and the
reapproximated in the midline and replacing the
easiest to identify with all other structures generally
sacrificed straps. JLFreeman
bearing a uniform relation to this artery. I commonly
do not dissect the vessel as high as the digastric
because I find this unnecessary but I do dissect the Although strap muscle resection is not required it may
right common carotid inferiorly as it turns into the be helpful in some circumstances other than invasive
innominate artery and then dissect the latter to disease in order for complete nodal removal of
demonstrate it in the mediastinum. I dissect and small nodes within the paratracheal region, which
display the left common to the mediastinum as may be adherent to the under surface of the
well. JLFreeman muscles. GWRandolph and GDionigi
Thyroid cartilage
Sternothyroid m.
Sternohyoid m.
Common carotid a.
Vagus n.
Internal jugular v. FIGURE 50-1. The lateral approach to the paratracheal
dissection and superior mediastinum from the patient’s
right. Note that the carotid artery has been dissected
from the subdigastric area to the subclavian artery. The
strap muscles are being released from their sternal
insertions as caudad as possible.
Disease in unusual locations is not surprising consid- When dissecting into the superior mediastinum, I lower
ering the most common approach to the thyroid bed is the patient’s head to a near flat or even Trendelenburg
through the median raphe of these muscles. In most position (also raise the bed) and reposition myself at the
circumstances, the infrahyoid strap musculature is head (top) of the table instead of standing at the patient’s
released at the most inferior extent of the sternal attach- side. This provides a very important vantage point in
ments in order to provide adequate access to the supe- visualizing and dissecting the superior mediastinum.
rior mediastinum. As the carotid and subclavian arteries are dissected
with mosquito hemostats along their lateral border, the
After the skin flaps are elevated I divide the straps strap musculature is released. The common carotid
vertically in the midline. In reoperative cases I separate artery is dissected along its lateral surface to the innomi-
the sternohyoid and sternothyroid muscles. This plane nate and subclavian arteries.
has usually not been dissected during the initial The release of the strap muscles must be done with
surgery. If there is no invasion of the sternohyoid meticulous dissection and bipolar or monopolar cautery
muscle by recurrent disease, I preserve this muscle. In for a dry surgical field. Once the strap musculature is
reoperative cases I routinely resect the sternothyroid released, the superior mediastinal contents are ready to
muscle to facilitate dissection and address seeding of be delivered and dissection can, in most circumstances,
this muscle. After the straps are divided and retracted, extend to the level of the aortic arch.
I palpate the ligament that is palpable in the sternal
notch. I bluntly dissect the soft tissue away from the
posterior aspect of the ligament and divide it to the The fibroareolar tissue and thymic remnant envelope
sternal notch. This facilitates increased inferior draining veins that empty into the brachiocephalic,
exposure for the mediastinal dissection. RSWeber lower internal jugular, and the subclavian veins. It is
important to ligate these structures meticulously to
avoid hemorrhage. Also, retraction on these veins
STEP 14. A prevascular dissection along the subclavian should be done with gentle technique to avoid
and innominate arteries provides safe release of these avulsing them from the major vessels. RSWeber
muscles and excellent visualization of the superior
mediastinum (see Figure 50-1). Note that the anterior jugular vein is usually domi-
nant bilaterally and is located on the lateral surface of
As mentioned, early in the procedure the straps are the sternothyroid muscle. I generally stick-tie this vessel
divided horizontally between the cricoid and the because its variable drainage may create a retrograde
sternal notch. The cut ends are then reflected venous ooze from the subclavian vein that may be dif-
cephalad and caudad, respectively to maximize ficult to locate once this vessel is sectioned.
exposure of the central compartment and superior
mediastinum. These muscles are then reapproximated The best instrument for this surgical exploration is the
at the end of the procedure to avoid unsightly long Adson (tonsil) clamp. Micro mosquito clamps are
tethering of the skin overlying the trachea with speech quite helpful and are generally available in the plastic
and swallowing. JLFreeman surgical set. These are very helpful to dissect along
Thyroid Paratracheal
cartilage disease
Trachea
Recurrent
laryngeal n.
FIGURE 50-2. The subclavian, carotid, and cephalad

components of the aortic arch facilitate the identification
of the recurrent laryngeal nerve along the
tracheoesophageal groove. The gently curved fine-tipped
instrument dissects along the long axis of the arborized
branches of the recurrent laryngeal nerve.
the nerve or control minor bleeding. Bipolar previously dissected paratracheal region, below the
electrocautery is crucial for this dissection, especially previous surgeon’s scar. This area can be “un-roofed”
if there is minor bleeding along the recurrent laryngeal by dividing the lateral-most portion of the sternohyoid
nerve. The Harmonic scalpels may be used, especially muscle where it fans out to its clavicular insertion
for transecting muscles or dissecting soft tissues over the carotid artery. This maneuver allows a full
mainly in the inferior portion. The Harmonic scalpel visualization of the inferior-most paratracheal
can help control the inferior thyroid veins, which may region. GWRandolph and GDionigi
retract in the superior mediastinum and are difficult to
ligate. ARShaha
STEP 16. Once medial to the carotid arteries, identifica-

STEP 15. The recurrent laryngeal nerve (or nonrecurrent tion of parathyroid glands must always be considered.
laryngeal nerve) must be identified once the medial
Permanent hypoparathyroidism is a known and, in
aspect of the carotid artery and superior mediastinal
some circumstances, a potentially preventable operative
great vessels have been dissected (Figure 50-2).
risk. The inferior parathyroid glands can rarely be main-
It is best to identify the recurrent laryngeal nerves in tained on an effective vascular pedicle, whereas superior
areas previously undissected or with minimal dissection. parathyroid glands can remain vascularized in some
In this regard, the laryngeal nerves are most frequently circumstances.
easily identified more inferiorly in the paratracheal or If parathyroid tissue is identified distinct from recur-
superior mediastinal areas. Gently teasing the fascia rent carcinoma and becomes devascularized, it should
away from the lateral surface of the nerve along its long be immediately finely minced and frozen section patho-
axis with a combination cottonoid and mosquito pro- logically confirmed.
vides rapid identification of the nerve. Due to the nature of bilateral paratracheal dissec-
tion, the vascular blood supply to parathyroid glands is
frequently abrogated and at least a portion of even in
This is a key step in the operation and I completely
situ preserved superior parathyroid glands should be
agree with the strategy and technique. JLFreeman
considered for autotransplantation to minimize the risk
of long-term hypoparathyroidism.
Nerve stimulation and mapping prior to nerve Facilitation of parathyroid localization in recurrent
visualization allow for extremely directed subsequent thyroid surgery involving the central compartment
nerve dissection. The nerve can be completely should be considered. Both preoperative sestamibi injec-
electrically mapped out within the scarred paratracheal tion as well as methylene blue intraoperative intrave-
region with the nerve monitor prior to dissection. This nous delivery may be used to facilitate parathyroid
technique coupled with good surgical skill and gland localization. Although sestamibi may only facili-
knowledge of anatomy adds a functional dynamic to tate identification of glands in approximately 10% of
the surgery that can be tremendously helpful. The patients, it must be noted that nothing has more exuber-
nerve can be found in the inferior-most portion of the ant uptake of sestamibi than recurrent papillary thyroid
carcinoma in cervical metastases.
Superiorly, the dissection posterolateral to the nerve is

Identification of parathyroid glands is done best
performed, generally, not in continuity.
by visualization; however, in a previously operated
and scarred field this may be exceedingly
In many cases metastatic lymph nodes are found
difficult. JLFreeman
deep to the recurrent nerve. In these cases the nerve
is mobilized and gently retracted with a blunt nerve
Ex vivo analysis of specimens prior to submission hook. The fibroareolar tissues between the carotid
for pathologic analysis may be required to identify laterally and esophagus medially are dissected from
parathyroid tissue clearly separable from metastatic lateral to medial, thus skeletonizing all of these
carcinoma. structures. RSWeber
Identification and preservation of the parathyroid

glands are very important in reoperative surgery. Every The right paratracheal region is anatomically more
attempt should be made to preserve the parathyroid complex than the left for two reasons: First, the
glands with their blood supply. However, due to recurrent laryngeal nerve on the right tends to ascend
previous surgery and scarring, this may be difficult. If the right paratracheal region by running diagonally
the structure appears as a parathyroid and is through it. The left recurrent laryngeal nerve tends to
devascularized, autotransplantation, preferably in the travel in a more strictly tracheoesophageal groove
contralateral sternomastoid muscle, should be location typically. Second, the right paratracheal
attempted. I have not used the trapezius for region has greater depth than the left due to the fact
autotransplanting the parathyroid; however, the that the innominate artery and inferior right common
parathyroid can be easily transplanted in the carotid artery and subclavian bifurcation extend ventral
contralateral sternomastoid so that if one needs to the trachea. The obliquely running right recurrent
reoperative surgery in the same side of the neck, the laryngeal nerve and the depth of the right paratracheal
parathyroids can be preserved on the other side. There region allow for more locations within the right
is hardly any reason to autotransplant the parathyroids paratracheal region to harbor sometimes difficult to
in the forearm in thyroid surgery. However, before identify nodal disease. GWRandolph and GDionigi
transplanting the parathyroid gland, one should take a
small piece for biopsy to confirm that it is indeed In cases of unilateral paratracheal disease, the con-
parathyroid tissue and not a lymph node or, especially, tralateral recurrent laryngeal nerve is identified and the
metastatic thyroid cancer. ARShaha paratracheal area inspected for disease. In order to
dissect, the operating surgeon moves to the side of the
paratracheal area that is being dissected.
STEP 17. Gentle microdissection of the recurrent (or
In the absence of identified contralateral disease, the
nonrecurrent) laryngeal nerves is required in a stepwise
contents medial to the recurrent laryngeal nerve are
fashion to mobilize the laryngeal nerves and provide
freed from their fascial attachments to the nerve and the
comprehensive level VI dissections.
pretracheal fascia elevated toward the effected side of
The laryngeal nerves are meticulously microdissected disease in the prevascular mediastinal vessel plane.
into their laryngeal inlet identifying the frequently arbo- Meticulous microdissection of even the only func-
rized laryngeal branches and sparing them in their tioning laryngeal nerves can be safely performed
entirety. using meticulous microdissection techniques (avoiding
A combination technique of low-power setting tracheostomy).
bipolar cautery and microscissors dissection is used.
With each release of fascia, the nerves are gently poste- At times, metastatic disease occurs under the
riorly displaced with the use of a cottonoid. This recurrent nerve(s); this necessitates carefully
alternating approach to dissection and mobilization dissecting the nerve(s) from the disease and then
minimizes nerve trauma and effectively (in a stepwise delivering the nodes in continuity with the central
fashion) identifies arborization of the nerve. Larger specimen. Invasive disease may be dissected sharply
vessels, including the inferior thyroid artery, are suture from the nerve but it may be impossible to separate
ligatured. nerve from disease, so sacrifice of the nerve may be
Dissection medial to the nerve is required. Lateral necessary to remove the disease. I have frequently
dissection to the nerve is required for more extensive encountered metastatic nodes lateral to the nerve and
disease but greatly increases the risk of hypoparathy- lying on the esophagus. Removing these as a separate
roidism especially with bilateral dissections. This step- specimen is safe and preferable to trying to pass them
wise approach to the recurrent laryngeal nerve dissection under the nerve to maintain an en-bloc resection for
provides lateral mobilization of the nerve and medial- no good reason. JLFreeman
ization of the paratracheal contents more inferiorly.
Thymus
gland
Subclavian v.
Common carotid a.
Vagus n.
FIGURE 50-3. The superior mediastinal contents Internal jugular v.
are stepwise freed from their inferior attachment.
The thymic lobes are clamp ligated due to inferior
venous and lymphatic drainage.
Stick-tying the most inferior aspect of the inferior

Dissecting the central compartment and removing the
thymic lobes is critical because of their venous outflow
recurrent thyroid cancer may lead to temporary or
into the subclavian venous systems.
permanent nerve injury. It is crucial to dissect the
nerve carefully and avoid any trauma. Injury to the
vasa nervosum may lead to temporary nerve
I have found a useful technique of dissection in this
weakness. If this occurs on both sides, the patient
area—I call it the pinch-burn technique. I use a fine
may have airway-related issues. Generally I prefer to
ophthalmic bipolar cautery. If one grasps the tissue
extubate the patient in the operating room or recovery
between the tips and applies the current, with gentle
room if there is any airway-related issue. If the patient
“pinching,” the coagulated tissue then falls apart. This
has difficulty in breathing, we would generally
allows very precise cautery and cutting simultaneously,
reintubate and observe the patient for 24 hours with
providing an accurate bloodless dissecting technique
steroids and conservative measures, then extubate
that is safe, fast, and precise. This is especially
after 24 hours. If the patient still has airway-related
effective when removing the central compartment from
problems and stridor, an elective operating room
the innominate artery. JLFreeman
tracheotomy is preferred. ARShaha
STEP 19. The superior mediastinal and paratracheal

Neural monitoring stimulation of the nerves at
contents are then stepwise freed from the pretracheal
the level of the vagus at the completion of surgery
fascia.
provides accurate prognostic information on which
perioperative airway planning can be made. Electrocautery in the pretracheal fascial plane can be
GWRandolph and GDionigi safely used as long as the recurrent laryngeal nerves are
visualized at least 1 cm from the nerves.
STEP 18. Once the recurrent (or nonrecurrent) laryngeal

nerves have been dissected into their respective laryn- STEP 20. The infrahyoid and infrathyroid strap muscula-
geal inlets, the thymus and superior mediastinal con- ture is then released from its more superior attachments
tents are freed from their inferior mediastinal vascular (Figure 50-4).
supply in a stepwise meticulous hemostatic fashion
(Figure 50-3). The superior thyroid artery and vein are usually sacri-
ficed more proximally and the superior laryngeal nerve
It should be noted that frequent vascular structures sup- identified and preserved.
plying the thymic and mediastinal lymph nodes may
originate or drain into the aortic arch and subclavian
venous structures, respectively. I prefer tying these This is an important step to maintain vocal
vessels in order to maintain a dry surgical field over integrity. JLFreeman
bipolar techniques.
Sup. thyroid a./v. Thymus

Sup. laryngeal n. gland
Paratracheal FIGURE 50-4. The superior laryngeal nerve is

Sup. Inf. disease
Recurrent spared and the sternohyoid and sternothyroid
laryngeal laryngeal n. thyroid a. muscles released superiorly to connect to the
a./v.
Sup. parathyroid inferior dissection and arborized recurrent laryngeal
gland nerve dissection more inferiorly.
STEP 21. Attention to previously retained thyroid tissue

or carcinoma in the pyramidal and superior lobe areas
is addressed at this juncture.
Sup. laryngeal n.
Sup. thyroid a. /v.
This is an important step to ensure that all thyroid
tissue, both benign and malignant, has been
Sternothyroid m.
extirpated. JLFreeman Sup. parathyroid
gland
Common
carotid a.
Vagus n.
Sternohyoid m.
Pretracheal lymph nodes may also be located in the
cricothyroid membrane area as well as superiorly toward
the hyoid in the midline. Internal
jugular v.
Lateral persistent disease may also be found in Inf. thyroid a.
retained thyroid superior pole structures. Less fre-
quently, lymph nodes in the area of the constrictors of Recurrent
the pharynx and esophagus, and lateral and medial to laryngeal n.
the recurrent laryngeal nerve at its inlet may be found.
Subclavian a.
STEP 22. The lateral surface of the thyroid lamina is then
identified in a supraperichondrial and muscular dissec- Inf. thyroid v.
Subclavian v.
tion with direct visualization of the arborized laryngeal
nerves into the inlet area.
STEP 23. The resultant dissection including the common

carotid arteries, vagus nerve, innominate artery, subcla- FIGURE 50-5. Completed central compartment dissection
vian artery, subclavian veins, recurrent laryngeal nerves performed for multiply recurrent disease. Note the resected
(or nonrecurrent), laryngeal nerves, superior laryngeal sternothyroid and sternohyoid muscles are spared in
nerves, esophagus, and tracheal and laryngeal organs previously unoperated-on patients but the resultant dissection
deep to those structures is unaltered.
are all preserved (Figure 50-5).
that the patient does not have a retroesophageal

Incidence of a nonrecurrent laryngeal nerve is rare, subclavian artery or innominate artery. If such an
occurring in less than 1% of patients. However, if the abnormality is noted (arteria lusoria), the patient is
patient had a CT scan performed for other reasons, more likely to have a nonrecurrent recurrent laryngeal
the surgeon should review the scan to make sure nerve. ARShaha
into a luer-lock syringe in 3 mL total volume. Addi-

I infrequently carry the dissection as high as the hyoid
tional serum or tissue salt is used to wash the Petri dish
because the vast majority of central compartment and
to obtain any retained cellular content.
paratracheal and superior mediastinal disease is
An 18-gauge needle is then inserted into the desired
restricted to the region below the cricoid cartilage.
site of autotransplantation. In patients with recurrent
Occasionally I dissect somewhat higher with the
papillary thyroid carcinoma, the midbody of the trape-
detection of positive delphian nodes. JLFreeman
zius muscle is chosen for autografting. The needle is left
in the intramuscular position and an additional 1 mL is
drawn into the syringe to further wash out the syringe.
STEP 24. Intraoperatively, the specimen is maintained
With more than 15 years of experience with this tech-
sterile, and a rapid parathyroid hormone level may be
nique, no autografted complications have occurred.
obtained to confirm intact parathyroid function. Identi-
fied and confirmed parathyroid tissue is autotransplanted
I usually dice the parathyroid with a No.15 blade and
using an injection technique as described following.
insert the tissue into a well-vascularized muscle
pocket and secure the graft with a figure-eight suture
I do not have experience of intraoperative parathyroid of 4-0 Vicryl. This is just one of many ways to
hormone (PTH) for thyroidectomy, even though we autotransplant. JLFreeman
have a good experience with parathyroid surgery.
Intraoperative PTH, if normal, confirms some
The authors have used an 18-gauge needle for
parathyroid function and the likelihood of getting the
autotransplanting the parathyroid, but I generally
patient off calcium supplementation in the future.
perform this by exposing the sternomastoid muscle,
However, it does not predict who requires calcium
opening the fascia on the sternomastoid, dissecting
supplementation or extended hospitalization. ARShaha
the muscles, and autotransplanting the multiple pieces
of parathyroid tissue. I generally put a staple or silk
stitch to identify the location, which may be helpful in
STEP 25. Powdered Avitene is placed in the paratracheal future reexploration. ARShaha
areas and then Gelfoam is placed over the recurrent
laryngeal nerves and any in situ parathyroid glands.
This protects these important structures from the poten-

tial of drain suction trauma.
Most patients are discharged the morning following
Troublesome bleeding can occur close to the recurrent surgery following wound care instruction. The patient’s
nerves, and I have found that an excellent hemostatic parathyroid function is verified with an intact parathor-
agent is free muscle laid over the bleeding site. mone assay immediately following surgery.
This can easily be harvested from adjacent strap Patients with PTH greater than 10 pg/dL are pro-
musculature. JLFreeman vided calcium supplementation of 1 g of elemental
calcium twice daily. Patients with PTH less than 10 pg/
dL are given 0.25 mcg of vitamin D twice daily and 2 g
of elemental calcium three times daily.
STEP 26. The wound is drained with closed-suction
drainage. Wound closure is performed in an aesthetic
fashion with platsymal plication, subcuticular skin The above strategy has been given evidence basis by
closure, and application of Steri-strips. our publication (Vescan et al, 2005). JLFreeman
Maintained or improving serum calcium levels are

Approach to Autotransplantation verified prior to discharge. Thyroid hormone is imme-
Using a standard tissue culture technique, pathologi- diately reinstated in patients with recurrent disease.
cally confirmed parathyroid tissue distinct from meta- Previously untreated patients are begun on liothyronine
static carcinoma is autotransplanted. The tissue is (Cytomel) 25 mcg twice daily.
minced immediately on devascularization and sus-
pended in approximately 1 to 2 mL of the patient’s
autologous serum or tissue salt solution. It is critical for Even though the authors mention starting the patient
it to be minced as well as remain moist to prevent desic- on liothyronine (Cytomel) 25 mcg twice daily, we
cation and nonviable autograft. generally start the patient on levothyroxine (LT4)
Once pathologically confirmed as parathyroid tissue standard dosage and we prefer to use radioactive
devoid of carcinoma, the cellular suspension is drawn
Suggested Reading
ablation with recombinant thyroid-stimulating hormone
(TSH). However, this depends on the institutional Vescan A, Witterick I, Freeman J: Parathyroid hormone as a
practice. The quality of life is extremely well predictor of hypocalcemia after thyroidectomy. Laryngo-
maintained in patients receiving radioactive iodine scope 115:2105-2108, 2005.
ablation with recombinant TSH. ARShaha
Patients are encouraged to use antiinflammatory

medications for postsurgical discomfort, with narcotics
reserved for breakthrough pain.
EDITORIAL COMMENT: The main theme that

arises from the text and commentary is the
absolute importance of a preoperative map,
created by extensive imaging, that defines the
location of recurrent disease. Although the
dissection is compartment based, the scarring
seen in the reoperative situation can make the
limits of the dissection difficult to define and
tedious—knowing where the disease is helps
guide the aggressiveness with which each area
is pursued.
There is some controversy over handling of the
overlying strap muscles, primarily surrounding the
degree to which the various surgeons feel they
limit exposure and the risk that they may harbor
recurrent disease—all the authors agree on these
issues; personal preference, disease location, and
experience then guide them as to whether they
retract, divide, or sacrifice these structures.
Given the paucity of detailed descriptions that
have been published about this operation, the
degree to which all these authors agree on
technique is striking and underscores the
fundamental nature of the anatomic principles that
guide it. JICohen
CHAPTER
Transcervical Thymectomy and Superior
51 Mediastinal Dissection
Author Gary L. Clayman
Commentary by Claudio R. Cernea, Larry R. Kaiser, Eric S. Lambright, and Joe B. Putnam, Jr.
Preoperative Evaluation bounded anteriorly by the sternum, posteriorly by the

and Surgical Planning pericardium, and laterally by the pleural reflections.
This chapter focuses more on the technical approach of Also included in this space are the innominate vein
transcervical thymectomy and superior mediastinal dis- and the brachiocephalic vessels. LRKaiser
section rather than the indications for this surgery. The
approach for central compartment disease in thyroid Preoperative evaluation of vocal cord function and
cancer addressing level VI and VII lymphatics is prelaryngeal positioning (rotation) should be performed in
sented in Chapter 50, and therefore this chapter focuses all patients by either indirect or fiberoptic examination.
more on approaches to the thymus and superior medi- Subtle laryngeal dysfunction may require videostrobo-
astinum. Indications include multiglandular involve- scopic examination to clarify functional laryngeal issues.
ment of parathyroids in multiple endocrine neoplasia Although technically this surgery can be performed
type 1 (MEN-1), MEN-1 patients with risk for thymic without the assistance of magnification, magnified
carcinoma or secondary hyperparathyroidism associ- surgery of at least 2.5× facilitates safe surgery.
ated with thymic or superior mediastinal locations, as
well as myasthenia gravis thymic surgery.
I prefer 3.5× magnification. CRCernea
The technique described here is a thorough and

Magnification is not required in this region and really
complete superior mediastinal dissection, which has
adds little. The recurrent laryngeal nerves are easily
great relevance for identifying extranumerary
identified without the need for magnification. With
parathyroid sites. However, this degree of dissection
regard to the parathyroid glands, not uncommonly an
may not be required in patients who are undergoing
inferior gland is taken with the thymus even if the
resection of the thymus for myasthenia gravis or other
parathyroid is not in an intrathymic location. LRKaiser
primary mediastinal pathology. ESLambright and
JBPutnam
It provides early identification of the recurrent laryn-
geal nerves and their arborized branches from injury,
There is no role for superior mediastinal lymph node early and accurate detection of parathyroid glands, and
dissection for thymectomy for myasthenia gravis, even allows accurate identification of small vessels to main-
in those patients who present with thymoma. From a tain a meticulous and bloodless field.
thoracic surgical standpoint, we refer to the superior For hemostasis, both bipolar electrocautery and vas-
mediastinum as that compartment defined by the right cular suture ligation are used. Surgical clips are not
subclavian artery superiorly, the azygos vein inferiorly, recommended in patients because imaging techniques in
the trachea posteriorly, and the inferior vena cava follow-up, particularly cross-sectional computed tomog-
anteriorly. A superior mediastinal dissection is raphy (CT) or magnetic resonance imaging (MRI), will
accomplished mainly via a right thoracotomy at the be plagued with scatter artifact and make these monitor-
time of a pulmonary resection for lung cancer. ing strategies suboptimal.
Performing this dissection from an anterior approach
is difficult and usually unsatisfactory at least as Harmonic scalpel is also useful, as long as the
defined by the boundaries enumerated earlier. surgeon avoids any inadvertent contact between the
The area occupied by the thymus gland is more tip of active blade and major vessels, which can cause
appropriately referred to as the anterior mediastinum severe bleeding. CRCernea
512
CHAPTER 51 Transcervical Thymectomy and Superior Mediastinal Dissection 513
We have not used bipolar cautery in this region but When done properly, the entire gland can be removed
have routinely used surgical clips. MRI of the via the transcervical approach including the inferior
mediastinum adds little if any additional information aspect of the gland. The use of the Cooper
over CT when used for follow-up, and the presence of thymectomy retractor placed in the sternal notch
surgical clips has not created any significant problems facilitates the complete removal of the gland. LRKaiser
when trying to identify recurrent disease. Suture
ligation is not necessary when dealing with the small
vessels that require ligation in this region. Specifically
Ectopic or supernumerary parathyroid glands may
the tributaries of the innominate vein may either be
be located in the superior mediastinum itself, as well as
clipped or simply ligated. LRKaiser
within the thymus gland proper. In instances in which
the parathyroid abnormality is within the thymus itself,
the offending thymic lobe can be removed and the para-
We agree that vascular control is optimally performed
thyroid gland identified ex vivo (my preference). In con-
with ligature instead of surgical clips. ESLambright
trast, the thymus gland can be incised and the parathyroid
and JBPutnam
abnormality dissected out of the thymus proper.
Limitations and Nuances of We agree that ex vivo identification of ectopic

Transcervical Thymectomy and parathyroid glands is optimal. ESLambright and
Superior Mediastinal Dissection JBPutnam
Not all thymus glands or all thymus tissue can neces-

sarily be effectively or completely removed transcervi-
When performing this maneuver, I always try to keep
cally in every patient.
the individual vascular pedicle of the inferior
parathyroid gland intact, if possible. CRCernea
We disagree with the statement that not all the thymic
tissue can be removed transcervically. In our
experience, complete thymectomy can be routinely It is easier and far preferable to excise the entire
achieved with rare exception. With optimal exposure thymus gland and then identify the parathyroid within
and systematic dissection techniques, it is extremely the thymus once the gland is out. LRKaiser
rare that the total thymus cannot be removed
transcervically and maintain its capsule. A standard
Cooper thymectomy retractor greatly facilitates
I prefer to excise the entire thymus gland proper to
dissection (see Cooper et al, 1988). Exposure of the
avoid potential rupture or spillage of parathyroid tissue.
mediastinum is also improved with minimized tidal
volumes. ESLambright and JBPutnam
Imaging Studies
Given the fact that thymic remnants may be found in
High-resolution CT scan with contrast of the neck and
multiple locations, including the posterior mediastinum,
mediastinum is my preferred imaging for the thymus
within mediastinal fat, in the aortopulmonary window,
and mediastinal structures. The imaging is preferentially
and in many other sites, I am not sure that any
from the skull base to the carina area. Skilled technolo-
surgical procedure can be guaranteed to remove “all”
gists, knowledgeable in these imaging approaches, must
thymic tissue. There is no doubt that, when performed
make sure that the shoulders are pulled caudad to
correctly, transcervical thymectomy can remove
prevent shoulder imaging (beam hardening) artifact.
essentially the entire thymus gland. This is
Anatomic variants and limitations of transcervical
underscored by the fact that the remission rate for
approach to this area are generally well predicted by
myasthenia gravis, seemingly related to “complete”
preoperative cross-sectional imaging.
removal of the gland, is essentially the same whether
Generally speaking, pathology to the level of the
the thymectomy is performed via a median sternotomy
aortic arch can be safely and effectively performed in
or via the transcervical route. LRKaiser
most individuals.
With the use of the Cooper thymectomy retractor,

Depending on the disease and condition of the pathology well inferior to the aortic arch can safely be
patient, total thymectomy can be performed trans removed under direct vision. LRKaiser
cervically.
Limited cervical mobility, advanced age, and prior

surgical procedures in the mediastinum all may provide
significant complexity and limitations to transcervical
approaches alone.
Limited neck extension makes the transcervical

approach more challenging but still feasible. Neck
extension should be assessed in the outpatient
setting, but proper positioning of the patient facilitates Thyroid
and maximizes neck extension. Previous surgical cartilage
procedures that involve the mediastinum usually but
not always preclude a transcervical approach to the Trachea
thymus but it really depends on the extent of the
previous surgery. I have found that a previous Incision
parathyroid exploration that includes a thymectomy
usually does not interfere with my performing a
complete excision of the thymus via a transcervical
Manubrium of
approach. A previous median sternotomy with
sternum
dissection in the anterior mediastinum, on the other
hand, usually renders a transcervical approach as
being not feasible. LRKaiser FIGURE 51-1. The incision is drawn with the patient in a
seated position and is optimally located in a cervical crease if
one is available.
Pericardial extension and more inferior or posterior
mediastinal extension below the aortic arch level should
include consultation and potential combined surgical
approach with cardiothoracic surgical specialists.
locaudal location with the patient awake and in a seated
position.
A midline incision approximately 4 cm in length is

If the thymoma is less than 5 cm in size and appears
usually located approximately between the first and
to be encapsulated, then an attempt at transcervical
third tracheal rings.
excision in the right hands may be warranted.
LRKaiser
I would describe this as a horizontal incision placed on
the central aspect of the neck. CRCernea
Imaging studies such as sestamibi-SPECT fused with
4D CT scan, ultrasound, and MRI may have been
For transcervical thymectomy, we make the incision as
acquired based on the patient’s disease for which the
close as possible to the sternal notch with the length
procedure is being considered.
of the incision dependent on the degree of neck
extension and the size of the patient. LRKaiser
Anesthetic Choice
Transcervical thymectomy and mediastinal dissection If the patient has a cervical crease(s), the incision
are performed under general anesthesia. Recurrent should be strongly considered for this location. Leaner
laryngeal nerve monitoring can be used, but I generally patients may have a slightly more superior-based inci-
consider it not indicated unless the patient has under- sion because flap “conflict” with visualization is gener-
gone prior surgical procedures or more superior dissec- ally not an issue in these patients.
tion along the recurrent laryngeal nerve is anticipated Incision length must be based on several factors. The
due to cephalad extension of disease or planned dissec- surgeon must have adequate visualization. Patient
tion in the area of the laryngeal nerve inlet. habitus may also play a role—obese and sometimes
stocky muscular male necks may require a somewhat
lower incision to provide optimal visualization of the
Operative Technique mediastinal structures (Figure 51-1).
STEP 1. Imaging is reviewed and the patient site-marked I agree. See my earlier comment. A longer incision
in the area of presumed pathology. usually is required in the obese patient. LRKaiser
We find a 4-cm incision is optimal. ESLambright and STEP 6. The incision is made with a scalpel through to
JBPutnam the subcutaneous tissues.

In those patients with prior midline surgical cicatrix hypertrophy.
approaches to the thyroid or parathyroid glands, the
prior incision should be used except in very extenuating
circumstances when the incision location is concerning
enough that visualization will be impaired. A happy
ous tissues deep to the platysma to the fascia envelop-
medium between a cosmetic anticipated cicatrix and not
ing the strap musculature and the communicating
“struggling” under the “visor” of a lengthy inferior flap
unfortunately comes with experience.
platysmal in neck dissections, in central compartment
STEP 3. The patient is initially positioned on a shoulder surgery, especially in obese individuals (in the midline),
roll in a slightly hyperextended neck position. The back elevating at the level of the investing fascia of the ante-
section of the table is elevated to reduce venous con- rior jugular veins eliminates the potential need for
gestion and the table placed in Trendelenburg to facili- lipectomy.
tate the initial flap elevation of the surgery (a lounge
chair position).
Subplatysmal flap elevation is preferred and works
Even when performing a thyroidectomy, I do not place well. I use electrocautery to elevate the superior and
this roll anymore, to avoid postoperative cervicalgia, inferior subplatysmal flaps. LRKaiser
especially in older adult patients. Hyperextending the
neck and elevating the dorsum works well, in my
experience. CRCernea If there is a site of previous incision, it is excised
through to the subplatysmal level and sent for routine
pathologic analysis.
We use an inflatable bag (Roho) that is pumped up to
the level necessary to achieve maximal extension
without the head hanging. The head rests in a donut
STEP 8. The flaps are elevated to the thyroid cartilage
to prevent lateral motion. The bag is deflated when
superiorly and at least 2 cm below the level of the sternal
appropriate to facilitate maximal visualization of the
notch inferiorly and the clavicles laterally (Figure 51-2).
mediastinum. LRKaiser
The legs are lowered and compression stockings pendicular allows the plane above the anterior jugular
placed on all patients. I leave the patient with the head veins and strap musculature to be readily visualized and
toward the anesthesiologist and simply request space opened with electrocautery.
around the head by moving the table about 2 feet away
from the anesthesia machine.
Skin rake tension applied perpendicular and good pull
opposite with the hand allows the superior flap to be
STEP 4. The chin is pointing upward, toward the ceiling. elevated while avoiding the anterior jugular veins.
LRKaiser

1 : 200,000 epinephrine. Do not limit your visualization inferiorly by inade-
quate elevation and retraction of the inferior flaps.
We have not used local anesthetic either with or

without epinephrine. Postoperative pain from this neck
incision usually is only moderate, lasts only a couple
of days, and is well tolerated. LRKaiser
a moistened sponge to keep them from drying.
This provides both postoperative pain management Although some surgeons prefer self-retaining retractors,
and incision hemostasis without cautery. An anesthetic I have not used them and prefer suture suspension to
also facilitates postoperative pain management. anchored drapes on the patient.
In previously dissected necks, the internal jugular

vein can be found surprisingly superficial within the
neck and may also be significantly adherent to the
ventral surface of the sternocleidomastoid muscle. This
is nevertheless an indication for meticulous technique
and not vein sacrifice.
The internal jugular vein is identified as the most
lateral point of the dissection unless lateral compart-
ment disease has been preoperatively identified (high-
resolution ultrasound or CT scan).
Note that carotid/vertebral pathology is frequently a
site of mediastinal extension of disease but may be mis-
Thyroid notch
interpreted by ultrasound as central compartment disease.
Dissection of the carotid/vertebral locations requires
a comprehensive anterior level IV and V dissection. This
site is well visualized on cross-sectional imaging but
infrequently dissected in the standard aerodigestive tract
“modified neck dissection.”
Certainly this type of dissection is not warranted for

the definitive treatment of either thymoma or thymic
carcinoma, a distinction that often cannot be made
Sternal notch until after the specimen is removed. For that matter,
if the pathology is thymic carcinoma, the appropriate
procedure is a median sternotomy with removal of the
entire thymus gland and adjacent mediastinal contents
that may be invaded by the malignancy. This is clearly
referring to thyroid malignancies with known nodal
involvement in these areas. LRKaiser
FIGURE 51-2. Skin flaps have been elevated in the
prevascular plane and sutured back for visualization.
STEP 12. The common carotid artery is identified more

medially along its anterior surface.
We have not used sutures to retract the flaps but have
found the use of two Gelpi self-retaining retractors to
Generally speaking, among patients who have under-
work well. LRKaiser
gone prior surgery to this vicinity, working in areas
more distant from the prior areas of dissection is pursued
to safely identify neural and vascular structures and
Getting the flaps “out of the way” and retained in then safely transition into the previously surgically
that position is of significant importance. managed areas.
STEP 10. The anterior fascia over the medial third of the
STEP 13. The common carotid artery is dissected along
sternocleidomastoid muscle is skeletonized with elec-
its anterior surface from the level III of the neck to the
trocautery dissection from level III of the neck to its
innominate artery (left) and the brachiocephalic and
sternal insertion bilaterally.
subclavian artery system (right) (Figure 51-3).
Based on patient age, cervical flexibility, and general

STEP 11. The sternocleidomastoid muscle is laterally anatomic differences, this dissection may reach signifi-
retracted with a five-prong rake initially and then transi- cantly inferior to these vessels.
tioned to a Richardson retractor as it is skeletonized
along its medial and ventral surfaces, exposing the ante- Up to this point the operation is a neck dissection.
rior surface of the internal jugular vein. The dissection “inferior” to this level would be defined
as mediastinal. LRKaiser
Once the medial surface begins to mobilize, I prefer
Richardson retractors to limit trauma to the ster In doing this inferior dissection, I tend to place the
nocleidomastoid muscle. patient flat or sometimes even more Trendelenburg
Recurrent
laryngeal n.
Common
carotid a.
Vagus n.
Recurrent
laryngeal n.
Vagus n.
Common
carotid a.
Sternal notch
FIGURE 51-3. The common carotid artery is dissected from FIGURE 51-4. The lateral and ventral surfaces of the strap
level III of the right neck to the subclavian and musculature are skeletonized as the superior mediastinal
brachiocephalic arterial systems. The right recurrent laryngeal vasculature is revealed along the ventral under surface.
nerve is identified medial to the carotid along it angular
course in the inferior central compartment. Note the dominant
anterior jugular veins coursing the strap musculature. STEP 14. In those patients previously unoperated, the
medial (linea alba) and then ventral surfaces of the strap
musculature are skeletonized via a midline approach to
the lateral border of the muscles already dissected.
position (and raise the table) and position myself at the
head of the table, looking directly (inferiorly) into the Adequate retraction of these muscles is necessary, but in
mediastinum (instead of standing at the patient’s side). many circumstances this can be limiting for more exten-
sive mediastinal masses or dissection.
Releasing the strap musculature inferiorly with an
This is an important point. A transcervical dissection in
approximately 1-cm cuff for reapproximation can
the anterior mediastinum must be done with the
provide tremendous superior mediastinal access and
surgeon positioned at the head of the table. LRKaiser
visualization with minimal, at most, long-term conse-
quences. Do not hesitate to release this musculature in
Dissection is greatly facilitated if the surgeon is patients with larger masses, prior surgery, or limited
positioned at the patient’s head and looks down into cervical extension.
the mediastinum as described. ESLambright and
JBPutnam I have never found this maneuver necessary. The
sternohyoid and sternothyroid muscles are separated
in the midline, providing more than adequate exposure
This provides a very important vantage point in visu- of the superior mediastinum. So-called larger masses
alizing and dissecting the superior mediastinum. should be dealt with via median sternotomy if
The lateral and immediate ventrolateral surfaces of separation of the strap muscles provides inadequate
the strap musculature are skeletonized with electrocau- exposure. LRKaiser
tery (Figure 51-4).
When release is considered for nonbulky or isolated

disease, a stepwise release can be performed (not neces-
sarily releasing all of the sternothyroid and sternohyoid
musculature).
Note that the innominate vein is usually intimately
associated with the ventral surface of the thymus gland,
and whenever there is a question, I would rather release
strap muscles than have difficulty identifying the innom-
inate vein or inferior thymic vessels draining into this
system.
Thyroid
gland
The thymus almost always traverses anterior to the

innominate vein and can be freed under direct vision
mostly with blunt dissection. Maximal neck extension Common
facilitates visualization of the innominate vein. carotid a.
Occasionally a lobe of the thymus passes posterior to Vagus n.
the innominate vein. LRKaiser R/L lobes of
Recurrent thymus gland
laryngeal n.
STEP 15. A dissection along the anterior surface of the Sternal notch
brachiocephalic, subclavian, and innominate arteries
provides safe release of these muscles and excellent
visualization of the superior mediastinum.
As the carotid, subclavian, and innominate arteries are

dissected with mosquito hemostats along their lateral
surface, the strap musculature is released. The common
carotid artery is dissected along its anterior lateral FIGURE 51-5. The right thymic lobe and thyrothymic vascular
surface to the innominate and subclavian arteries. and fascial communication are shown in situ with the
The release of the strap muscles must be done with recurrent laryngeal nerve laterally displaced with a cottonoid.
meticulous dissection and bipolar or monopolar cautery
for a dry surgical field.
Once the strap musculature is elevated or released,
the superior mediastinal contents are ready to be deliv-
easily identified more inferiorly in the paratracheal or
ered and dissection can, in most circumstances, extend
superior mediastinal areas.
to the level of the aortic arch.
Recall that the right recurrent laryngeal nerve takes
The laryngotracheal apparatus is pulled with hand
a more lateral course, whereas the left recurrent laryn-
traction superiorly and medially away from the vessels
geal nerve generally assumes a more longitudinal course
being dissected. This retraction transitions the superior
along the tracheoesophageal groove.
mediastinal vessels of the aortic arch into the sternal
notch area.
Note that the anterior jugular vein is usually domi- I would state this important anatomic pearl differently:
nant bilaterally and is located on the lateral surface of the right recurrent nerve has an oblique position
the sternohyoid muscle. I generally stick-tie this vessel regarding the tracheoesophageal groove, whereas the
because its variable drainage may create a retrograde left recurrent nerve generally assumes a more parallel
venous ooze from the subclavian vein that may be dif- course. Also, it is important to keep in mind the
ficult to locate once this vessel is sectioned. possibility of a nonrecurrent inferior laryngeal nerve,
always on the right side. CRCernea
STEP 16. The recurrent laryngeal nerve must be identified

once the medial aspect of the carotid artery and superior
Gently teasing the fascia away from the lateral
mediastinal great vessels have been dissected.
surface of the nerve, along its anticipated course in the
It is best to identify the recurrent laryngeal nerves in direction of its long axis, with a combination cottonoid
areas previously undissected or with minimal dissection. and mosquito hemostat provides rapid identification of
In this regard, the laryngeal nerves are most frequently the nerve (Figure 51-5).
thymus, because this further confuses identification of

the gland. In a bloodless field the gland is salmon
pink, allowing it to be distinguished from the cervical
fat. Both lobes are identified in the neck in this manner
and then dissected laterally and inferiorly down into
the anterior mediastinum. Silk ties are placed on the
apex of each lobe to use as a “handle” to elevate
each lobe to facilitate the dissection. LRKaiser
The “ligament” is obviously not a true ligament.

There are variable fascial and vascular communications
between the inferior pole of the thyroid and the superior
Recurrent extent of the thymus gland.
laryngeal n.
Common
The thymus separates readily from surrounding tissue,
carotid a.
and I would be hesitant to refer to these attachments
as a “ligament.” A small vessel usually is seen at the
apex of each lobe and is simply clipped and divided.
Thymus gland The importance of following each lobe to its origin
cannot be overstated. LRKaiser
These are readily visible and can be hand tied with

silk or other vascular ligatures.
In contrast, with the same superior lateral traction
of the laryngotracheal apparatus, the entire thymus can
also be cephalad displaced and the inferior thymic vein
ligated primarily prior to mobilizing the gland. This
FIGURE 51-6. The thyrothymic “ligament” has been approach is described in Chapter 50.
sectioned and the thymus is being elevated off of the
pretracheal fascia with electrocautery. A digit can then be
placed in the pretracheal fascia to facilitate delivery of the The lateral venous tributaries drain into the internal
mediastinal component of the thymus gland. mammary system. Once these lateral vessels have
been taken, there are no other vessels that cause
STEP 17. In most circumstances, for isolated transcervi- concern. Elevate the gland with the sutures on each
cal thymectomy, the inferior-most extent of the thymus lobe, then bluntly separate the gland from the
may be easier mobilized and delivered by releasing the innominate vein using peanut dissectors. Venous
thyrothymic ligament first and separating the thymus tributaries are individually identified and either clipped
from the pretracheal fascia (Figure 51-6). or ligated and divided. The gland must be freed from
the sternum anteriorly using blunt dissection. This is
most readily accomplished with tonsil ball sponges
Notwithstanding the neck dissection that has been placed in a ring forceps. Once all of the venous
described, the thymus gland is most easily identified tributaries have been divided and the gland completely
immediately posterior to the sternothyroid muscle. freed from the innominate vein, the gland is freed off
After separating the sternohyoid and sternothyroid the pericardium again using blunt dissection with ball
muscles in the midline, one side is elevated, and sponges. It is at this point that the Cooper
sharply dissecting the plane immediately posterior to thymectomy retractor is placed in the sternal notch
the elevated strap muscles allows the surgeon to and the air let out of the inflatable bag that has been
identify the thymus and follow the lobe to its origin placed behind the patient’s shoulders. The patient at
superiorly. The gland is always located anterior to the this point is literally suspended by the sternal notch,
inferior thyroid veins. If the surgeon finds that allowing excellent visualization of the entire anterior
dissection is proceeding posterior to these veins, the mediastinum. The thymus gland is then bluntly freed
thymus has been missed. Identifying the gland can be off each pleural reflection and from the pericardium to
difficult, especially in a fatty neck, because the its inferior extent. The gland is then mobilized from
cervical fat may look very much like the thymus. It is inferior to superior, all under direct vision, occasionally
critically important to not breach the capsule of the sharply dividing pericardial attachments. LRKaiser
central compartment dissection, the thymus and supe-

For thymectomy, the superior horns of the thymus are
rior mediastinal contents are stepwise freed from the
localized just posterior to the strap muscles. Clear
pretracheal fascia.
identification at this point facilitates mobilization. We
tie the horns with silk and use the ties as gentle A cottonoid placed on the lateral surface of the recur-
retraction to facilitate exposure. The posterior aspect rent nerve further laterally displaces the nerve and pro-
of the thymus is dissected and followed into the tects it from inadvertent injury.
mediastinum. The draining veins to the innominate Dissect along the anterior surface of the nerve with
vein are identified, ligated, and divided. We do not use a mosquito hemostat, superior toward the thyroid
cautery in the mediastinum to avoid phrenic nerve gland, then displace it again laterally with the use of a
injury or paresis. Releasing the strap muscles is cottonoid.
typically not required. We rely on the thymectomy Electrocautery in the pretracheal fascial plane, both
retractor and technique with the mediastinal dissection deep and along the lateral margins of the tissue, can be
rather than retraction of the laryngotracheal apparatus safely used as long as the recurrent laryngeal nerves are
as described. Once the draining veins are ligated, the safely visualized at least 1 cm from the point of cautery.
thymus can be dissected with blunt and sharp
techniques. The pericardium is readily identifiable and In my experience, a bipolar cautery is preferable over
small areas can be resected transcervically if required. a monopolar cautery, in order to avoid electrical
The inferior poles of the thymus can be well visualized damage. Also, I find the Harmonic scalpel to be very
and completely dissected. We also mobilize the useful. CRCernea
perithymic fat to ensure complete resection of the
thymus gland. Provided the draining thymic veins to
the innominate are controlled, bleeding is rarely an STEP 20. As the thymus is elevated from the pretracheal
issue even when the majority of the mediastinal fascia with the use of electrocautery, the thymus and
dissection is performed with blunt techniques. We superior mediastinal contents are freed from their
minimize dissection in proximity to the neurovascular inferior-most mediastinal vascular supply in a stepwise,
structures in the mediastinum unless absolutely meticulous hemostatic fashion (Figure 51-7).
required. ESLambright and JBPutnam
The thymus is easily mobilized using peanut dissectors

and countertraction from the ties placed on each lobe.
STEP 18. Once medial to the carotid arteries, a watchful
Electrocautery is unnecessary. The gland readily
eye for the inferior parathyroid glands must always be
separates from surrounding structures. Lateral
considered.
attachments usually need to be taken sharply.
If parathyroid tissue is identified distinct from the LRKaiser
targeted disease, it should be spared. If it becomes
devascularized, it should be immediately finely minced, The thymus and mediastinal contents can then be
pathologically confirmed by frozen section, and gently elevated with the suture-ligatured thyrothymic
autotransplanted. pedicle with digital pretracheal dissection to its inferior-
most attachment.
It should be noted that frequent vascular structures
both supplying the thymic and mediastinal lymph nodes
Unless other parathyroid glands have been taken this may originate or drain into the aortic arch, innominate,
is unnecessary. It may be particularly difficult to brachiocephalic, and subclavian venous structures. I
identify an inferior parathyroid during a thymectomy prefer stick-tying these vessels in order to maintain a
because the gland may not be visible until after the dry surgical field over bipolar techniques.
entire specimen is removed. LRKaiser Stick-tying the most inferior aspect of the inferior
thymic lobes is critical due to their venous outflow into
the innominate venous system.
Ex-vivo analysis of specimens prior to submission In contrast, if the chosen approach was an inferior
for pathologic analysis may be required to identify para- release primarily, the thymus and mediastinal contents
thyroid tissue inadvertently excised with the mediastinal can then be gently elevated with digital pretracheal dis-
content. section to the thyrothymic ligament area.
STEP 19. Whether from the thyrothymic (superior) STEP 21. The resultant dissection including the
release or inferior-based release from comprehensive common carotid arteries, vagus nerve, innominate/
Recurrent
laryngeal n.
Inf. thymic v.
Aortic
arch
Vagus n.
FIGURE 51-7. The laryngotracheal
apparatus is pulled superiorly and
medially from the carotid/
brachiocephalic system delivering the
thymus cervically for inferior vascular
control of the inferior thymic vessels.
brachiocephalic system, subclavian artery, subclavian

veins, recurrent laryngeal nerves, and trachea are all I do not place a drain following transcervical
preserved. thymectomy and do not think that drainage is either
necessary or desirable. The procedure as described
by the author results in far less than a complete
STEP 22. Powdered Avitene is placed in the paratracheal thymectomy, which would be inadequate if the
and superior mediastinal areas and then Gelfoam is operation were being done for myasthenia gravis.
placed over the recurrent laryngeal nerves and any in The operation that we perform involves a transcervical
situ parathyroid glands. approach with direct visualization of the anterior
mediastinum following complete mobilization of the
This protects these important structures from the poten- thymus gland in the neck. The gland is freed from the
tial of drain suction trauma. pleural reflections laterally, the pericardium posteriorly,
and the sternum anteriorly and followed to its inferior
extent, which may include extension to the
I have never used any of this material in the aortopulmonary window on the left side. LRKaiser
mediastinum, but I assume the concern here is caused
by the dissection along the neck vessels. LRKaiser
STEP 24. Wound closure is performed in an aesthetic
fashion with platsymal plication, subcuticular skin
STEP 23. The wound is drained with closed suction closure, and application of Steri-strips.
drainage if thymectomy is being performed with lymph-
Strap musculature is reapproximated (if sectioned) with
adenectomy for non-thymus central compartment
figure-eight absorbable suture.
malignancy.
Usually a single 7-mm Blake drain is placed with its A transcervical approach to the thymus and
cutaneous exit in what would be a lateral extension of mediastinum is a technique that can minimize the
the cervical incision if such would have occurred.
Suggested Readings
morbidity of sternotomy. Surgeons must also
recognize the limits of transcervical thymectomy and Calhoun RF, Ritter JH, Guthrie TJ, Pestronk A, Meyers BF,
proceed with sternotomy or upper sternal split when Patterson GA, et al: Results of transcervical thymectomy for
necessary. Combining the expertise of a thoracic myasthenia gravis in 100 consecutive patients. Ann Surg
surgeon and a head-and-neck surgeon may be 230:555-559, 1999.
optimal for selected patients. ESLambright and Cooper JD, Al-Jilaihawa AN, Pearson FG, Humphrey JG,
Humphrey HE: An improved technique to facilitate trans-
JBPutnam
cervical thymectomy for myasthenia gravis. Ann Thorac
Surg 45:242-247, 1988.
Shrager JB,Nathan D, Brinster CJ, Yousuf O, Spence A, Chen
Postoperative Management Z, et al: Outcomes after 151 extended transcervical thymec-
Most patients are discharged the morning after surgery tomies for myasthenia gravis. Ann Thorac Surg 82:1863-
following wound care instruction. 1869, 2006.
Patients may be discharged the same day following

extended transcervical thymectomy. LRKaiser
Patients are encouraged to use antiinflammatory

medications for postsurgical discomfort, with narcotics
reserved for breakthrough pain.
EDITORIAL COMMENT: Although the commentary

seems at times to be in conflict with the author’s
approach, the differences can be primarily
explained by the different backgrounds (thoracic
surgery as compared with head and neck surgery),
which these clinicians bring to the discussion and
the different disease processes that they primarily
treat. For the thoracic surgeon, thymectomy for
primarily intrathymic disease or myasthenia gravis
becomes the emphasis. For the head and neck
surgeon, parathyroid disease, both intrathymic and
perithymic, or mediastinal lymphadenopathy from
a head and neck process that can only be safely
and completely cleared, especially in the case of
reoperation, by including the thymus, is usually the
focus. Therefore it is really the handling of
interface of the thymus and the surrounding tissue
that differs because in one case, separation of the
thymus from the surrounding tissue becomes the
goal, whereas in the other, inclusion of the
surrounding tissue may be necessary or part of
the goal. With this in mind, the differences are
easily reconciled. JICohen
SECTION B Parathyroid Operations
CHAPTER
Targeted Parathyroidectomy
Commentary by Lisa A. Orloff and Robert A. Sofferman
Preoperative Evaluation due to lack of sun exposure, and these patients often
and Surgical Planning have mild to moderate elevation of intact PTH with a
Preoperative Considerations relatively normal calcium level. Correction of the
vitamin D deficiency normalizes the PTH, and these
The establishment of targeted (or minimally invasive) patients do not have hyperparathyroidism.
parathyroidectomy as an accepted surgical approach RASofferman
to patients with primary hyperparathyroidism (non–
multiple endocrine neoplasia (MEN) patients) began in
the 1970s with evidence suggesting cure can be achieved A 24-hour urine calcium collection demonstrating
in more than 90% of patients with single gland disease calciuria (must rule out familial hypocalciuric hypercal-
treated with isolated parathyroidectomy. cemia [FHH]) is as follows:
■ Inactivating mutation of calcium sensing receptor
I agree, but the strongest voice of opposition is ■ May have elevated PTH and serum calcium
Siperstein (see Siperstein et al, 2008). Still, even this ■ Ratio of calcium clearance to creatinine clearance
group has not documented that the recurrence rate less than 0.01 suggests FHH
of hyperparathyroidism after what is thought to be ■ No treatment generally indicated (not a surgical
a successful single gland excision or unilateral disease)
exploration is any higher than if routine bilateral Preoperative evaluation of vocal cord function and
exploration is performed. LAOrloff laryngeal positioning (rotation) should be performed in
all patients by either indirect or fiberoptic examination.
A thorough history (and physical) is required in all Subtle laryngeal dysfunction may require videostrobo-
patients. MEN syndromes are particularly worrisome in scopic examination to clarify functional laryngeal issues.
young men. Look for family history of renal stones and
gastric ulcer disease.
Serologic analysis: This enables better postoperative assessment and
❏ Serum total calcium above the limits of normal comparison of any voice symptoms that might arise.
corrected with serum albumin or an elevated LAOrloff
ionized serum calcium.
❏ Elevated parathyroid hormone (PTH) with
normal vitamin D level. Although parathyroid surgery can be performed
without the assistance of magnification, magnified
In primary hyperparathyroidism, the intact PTH may be surgery of at least 2.5X facilitates safe surgery.
midrange normal, whereas the calcium is significantly
elevated. This “normal PTH” value is actually elevated Of course this depends on the surgeon’s visual acuity,
because the PTH should be suppressed at the low too. I would not go so far as to say that surgeons who
level of the normal range. Hypovitaminosis D is do not use magnification are practicing unsafe
common in northern tier states in the winter months surgery, but I personally use magnification. LAOrloff
523
This provides early identification and protects the

obtain an intraoperative PTH in this circumstance
superior and recurrent laryngeal nerves and their arbo-
because there is a 99% chance of success when
rized branches from injury.
concordance exists. We use concordance as one of
several important criteria for considering local
I echo the sentiment of the use of magnification and anesthesia. RASofferman
actually indicate that this is mandatory state-of-the-art
technique in modern thyroid and parathyroid surgery.
The delicate blood supply and color of the normal Sestamibi-SPECT Fused with 4D Computed
glands can only be assessed adequately with loupes Tomography (CT) Scan (Timed Infusion
(2 to 5X) and often it is size and appearance of of Contrast)
the normal glands that pose the most difficult
intraoperative decisions. RASofferman This is the gold standard study for localization.
However, it is not universally available, and 2D planar
sestamibi scans and 3D sestamibi-SPECT (CT with
Imaging Studies nontimed contrast) are more commonly performed.
LAOrloff
It is important to note that imaging is more difficult
in patients with thyroiditis because of thyroid
For patients with equivocal findings, consider thyroid
heterogeneity and presence of many reactive
hormone suppression of thyroid uptake with 25 mcg of
perithyroidal lymph nodes. LAOrloff
liothyronine (Cytomel) twice daily for 1 week. This is
particularly useful for superior parathyroid abnormali-
High-Resolution Ultrasound ties overshadowed by the intact thyroid gland as well
as ectopic gland sites and is excellent for localizing in
This is most useful with inferior parathyroid abnormali-
less common locations such as mediastinal and retro-
ties and the rare intrathyroidal adenoma.
esophageal sites.
I find ultrasound useful in every patient, especially in Both ultrasound and sestamibi are highly operator
the most common locations of diseased glands. Most dependent. Sestamibi timing of delayed images is
common limitations are retrosternal lesions and obese critical, and is not the same in every patient. LAOrloff
patients. Fine-needle aspiration (FNA) is used only to
confirm intrathyroidal parathyroid adenomas or when
If the sestamibi-SPECT fused 4D CT scan is negative,
multiple targets are identified, or sometimes in cases
look for contributing issues such as thyroid uptake pre-
of persistent hyperparathyroidism after failed
venting visualization, non-sestamibi avid parathyroid
exploration. LAOrloff
pathology (clear cell adenomas, for example), as well as
medication interference (such as lithium).
It is useful for the potential simultaneous thyroid Selective venous sampling is rarely indicated except
malignancy. reoperative circumstances with unclear localizing efforts.
Osteocalcin and carboxy-terminal collagen crosslinks
High-resolution ultrasound has many benefits in (CTX) measurement should be obtained for assessment
parathyroid surgery. I have managed several cases of of bone health.
double adenoma in which only one lesion has been
I find measurement of alkaline phosphatase useful,
sestamibi positive. Any lesion suspected as an
especially for predicting hungry bone syndrome
enlarged parathyroid is accessible to ultrasound-
postoperatively. LAOrloff
guided PTH sampling. This is certainly not a routine
requirement, but occasionally an adenoma is atypical
in appearance or position. The sample aspirate is Bone Mineral Density Analysis
more definitive in this circumstance than any imaging A baseline bone mineral density analysis is routinely
study. A patient with abnormally high calcium levels obtained. Guidelines for surgical intervention for
and lymphadenopathy may have a parathyroid primary hyperparathyroidism have been established by
carcinoma; the node can be sampled for PTH and the National Institutes of Health (NIH).
surgical planning can be optimized. When there is
concordance between ultrasound and sestamibi The most recent consensus guidelines from the NIH
scanning, a single adenoma in the imaged position is have become more liberal in recommending surgical
nearly always the offending lesion. Gwande and intervention, especially in patients with osteopenia or
colleagues have suggested that there is no need to osteoporosis on bone densitometry. In 1999 Bilezekian
CHAPTER 52 Targeted Parathyroidectomy 525
and Silverberg suggested that many patients with ❏ Revision parathyroidectomy

hyperparathyroidism could safely be followed without ❏ MEN syndrome
surgery for 10 years or more. As more of their data ❏ Negative sestamibi scan
accrued, they have reassessed this position with ❏ Need for concomitant thyroidectomy
special attention to bone disease. They have ❏ Double adenoma or diffuse hyperplasia on
demonstrated a 12% to 14% improvement in bone ultrasound
density of the hip and lumbar spine at 3 to 4 years ❏ Abnormal neck anatomy: marked obesity;
after parathyroidectomy. RASofferman abnormally low-lying thyroid gland; heavy, short
neck
❏ Allergy to local anesthetics
Preoperative Calcitriol RASofferman
Supplementation
Especially in patients with long-standing primary hyper-
parathyroidism and significant bone demineralization, Intraoperative Localization
initiate vitamin D supplementation at 0.25 mcg twice Although I do not routinely use localization techniques,
daily 4 days prior to their surgery to prevent precipitous in reoperative cases and in instances in which there is
drop in serum calcium and prolonged hospitalization ambiguity in imaging, intraoperative localization can
due to hungry bone syndrome. be used.
Anesthetic Choice I prefer preoperative sestamibi localization of some

type in every case of primary hyperparathyroidism for
Targeted parathyroidectomy can be performed with
one reason: the exclusion of a mediastinal parathyroid
local anesthesia, conscious sedation, and general anes-
adenoma. An unrecognized adenoma in the chest
thesia. In most circumstances I prefer general anesthesia
can become a surgical frustration of the highest
but will defer to the recommendations of the anesthesi-
magnitude and the extensive surgical exploration
ologist and other medical consultants. Recurrent laryn-
and requisite reoperation a true morbidity for the
geal nerve monitoring can be used for those patients
patient. RASofferman
under general anesthesia.
I also consider patient preference and comorbidities When parathyroid surgery is easy, it is truly easy.
when considering whether to use general anesthesia. When it is difficult, you wish that someone else were
LAOrloff there. These localizations may assist surgeons in these
more difficult situations.
Selected patients with primary hyperparathyroidism Perioperative Sestamibi

may be candidates for targeted parathyroidectomy
under local anesthesia. Although this does pose some If the sestamibi-SPECT fused 4D CT scan demonstrates
added challenges to the surgeon including draping the offending gland or glands, a 1-hour preoperative
techniques, dialog with the operating personnel and dosing and intraoperative collimated neoprobe for
resident or assistant, and technique of local infiltration, localization can be used. If using sestamibi intraopera-
once properly mastered it can be a rewarding adjunct tively, I prefer to suppress the patient’s thyroid gland
to one’s surgical practice. This approach is usually uptake by placing the patient on liothyronine (Cytomel)
patient motivated or occasionally for the older adult twice daily for 10 days prior to surgery. Although early
patient or those who are not good candidates for in my operative experience I used this technique, I have
general anesthesia. In general, the patient should have not used it with the above preoperative imaging and
concordant positive sestamibi and ultrasound images. surgical indications approach.
Contraindications to parathyroidectomy under local
anesthesia are as follows, although some are relative Sestamibi-SPECT 4D CT fusion is a sophisticated
and not absolute: imaging study that requires dedicated and skilled
❏ Secondary hyperparathyroidism radiologist attendance at the examination. Many
❏ Patient is unable to lie flat for a reasonable centers do not have the availability of this technology
amount of time because of lumbar spine issues, and resort to biplanar Tc-sestamibi or sestamibi-
kyphosis SPECT without 4D. The addition of SPECT alleges a
❏ Patient anxiety or inability to tolerate the 10% additional sensitivity to the conventional
concept of local anesthesia/surgery sestamibi scan and allows the clinician to determine
the position of the adenoma in a third plane. An

ectopic retroesophageal adenoma may be
appreciated. The clinical determination of whether a
chest adenoma resides in either the anterior or
posterior mediastinum is necessary to the
development of the proper surgical approach.
RASofferman
Thyroid cartilage
Methylene Blue
In rare circumstances, when preoperative imaging has Trachea
been misleading or intraoperative PTH correction has
not occurred and the offending gland(s) have not been Incision
discovered, methylene blue can be given intravenously.
Anesthesia personnel must be informed of the inability
to monitor O2 saturation, and urinary clearance of the
dye must be explained to the patient. Severe allergic Manubrium of
sternum
reactions to this dye have been reported.
Cases of central nervous system toxicity from this dye FIGURE 52-1. The incision is drawn with the patient in a
have occurred particularly in patients who are taking seated position and is optimally located in a cervical crease if
serotonin reuptake inhibitors. Methylene blue, which one is available.
acts like a monoamine oxidase (MAO) inhibitor, should
not be used in such patients (see Pollack et al, 2009).
LAOrloff
I used to do this but have found that the marking site
migrates significantly once the patient is supine, and
does not always correlate well with where I would
Because of these precautions, methylene blue is no
favor making the incision based on ultrasound
longer authorized for intravenous use in our and other
performed in the supine patient (in the operative
institutions and should not be relied on as an option
position). LAOrloff
in intraoperative identification of parathyroid tissue.
RASofferman
In most circumstances I prefer a midline incision

Intraoperative intravenous selective PTH analysis for approximately 3 cm in length at the lower level of the
localization can be expensive and is rarely indicated cricoid cartilage.
except in extraordinary circumstances.
I tend to go slightly lower unless it is a known superior

However, simple right and left internal jugular vein parathyroid. I rely more on ultrasound in the operating
PTH sampling is a less expensive, although less room just prior to making my incision. LAOrloff
precise, alternative, at least for lateralizing some
lesions. LAOrloff
For anticipated inferior glands, a slightly lower inci-
sion can be used. If the patient has a cervical crease(s),
the incision should be strongly considered for this loca-
Operative Technique tion. Incision length must be based on several factors.
First, it is imperative that the surgeon have adequate
STEP 1. Imaging is reviewed and the patient site-marked visualization. In general, the incision must extend
in the area of presumed pathology. enough to adequately deliver the parathyroid itself.
Smaller parathyroid masses can be removed through
shorter incision lengths to ultimately about 2 cm (that
STEP 2. Mark the incision’s cephalocaudal location with of the video-assisted parathyroidectomy).
the patient awake and in a seating position with a Fracture or spillage of a parathyroid adenoma may
marking pen (Figure 52-1). lead to parathyroidmatosis and should be avoided.

Do not let the incision size cramp you excessively, and
at the level of the investing fascia of the anterior jugular
avoid direct grasping or forceps retraction on the
veins eliminates the potential for lipectomy or searching
actual parathyroid lesion. LAOrloff
for the linea alba.
STEP 3. The patient is positioned with the back section STEP 9. The flaps are elevated to the level of the thyroid
of the table elevated to reduce venous congestion notch superiorly and the sternal notch inferiorly.
and the table placed in Trendelenburg to facilitate
visualization.
In cases in which the adenoma is well localized before
surgery, a limited flap elevation may be performed.
RASofferman
Reverse Trendelenburg can be helpful in obese or
large-chested patients. LAOrloff
Rake retractors should be placed beneath the skin and
The legs are lowered and compression stockings placed platysma to allow elevation superficial to the anterior
on all patients. The patient is slightly hyperextended in jugular veins. This allows the strap musculature to be
the neck. I leave the patient with the head toward the readily visualized and the median raphe incised with
anesthesiologist and simply request space around the cautery.
anesthesia machine.
STEP 10. The flaps are suspended with the use of 2-0
silk sutures placed at the very base of the elevated flap
with a moistened sponge to keep from drying.
tors, I have not used them and prefer suture suspension
STEP 5. Blood is drawn for a baseline rapid PTH level to anchored drapes on the patient.
prior to prepping the neck or palpating the neck.
STEP 11. The linea alba is identified inferiorly and incised

STEP 6. Field anesthetic is used with 0.5% mepivacaine with the use of electrocautery.
1 : 200,000 epinephrine. In most patients, the linea alba or median raphe of the
This provides both postoperative pain management strap musculature is self-evident. The linea alba is
and incision hemostasis without cautery. The anesthetic unquestionably much easier to define first, lower in the
also allows postoperative pain management with anti- neck. Gentle lateral tension of the sternothyroid muscle
inflammatory medication only and outpatient surgery with application of the electrocautery on the raphe from
facilitation. the immediate suprasternal area to the thyroid notch is
performed to separate these muscles.
However, few patients require postoperative narcotics
even without long-acting local anesthetic I palpate for the innominate artery during this process.
administration. LAOrloff LAOrloff
In targeted parathyroidectomy I elevate only mini-

STEP 7. The incision is made with a scalpel through to mally the sternothyroid muscle from the anterior surface
the subcutaneous tissues. of the thyroid gland on the contralateral side of the
Attention to detail in incising and handling skin reduces lesion.
cicatrix hypertrophy. Communicating branches of the anterior jugular
ligatures or a harmonic or similar type of ultrasonic
STEP 8. Electrocautery is used to incise the subcutane- device.
STEP 12. The sternothyroid and sternohyoid strap
muscles are elevated off of the anterior and lateral
Although skin flap elevation is generally immediate sub- surface of the thyroid gland and central compartment
platysmal in neck dissections, in parathyroid surgery, fibrolymphatic and fascial structures with the use
of electrocautery on the side of the anticipated

adenoma.
As the muscles are laterally retracted with army-navy or

small Richardson’s retractors, the muscles are separated
Recurrent laryngeal n. from the anterior and lateral surfaces of the thyroid
gland.
STEP 13. Elevate the strap musculature laterally to the

common carotid artery and use a small Richardson or
army-navy retractor to hold the strap musculature
Thyroid Inf. parathyroid
gland
laterally.
gland
STEP 14. Open the fascia along the anterior and medial
surfaces of the carotid sheath in the anticipated location
of the preoperatively imaged parathyroid adenoma.
STEP 15. The thyroid gland fascia along its lateral surface
is dissected with a mosquito hemostat and incised with
FIGURE 52-2. The depicted left inferior parathyroid adenoma electrocautery.
is displaced with the cottonoid and the recurrent laryngeal When encountered, small perforating vessels are bipolar
nerve visualized deep to the offending gland.
coagulated. Vessels greater than 1 mm are suture
ligatured.
STEP 16. A cottonoid pledget, held rigidly with a heavy

hemostat, is used to displace the central compartment
tissues medial to the carotid artery and lateral to the
thyroid gland.
This displacing force generally allows visualization of

Recurrent the pathologic parathyroid gland (Figure 52-2).
laryngeal n.
Sup. parathyroid
gland STEP 17. A capsular excision of the gland is performed
and the arterial and venous contributions suture
ligatured.
I do not inspect or dissect any of the other parathyroid

Thyroid
gland
gland predicted locations. This minimizes dissection and
potential trauma to the normal retained parathyroid
glands.
STEP 18. The recurrent laryngeal nerve may require dis-

section based on the pathologic gland location. Some of
the anatomic course and issues pertaining to nerve dis-
section and visualization are discussed in Chapter 47
(Figure 52-3).
FIGURE 52-3. A left superior parathyroid adenoma is Some surgeons prefer a lateral approach when the gland
depicted in a paraesophageal location with dissection of the is predicted preoperatively to be in the tracheoesopha-
anterior arborized branches of the recurrent laryngeal nerve geal groove and superoposterior locations.
already accomplished and the parathyroid gland being In these lateral approaches the incision is placed in
delivered posterior to the nervous branches. the horizontal position to the right or left of the midline
(as if the incision were extended laterally but not involv-

One simple cosmetic trick involves Telfa and
ing the midline). The sternocleidomastoid is laterally
Tegaderm. A thin strip of Telfa along the subcuticular
dissected and the anterior and medial dissection of the
suture line absorbs the small droplets of blood that
common carotid artery performed.
are inevitable. A slightly larger strip of Tegaderm
keeps the Telfa in place, but the combination looks
bloody and messy within a few hours if only this one
And in this case, I do place the incision at the level of
layer is used. A second layer of Telfa slightly larger
the cricoid, or cricothyroid membrane, where there is
than the original strip and a final second strip of
usually a natural skin crease, and I displace it laterally
Tegaderm are placed as a composite at the initial
to the side of the lesion. LAOrloff
dressing and completely camouflage the unsightly
dressing. This outer Telfa remains white and clean
until the first postoperative visit or the patient can
This approach minimizes the dissection approach
remove this electively at home a few days after
and provides more direct access to the more posterior
surgery. Patients appreciate this subtle attention to
and lateral parathyroid gland locations and thus reduces
detail and hygiene. RASofferman
or essentially eliminates extensive nerve dissections in
these locations.
STEP 21. Fifteen minutes after gland complete removal,
It also decreases the amount of retraction and a serum sample is drawn for rapid PTH analysis.
dissection required along the thyroid border. LAOrloff
Although PTH half-life should allow for earlier sam-
pling, I prefer a single serum analysis rather than mul-
In those less frequent circumstances of multiple ade- tiple samples over 5 and 10 minutes.
nomas, it provides adequate access to those homolateral
abnormalities, but inferior access to contralateral
pathology. I actually draw 10- and 20-minute samples. The two
samples allow me to see an ongoing decline with time,
which I think further supports the diagnosis of a single
This necessitates a second incision or significant pathologic gland. I have had patients whose first
lengthening of the initial incision to access the postexcision PTH was more than a 50% drop but not
contralateral side. LAOrloff within normal range (generally because the starting
point was so high) who then drop further and into
the normal range by the time of the second sample.
STEP 19. The wound is meticulously inspected for hemo- LAOrloff
stasis and any necessary bipolar or suture ligatures
applied. A 50% or greater drop in PTH level and within
normal range predicts a successful single gland surgery.
The patient is kept sedated and surgical field maintained
Care is taken not to injure the recurrent laryngeal until the laboratory results are received. Those patients
nerve during hemostasis maneuvers. LAOrloff with no change in PTH level or inadequate reduction of
the PTH likely have a secondary adenoma (or less likely
an unappreciated MEN patient).
and skin is performed with fine attention to detail. Or, the lesion that you removed was not a parathyroid
gland. This can be particularly the case in patients
The wound is closed in layers. I tend to use a fine sub- with Hashimoto’s thyroiditis and many enlarged
cuticular closure with skin adhesive and Steri-strips or perithyroidal lymph nodes that look similar to enlarged
Dermabond. parathyroids. To help confirm that what was removed
was indeed parathyroid tissue, I usually aspirate the
excised lesion into a syringe containing 0.5 mL of
I tend to use nylon skin sutures, mainly to force the saline, then eject into a purple-top tube and send the
patient to return postoperatively for suture removal, aspirate sample for PTH assay along with my serum
at which time I perform follow-up laryngoscopy, samples. The result should be in the high thousands if
serum calcium testing, and review of surgical the source is parathyroid, and it is faster and less
pathology. I think the cosmetic results are the expensive and I find more sensitive and specific than
same. LAOrloff frozen section. LAOrloff
For men, at least inspect the gland on the homolat- intraoperative verification of serum PTH normalization.
eral side of the dissection. Because I prefer a midline The patient’s first outpatient follow-up is at 1 week for
approach, I dissect and inspect the remaining three pathology review, wound inspection, and further instruc-
glands, seeking a second pathologic gland. Normal tion on wound care.
glands are not removed or biopsied. Duration and extent of vitamin D and calcium sup-
For women I generally assume a less aggressive surgi- plementation are based on preoperative bone mineral
cal approach because MEN is less likely. After removing density determination and interdisciplinary manage-
the defined adenoma, I dissect and inspect the homolat- ment with an endocrinologist.
eral side and accept the rare “failed” parathyroidectomy
and the subsequent contralateral surgery if so indicated Suggested Readings
in the future.
Bilezikian JP, Silverberg SJ: Clinical practice. Asymptomatic
primary hyperparathyroidism. N Engl J Med 350:1746-
Postoperative Care 1751, 2004.
Gwande A, Monchik JM, Abbruzzese TA, Iannuccilli JD,
Targeted parathyroidectomy is performed as an outpa- Ibrahim SI, Moore FD Jr: Reassessment of parathyroid
tient procedure. hormone monitoring during parathyroidectomy for primary
hyperparathyroidism after 2 preoperative localization
studies. Arch Surg 141:381-384, 2006.
Most of mine are 23-hour stays, termed “outpatient
Pollack G, Pollack A, Delfiner J, Fernandez J: Parathyroid
needing a bed.” LAOrloff surgery and methylene blue: a review with guidelines for
safe intraoperative use. Laryngoscope 119:1941-1946,
2009.
The patients are discharged on antiinflammatory
Siperstein A, Berber E, Barbosa GF, Tsinberg M, Greene AB,
pain medication with narcotics only for breakthrough Mitchell J, et al: Predicting the success of limited explora-
discomfort. The patients are supplemented with cal- tion for primary hyperparathyroidism using ultrasound,
citriol 0.25 mcg twice daily and elemental calcium 1 g sestamibi, and intraoperative parathyroid hormone: analy-
twice daily unless signs or symptoms of hypocalcemia sis of 1158 cases. Ann Surg 248:420-428, 2008.
present. No laboratory studies are required following
CHAPTER
Open Parathyroidectomy
Commentary by Lisa A. Orloff and Robert A. Sofferman
There has been much discussion in the literature regard- parathyroid hyperplasia). It is essential to choose the
ing the merits and complications of subtotal versus total smallest parathyroid gland (without nodules) as the
parathyroidectomy. remnant in performing a subtotal resection or for graft-
In my opinion, subtotal parathyroidectomy is the ing in total parathyroidectomy.
preferred primary procedure in multiple endocrine neo-
plasia type 1 (MEN-1) and MEN-2A because perma-
nent hypoparathyroidism can be such a long-term The smallest parathyroid gland is often the most
detrimental outcome. Although in MEN-2A, total para- normal-looking gland. I mark the gland or remnant that
thyroidectomy can be performed with forearm auto- is preserved in vivo with a small atraumatically applied
transplantation and cryopreservation and the ultimate HemaClip. LAOrloff
risk of permanent hypoparathyroidism can be tremen-
dously reduced, it is not eliminated. In MEN-1, I
prefer to retain a 50-mg portion of the most normal- I prefer to choose the best vascularized gland as the
appearing gland, cryopreserve, and refrain from primary remnant that may or may not be the smallest. The
transplantation. process of leaving a 40- to 50-mg remnant requires
experience and delicate technique including
Many surgeons do not have access to magnification loupes and avoidance of grasping or
cryopreservation, and even for those that do, it is manipulating the remnant. Once all of the parathyroid
expensive, it is indefinite, tissue viability deteriorates glands have been examined but left in situ, the
with time, and there are risks similar to those with planning of the remnant should be the first step in
transfusions (clerical errors in storing by the correct subtotal parathyroidectomy in case this segment
name, returning to the correct patient) as well as in becomes devascularized. In that circumstance another
maintaining sterility (see Borot et al, 2010). LAOrloff gland with still intact blood supply needs to be chosen
as the new remnant. In addition, it is imperative to
Comparison of the two procedures is often difficult return to inspect the remnant at frequent intervals.
because most failures are usually due to the presence of In circumstances in which recurrence of
supernumerary, ectopic glands, or parathyroidmatosis hyperparathyroidism is a reasonable concern, such as
(in surgical spilling and recurrences). Although some- secondary hyperparathyroidism and the surgeon elects
what controversial, I prefer the use of the rapid para- to do a subtotal resection, a remnant of the inferior
thyroid hormone assay to verify biochemical adequacy gland may be easier to access in the future. There is a
in subtotal and total parathyroidectomy procedures. lower risk of injury to the recurrent laryngeal nerve
because scarring and adhesion of the nerve to the
remnant are more likely when it is in the superior
Although I also use intraoperative parathyroid hormone
position. RASofferman
(IOPTH) during surgery for multigland disease, it is
fraught with difficulties related to timing of blood
draws and sequence of removal of parathyroid In subtotal parathyroidectomy, a small normal gland
glands. LAOrloff may be left intact. If all glands are abnormal, the small-
est most normal-appearing gland is reduced to approxi-
Because the contemporary acceptance of autotrans- mately 50 mg of tissue.
plantation as an effective means of preventing perma- Total parathyroidectomy with autotransplantation is
nent hypoparathyroidism in total parathyroidectomy, preferred in patients with multiple endocrine neoplasias
subtotal parathyroidectomy may be indicated if one possessing four “grossly” abnormal glands and second-
or two normal-sized glands occur simultaneously ary hyperparathyroidism, as well as in reoperative
with abnormal glands in non-MEN patients (primary circumstances.
531
Subtotal parathyroidectomy is still a reasonable Preoperative Evaluation

option, and often the decision is not made until the
and Surgical Planning
glands are inspected intraoperatively. LAOrloff
The ability to remove autografted forearm tissue to Family history: Consider multiple endocrine neoplasia
biochemical normality is certainly easier than surgical syndromes as well as stones, gastric ulcer disease, med-
management of recurrence within the central neck com- ullary thyroid carcinomas, pheochromocytomas, and
partments. In subtotal and total parathyroidectomy, at sudden death. Recommend genetic counseling if so
least four glands should be visualized prior to proceed- indicated.
ing with gland excisions. Serologic analysis: serum total calcium above the
limits of normal corrected with serum albumin or an
elevated ionized serum calcium, and elevated PTH level
This is an extremely important point. LAOrloff
with normal vitamin D level.
Transcervical thymectomy and central compartment In primary hyperparathyroidism, the intact PTH level
comprehensive dissections are required in a defined may be midrange normal, whereas the calcium is
number of patients with supernumerary glands (approx- significantly elevated. This “normal” PTH value is
imately 15%). Thymectomy should also be performed actually elevated because the PTH should be
prophylactically in MEN-1 patients due to the second- suppressed at the low level of the normal range.
ary risk of thymic neoplasms. Hypovitaminosis D is common in northern tier states in
Cryopreservation of parathyroid tissue can be per- the winter months due to lack of sun exposure, and
formed as a safeguard but successful transplantation these patients often have mild to moderate elevation
autograft results are significantly reduced in contrast to of intact PTH with a relatively normal calcium level.
fresh tissue autografts. The tissue should be optimally Correction of the vitamin D deficiency normalizes
used prior to 18 months of storage, otherwise graft take the PTH level, and these patients do not have
is unlikely. Cryopreserved graft take is approximately hyperparathyroidism. RASofferman
60% as compared with fresh tissue success of approxi-
mately 90%. A 24-hour urine calcium collection demonstrating
calciuria (must rule out familial hypocalciuric hypercal-
cemia [FHH]) is as follows:
The Washington University of St. Louis group has ❏ Inactivating mutation of calcium-sensing receptor
described a 60% functional level with delayed ❏ May have elevated PTH and serum calcium levels
reimplantation of cryopreserved parathyroid tissue (see ❏ Ratio of calcium clearance to creatinine clearance
Cohen et al, 2005). However others have not had this less than 0.01 suggests FHH
degree of success and one elaborate multi-institutional ❏ No treatment indicated (not a surgical disease)
study of nine centers reports a 10% functional rate ❏ Educate patient and family members
and another 10% partial return of function in their Preoperative evaluation of vocal cord function and
delayed cryopreserved cases stored for 11.1 months laryngeal positioning (rotation) should be performed in
(see Borot et al, 2010). Other similar published all patients by either indirect or fiberoptic examination.
experiences indicating poor functional rates along with Subtle laryngeal dysfunction may require videostrobo-
the impractical accrual of large numbers of never- scopic examination to clarify functional laryngeal issues.
to-be-used cryopreserved parathyroid glands have
resulted in the abandonment of cryopreservation of This enables better postoperative assessment and
parathyroid tissue in most centers. RASofferman comparison of any voice symptoms that might arise.
LAOrloff
Rapid parathyroid hormone (PTH) analysis per-

formed 15 minutes after completing the surgery of all Although parathyroid surgery can be performed
diseased glands should verify normalization of levels in without the assistance of magnification, magnified
subtotal parathyroidectomy patients and result in non- surgery of at least 2.5× facilitates safe surgery.
detectable or minimally detectable PTH levels in total
parathyroidectomy patients. Of course this depends on the surgeon’s eyes and
visual acuity, too. I would not go so far as to say that
I do 10- and 20-minute postexcision PTH levels. surgeons who do not use magnification are practicing
LAOrloff unsafe surgery, but I use magnification. LAOrloff
CHAPTER 53 Open Parathyroidectomy 533
This provides early identification and protects the

scanning, a single adenoma in the imaged position is
superior and recurrent laryngeal nerves and their arbo-
nearly always the offending lesion. Gwande and
rized branches from injury.
associates (2006) have suggested that there is no
need to obtain an intraoperative PTH level in this
I echo the sentiment of the use of magnification and
circumstance because there is a 99% chance of
actually indicate that this is mandatory state-of-the-art
success when concordance exists. We use
technique in modern thyroid and parathyroid surgery.
concordance as one of several important criteria for
The delicate blood supply and color of the normal
considering local anesthesia. RASofferman
glands can only be assessed adequately with loupes
(2 to 4×) and often it is size and appearance of the
normal glands that pose the most difficult
intraoperative decisions. RASofferman
Sestamibi-SPECT fused with 4D parathyroid com-
puted tomography (CT) scan (timed infusion) is the gold
standard study for localization, although many sur-
Imaging Studies geons do not perform for MEN patients.
It is excellent for localizing in less common locations
such as mediastinal and retroesophageal sites.
It is important to note that imaging is more difficult It is particularly useful for superior parathyroid
in patients with thyroiditis because of thyroid abnormalities overshadowed by the intact thyroid gland
heterogeneity and presence of many reactive and ectopic gland locations.
perithyroidal lymph nodes. LAOrloff Selective venous sampling is rarely indicated except
in reoperative circumstances. There should be genetic
counseling and testing in unknown or suspicious MEN
High-resolution ultrasound is most useful with infe- patients. Osteocalcin and carboxy-terminal collagen
rior parathyroid abnormalities and the rare intrathyroid crosslinks (CTX) measurement should be taken for
adenoma. assessment of bone health.
I find ultrasound useful in every patient, regardless of

location of disease. The most common limitations are
I find measurement of alkaline phosphatase useful,
retrosternal lesions and obese patients. LAOrloff
especially for predicting hungry bone syndrome
postoperatively. LAOrloff
Fine-needle aspiration is used only to confirm intra-
thyroidal parathyroid adenomas and simultaneous
thyroid malignancy.
A baseline bone mineral density analysis is routinely

Or when multiple targets are identified, or sometimes
obtained. Guidelines for surgical intervention for
in cases of persistent HPT after failed exploration.
primary hyperparathyroidism have been established by
LAOrloff
the National Institutes of Health (NIH).
High-resolution ultrasound has many benefits in

parathyroid surgery. I have managed several cases of
double adenoma in which only one lesion has been The most recent consensus guidelines from the NIH
sestamibi positive. Any lesion suspected as an have become more liberal in recommending surgical
enlarged parathyroid is accessible to ultrasound- intervention, especially in patients with osteopenia or
guided PTH sampling. This is certainly not a routine osteoporosis on bone densitometry. In 1999 Bilezikian
requirement, but occasionally an adenoma is atypical and Silverberg suggested that many patients with
in appearance or position. The sample aspirate is hyperparathyroidism could safely be followed without
more definitive in this circumstance than any imaging surgery for 10 years or more. As more of their data
study. A patient with abnormally high calcium levels accrued, they have reassessed this position with
and lymphadenopathy may have a parathyroid special attention to bone disease. They have
carcinoma; the node can be sampled for PTH and demonstrated a 12% to 14% improvement in bone
surgical planning can be optimized. When there is density of the hip and lumbar spine at 3 to 4 years
concordance between ultrasound and sestamibi after parathyroidectomy. RASofferman
Preoperative Calcitriol and resort to biplanar Tc-sestamibi or sestamibi-

Supplementation SPECT without 4D. The addition of SPECT provides
a 10% additional sensitivity to the conventional
Especially in patients with long-standing primary hyper-
sestamibi scan and allows the clinician to determine
parathyroidism and significant bone demineralization,
the position of the adenoma in a third plane. An
initiate vitamin D supplementation at 0.25 mcg twice
ectopic retroesophageal adenoma may be
daily 4 days prior to surgery to prevent precipitous drop
appreciated. The clinical determination of whether a
in serum calcium and prolonged hospitalization due to
chest adenoma resides in either the anterior or
hungry bone syndrome.
posterior mediastinum is necessary to the
development of the proper surgical approach.
Anesthetic Choice RASofferman
In most circumstances I prefer general anesthesia. Recur-
rent laryngeal nerve monitoring can be used for those
Methylene blue: In rare circumstances, when preop-
patients under general anesthesia.
erative imaging has been misleading or intraoperative
PTH correction has not occurred and the offending
gland(s) have not been discovered, intravenous methy-
I agree that general anesthesia is not only preferred, lene blue can be given. Anesthesia personnel must be
but necessary given the duration and extent of informed of the inability to monitor O2 saturation and
surgery. LAOrloff urinary clearance of the dye must be explained to the
patient. Severe allergic reactions to this dye have been
reported.
Intraoperative Localization
Although I do not routinely use localization techniques, Cases of central nervous system (CNS) toxicity from
in reoperative cases and in instances in which there is this dye have occurred particularly in patients who are
ambiguity in imaging, intraoperative localization can be taking serotonin reuptake inhibitors; methylene blue,
used. which acts like a monoamine oxidase (MAO) inhibitor,
should not be used in such patients (see Pollack et al,
2009). LAOrloff
I prefer preoperative sestamibi localization of some
type in every case of primary hyperparathyroidism for
one principal reason: the exclusion of a mediastinal Because of these precautions, methylene blue is no
parathyroid adenoma. An unrecognized adenoma in longer authorized for intravenous use in our and other
the chest can become a surgical frustration of the institutions and should not be relied on as an option in
highest magnitude and the extensive surgical intraoperative identification of parathyroid tissue.
exploration and requisite reoperation a true morbidity RASofferman
for the patient. RASofferman
Intraoperative intravenous selective PTH analysis for

Perioperative sestamibi: In patients with a failed localization can be expensive and is rarely indicated
prior surgery, a sestamibi-SPECT fused 4D CT scan may except in extraordinary circumstances.
demonstrate the offending gland or glands; a 1-hour
preoperative sestamibi dosing and intraoperative colli-
Simple right and left internal jugular vein PTH sampling
mated neoprobe for localization can be used. If using
is a less expensive, although less precise, alternative,
sestamibi intraoperatively, I prefer to suppress the
at least for lateralizing some lesions. LAOrloff
patient’s thyroid gland uptake by placing the patient on
liothyronine (Cytomel) 12.5 mcg twice daily for 10 days
prior to surgery.
Operative Technique
Sestamibi-SPECT 4D CT fusion is a sophisticated STEP 1. Imaging and patient history are reviewed.
imaging study that requires dedicated and skilled
radiologist attendance at the examination. Many
centers do not have the availability of this technology STEP 2. Blood is drawn for a baseline rapid PTH level
prior to prepping or palpating the neck.
I do not find this to be true. In my experience, the scar

usually remains superior to the sternal notch and
appears like a natural skin crease. I do agree that too
low an incision in the neck eventually ends up on the
chest. LAOrloff
Thyroid cartilage If the patient has a cervical crease(s), the incision

should be strongly considered for this location. Incision
length must be based on several factors:
n Providing adequate visualization
Trachea
n Adjusting for patient physical habitus
Incision n Considering areas of dissection
n Surgeon experience
Incisions designed too low produce unfavorable scar-
ring and result in an infraclavicular sternal cicatrix.
Manubrium of
sternum
STEP 4. The patient is positioned with the back section

of the table elevated to reduce venous congestion
FIGURE 53-1. The incision is drawn with the patient in a
and the table placed in Trendelenburg to facilitate
seated position and is optimally located in a cervical crease if
one is available.
visualization.
The anterior cervical veins are part of the systemic Reverse Trendelenburg can be helpful in obese or
venous circulation and the PTH values are no different large-chested patients. LAOrloff
than those accessed from the arm. Therefore we use
these veins for PTH sampling at the outset of the case
and any time during the case. These veins are easy to
identify and preserve and simplify the venipuncture
the neck. I leave the patient with the head toward the
issues. RASofferman
anesthesiologist and simply request space around the
anesthesia machine. The chin is pointing upward toward
the ceiling.
locaudal location with the patient awake and in a seating

I used to do this but have found that the marking site 1 : 200,000 epinephrine.
migrates significantly once the patient is supine, and
does not always correlate well with where I would This provides both postoperative pain management and
favor making the incision based on ultrasound incision hemostasis without cautery. Anesthetic also
performed in the supine patient (in the operative allows postoperative pain management with antiinflam-
position). LAOrloff matory medication only, and outpatient surgery
facilitation.
In most circumstances I prefer a midline incision
approximately 3 cm in length, which is usually at the
Few patients require postoperative narcotics even
lower level of the first tracheal ring area.
without long-acting local anesthetic administration.
LAOrloff
I rely on ultrasound in the operating room just prior to
making my incision. LAOrloff
the subcutaneous tissues.
Warn patients that initially following surgery, the
incision appears “higher” than expected but eventually Attention to detail in incising and handling skin reduces
results in a sternal notch cicatrix. cicatrix hypertrophy.


platysmal in neck dissections, in parathyroid surgery,
at the level of the investing fascia of the anterior jugular
veins eliminates the potential for lipectomy or searching
for the linea alba.
Thyroid notch
STEP 8. The flaps are elevated to the level of the thyroid

notch superiorly and below the sternal notch inferiorly.
In cases in which the adenoma is well localized before

surgery, a limited flap elevation may be performed.
RASofferman
Skin rake tension on the flaps elevated primarily per- Sternal notch
opened with the electrocautery. Both sternal heads and
the sternal notch need to be in clear view.
STEP 9. The flaps are suspended with the use of 2-0 silk FIGURE 53-2. The investing fascia of the anterior jugular
sutures placed at the very base of the elevated flap with veins is the deep layer of the subplatysmal flap elevation. The
a moistened sponge to keep from drying. flaps are suspended with silk sutures.

tors, I have not used them and prefer suture suspension
STEP 11. The sternothyroid and sternohyoid strap
to anchored drapes on the patient (Figure 53-2).
muscles are elevated off of the anterior and lateral sur-
faces of the thyroid gland and central compartment
fibrolymphatic and fascial structures with the use of
STEP 10. The linea alba is identified inferiorly and incised
electrocautery.
with the use of electrocautery.
As the muscles are laterally retracted with army-navy or
In most patients the linea alba or median raphe of the
small Richardson’s retractors, the muscles are separated
strap musculature is self-evident. The linea alba is
from the anterior and lateral surfaces of the thyroid
gland.
neck. Gentle lateral tension of the sternothyroid muscle
with application of the electrocautery on the raphe from
the immediate suprasternal area to the thyroid notch is
STEP 12. Elevate the strap musculature laterally to the
performed to separate these muscles.
common carotid artery and use a small Richardson’s
retractor to hold the strap musculature laterally.
I palpate for the innominate artery during this process. Some individuals prefer a lateral approach to the strap
LAOrloff muscles and then dissection of the carotid medially. In
multiple gland surgery, however, I prefer the midline
approach.
ligatures or a Harmonic or similar type of ultrasonic STEP 13. Open the fascia along the anterior and medial
device. surfaces of the carotid sheath inferiorly to the
innominate and bracheocephalic systems and superiorly

to the superior thyroid artery takeoffs.
is dissected with a mosquito hemostat and incised with
electrocautery. *
Small perforating vessels are bipolar coagulated. Vessels
greater than 1 mm are suture ligatured. The middle
*
thyroid vein is taken down from the thyroid gland **
fascia.
***
It is necessary to ligate and divide the middle thyroid *
vein in order to get adequate thyroid rotation and
exposure to both the superior and the inferior **
parathyroid glands. LAOrloff
*
Fine bipolar forceps are more gentle and less likely to
transmit unwanted heat to the parathyroid glands to
be preserved, especially during thyroid surgery and
separation of the normal parathyroids from the
posterior thyroid capsule. One useful tip is to keep the
bipolar tips immersed in a container of saline (a 20-mL
syringe barrel with the rubber disk removed from the
plunger end and placed over the outlet hole of the
barrel). This keeps the tips moist and clean and
produces better cautery transmission to the vessels. FIGURE 53-3. The predicted location of inferior parathyroid
RASofferman glands. ***, Most frequent to *, least frequent.
STEP 16. I prefer to proceed in an organized fashion

STEP 15. A cottonoid pledget, held rigidly with a heavy beginning with the most diseased gland. If all glands
hemostat, is used to displace the central compartment are diseased (or to be removed), I prefer to start with
tissues medial to the carotid artery and lateral to the the inferior parathyroid gland on the side where I am
thyroid gland. standing.
This displacing force generally allows visualization of
the pathologic parathyroid glands.
A minimum of four parathyroid glands should be STEP 17. The recurrent laryngeal nerve is then identified
visualized prior to proceeding with any gland excisions inferiorly within the right paratracheal area. A cottonoid
in subtototal or total parathyroidectomy. pledget is gently teased along the anticipated inferior
course of the predicted right recurrent laryngeal nerve.
(A nonrecurrent laryngeal nerve should be anticipated
based when the radiographic observation when a retro-
This is a very important point. My only exception is
esophageal subclavian artery is identified.)
that if, for example, only three glands are identified
after extensive effort, at some point one must proceed
with parathyroidectomy of identified glands, with the I usually identify the RLN before starting to remove
difficult decision of how much, if not all, of the three glands on either side—this step would precede Step
glands to remove. In addition to leaving a remnant of 16. Subsequent dissection of the RLN is undertaken to
“the most normal” parathyroid gland during any the extent necessary to remove the parathyroid glands
subtotal parathyroidectomy, I use as a criterion the safely while preserving the nerve. LAOrloff
“most accessible” gland, that is, the location that
would be the least morbid to reexplore in the future,
with the least risk to the recurrent laryngeal nerve STEP 18. The recurrent laryngeal nerve may require
(RLN). Usually this is an inferior gland. LAOrloff dissection based on the pathologic glands’ locations
(Figure 53-3). Some of the anatomic course and issues
In my experience the most common location is

somewhat more posterior. LAOrloff
Subtotal Parathyroidectomy
* STEP 21. In subtotal parathyroidectomy, the largest and

** most abnormal of the parathyroid glands are removed
*** first.
1 ** Thyroid
gland
* STEP 22. In decreasing order of abnormal size and
appearance, the subsequent glands are removed.
Recurrent Again, I weigh both abnormality of appearance and

laryngeal n.
Common accessibility. LAOrloff
carotid a. Thymus
gland
STEP 23. In MEN-1 patients, a vascular clip is applied to

the smallest, most normal, and well-vascularized para-
thyroid gland such that an approximately 50-mg remnant
is retained proximal to the clip. The clip is applied cleanly
Vagus n. with minimal manipulation of the gland itself. The
retained gland must be clearly identifiable and vascular-
ized with the vascular clip applied.
A Telfa pad or similar nonabsorbable material is placed

FIGURE 53-4. The predicted location of the superior
beneath the gland and a new blade is used to cut the
parathyroid glands. ***, Most frequent to *, least frequent. gland.
When it can be done atraumatically, I find it helpful to

apply the clip and keep the clip applier gripping the
pertaining to nerve dissection and visualization are dis- clip in the closed position while my assistant shaves
cussed in Chapter 52. or slices the parathyroid along the surface of the
applied clip. This maneuver provides a stable base for
STEP 19. The recurrent laryngeal nerve is dissected cutting. LAOrloff
more superiorly.
STEP 20. The thyroid gland is rotated medially to facili- The clip should be large for easy identification of
tate the dissection and removal of the superior glands. the gland if subsequent reoperative is indicated. The
The superior parathyroid glands may lie intimately with removed portion of this most normal gland is
the gland of Zuckerkandl. This posterior extension of the cryopreserved.
thyroid may require mobilization and dissection of the
recurrent laryngeal nerve and its arborized branches at
the laryngeal inlet (Figure 53-4). If facilities are available, cryopreservation can be used.
However, this portion of the gland should be kept up
on the sterile field on a moist Telfa until the IOPTH
results have been confirmed (in case it needs to be
The superior parathyroid may be missing and could be
autotransplanted). LAOrloff
the origin of a retroesophageal adenoma. Digital
palpation of the entire cervical and upper mediastinal
retroesophagus is the best maneuver to identify this STEP 24. In MEN-2A patients, known mutations match
ectopic superior adenoma. This is a very important parathyroid disease.
concept and is one of the key disadvantages to
endoscopic parathyroidectomy. RASofferman One must take into account age and childbearing status.
Only mutations of codons 609, 611, 618, 620, and 634
have been associated with hyperparathyroidism. Other

codon mutations are rare and others have never been
associated with primary hyperparathyroidism.
Autotransplantation should be done in the forearm,
in a single pocket, with clips at each end of the pocket
for easy identification. Do not transplant MEN-2A
patients in the neck.
**
The hyperparathyroid state in MEN-2A is often mild ** * *
and clinically irrelevant. If at the time of total
thyroidectomy large parathyroids are identified, these * Thyroid
gland
may be removed. Often this requires removal of only
one or two parathyroid glands and long-term follow-up
of calcium and PTH levels. RASofferman
**
STEP 25. Fifteen minutes following effective removal of
all four glands (total parathyroidectomy) or three plus
*
Common
glands leaving small remnant, an intraoperative PTH carotid a.
level should be obtained.
Thymus
gland
I like to do 10- and 20-minute postexcision levels,

mainly to observe an ongoing decline between 10 and Recurrent
20 minutes that better ensures that there is not a laryngeal n.
supernumerary gland. Because the time it takes to Vagus n.
remove 3 12 or 4 hyperplastic glands is greater and
more variable than the time to remove a single gland
(i.e., adenoma), I find there is more variability in the FIGURE 53-5. Ectopic or supernumerary superior gland
amount and rate of decline of PTH and I feel more locations (in decreasing frequency) include retroesophageal/
confident when I have two points in time, to confirm a tracheoesophageal, intrathyroidal, posterosuperior
trend. LAOrloff mediastinum, and carotid sheath. **, Most frequent to *, least
frequent.
In total parathyroidectomy with autotransplant, the been dissected in the initial four gland dissection (see
PTH level should be nondetectable or minimally Figures 53-5 and 53-6).
detected.
In subtotal parathyroidectomy, the PTH level should
be within a low-normal range. If the PTH level is not Occasionally when comprehensive surgical exploration
detectable despite the retention of a 50-mg retained fails to identify four parathyroid glands including
gland remnant, a forearm autotransplant should be inspection of the thymus, retroesophagus, and carotid
performed. sheath, intraoperative ultrasound with directed
Note: Total parathyroidectomy is removal of at least examination of the upper neck may identify an
all four identified parathyroid glandular abnormalities. undescended parathyroid adenoma. RASofferman
Biochemical PTH control of disease may require a com-
prehensive central compartment dissection and transcer-
vical thymectomy (see Chapters 50 and 51, as well as Parathyroid Autografting in Subtotal
analysis of less common glandular locations as described
in Figures 53-5 and 53-6, following). Extensive surgery
and Total Parathyroidectomy
such as this must be tempered with the hyperparathy-
roid disease itself. STEP 27. The ex vivo gland is immediately minced into
1-mm or smaller tissue pieces, remaining within 1 to
2 mL of autologous serum or tissue solution. A small
STEP 26. In instances in which the PTH level is not cor- section of the gland is confirmed by frozen section prior
rected as suggested earlier, one must look for unsus- to autotransplanting (although many consider this an
pected or missed glands in the areas that have not unnecessary expense) (Figure 53-7).
STEP 31. The gland pieces to be transplanted are placed

within the pocket that is being “tented” in opposite
directions to hold the autografted tissues within the
pocket.
I prefer to create individual pockets for one or two

autografted segments and place absorbable fascial
sutures before insertion of the parathyroid segments.
In this way the musculofascial edges can be tented up
and held closed to better retain the pieces of
parathyroid that have a tendency to wander out of the
pocket. The pockets are adjacent to one another, and
when the forearm autotransplant must be partially
excised in the future, the nodular mass seems to be a
coalescence of these individual transplants. The theory
behind individual pockets is that a seroma or
microhematoma in one pocket is less likely to affect
* the others. RASofferman
* ***
*
** Although seemingly simple, this portion of the proce-
** dure is best performed with an able assistant to prevent
extravasation of the autograft.
STEP 32. Two large surgical clips are placed at each

FIGURE 53-6. Ectopic or supernumerary inferior gland polar end of the muscular pocket surface to create a
locations (in decreasing frequency) include inferior pole/ complete seal.
thyrothymic ligament area, mediastinal thymus, cervical This prevents leakage of the grafted material and pro-
thymus, intrathyroidal, undescended, mediastinal outside of
vides easy identification of the grafted material for sub-
the thymus, and carotid sheath. **, Most frequent to *, least
frequent.
sequent reduction if indicated.
In parathyroid hyperplasia this is less of an issue, but I STEP 33. Transcervical thymectomy.
do send frozen section both to confirm parathyroid This procedure, described in detail in Chapter 51, is
tissue and rule out malignancy (mainly thyroid). indicated in patients with MEN-1, 4D parathyroid
Because I do this prior to autotransplanting during any CT-identified intrathymic ectopic glands, or continued
thryoidectomy case, I try to be consistent and do it for hyperparathyroidism (markedly elevated PTH level) fol-
parathyroidectomy cases, too. LAOrloff lowing successful 31 2- or 4-gland surgery.
STEP 28. A small incision is placed in the forearm in the

STEP 34. The wound is meticulously inspected for hemo-
area of the muscular bulge of the brachioradialis
stasis and any necessary bipolar or suture ligatures
muscle and the skin elevated to the fascia overlying the
applied.
muscle.
STEP 29. The skin is held with a self-retaining retractor. STEP 35. Meticulous closure of subcutaneous tissues
Senn retractors could also be used. LAOrloff The wound is closed in layers. I tend to use absorbable
suture in a subcuticular fashion and further apply adhe-
sive and Steri-strips as well. As an alternative, I have
STEP 30. The muscle is incised to create a pocket used Dermabond for those patients who tend toward
approximately 1 cm long and approximately 5 mm deep. hypersensitivity and ectopy.
Sup. parathyroid
gland (portion
removed)
Thyroid gland
Sup.
parathyroid
gland Parathyroid fragment
Brachioradialis m.
FIGURE 53-7. The retained normal gland is sectioned to maintain a viable in situ gland. The
remnant tissue can be cryopreserved or immediately autotransplanted based on patient issues
and intraoperative parathyroid hormone (IOPTH) results. In circumstances in which the IOPTH
level is less than 1 pg/mL, autotransplant immediately, even in subtotal parathyroidectomy
patients.
I tend to use nylon skin sutures, mainly to force the with “normal” serum calcium levels, patients may be
patient to return postoperatively for suture removal, at symptomatic and require calcium supplementation.
which time I perform follow-up laryngoscopy, as well Hungry bone syndrome can occur and may take
as serum calcium testing, and review of surgical several weeks or even months to resolve. LAOrloff
pathology. I think the cosmetic results are the same.
LAOrloff
The first outpatient follow-up is at 1 week for pathol-

ogy review, wound inspection, and further instruction
One simple cosmetic trick involves Telfa and on wound care.
Tegaderm. A thin strip of Telfa along the subcuticular Duration and extent of vitamin D and calcium sup-
suture line absorbs the small droplets of blood that plementation is based on preoperative bone mineral
are inevitable. A slightly larger strip of Tegaderm density determination and interdisciplinary manage-
keeps the Telfa in place, but the combination looks ment with an endocrinologist.
bloody and messy within a few hours if only this one
layer is used. A second layer of Telfa slightly larger
than the original strip and a final second strip of Suggested Readings
Tegaderm are placed as a composite at the initial Bilezikian JP, Silverberg SJ: Clinical practice. Asymptomatic
dressing and completely camouflage the unsightly primary hyperparathyroidism. N Engl J Med 350:1746-
dressing. This outer Telfa remains white and clean 1751, 2004.
until the first postoperative visit or the patient can Borot S, Lapierre V, Carnaille B, Goudet P, Penfornis A:
remove this electively at home a few days after Results of cryopreserved parathyroid autografts: a retro-
surgery. Patients appreciate this subtle attention to spective multicenter study. Surgery 147:529-535, 2010.
detail and hygiene. RASofferman Cheung PS, Bergstrom A, Thompson NW: Strategy in reopera-
tive surgery for hyperparthyroidism. Arch Surg 124:676-
681, 1989.
Cohen MS, et al: Long term functionality of cryopreserved
Postoperative Care parathyroid autografts; a 13-year prospective analysis.
Subtotal and total parathyroidectomy is performed as a Surgery 138:1033-1041, 2005.
23-hour observation procedure. The patients are dis- Gwande A, et al: Reassessment of parathyroid hormone moni-
toring during parathyroidectomy for primary hyperparathy-
charged on antiinflammatory pain medication with nar-
roidism after 2 preoperative localization studies. Arch Surg
cotics only for breakthrough discomfort. The patients
141:381-384, 2006.
are supplemented with calcitriol 0.25 mcg twice daily Hellman P, et al: Findings and long term results of parathyroid
and elemental calcium 1 g twice daily unless signs or surgery in multiple endocrine neoplasia type I. World J Surg
symptoms of hypocalcemia present. No laboratory 16:718-722, 1992.
studies are required if intraoperative verification of Hessman O, Westerdahl J, Al-Suliman N, Christiansen P,
serum PTH level is normalized. Hellman P, Bergenfelz A: Randomized clinical trial compar-
For a PTH level greater than 14 pg/mL, calcium ing open with video-assisted minimally invasive parathyroid
supplementation only is given. For a PTH level of 10 to surgery for primary hyperparathyroidism. Br J Surg 97:177-
14 pg/mL patients are supplemented with calcitriol 184, 2010.
0.25 mcg daily and 1 g of elemental calcium twice daily Levin KE, Clark OH: The reasons for failure in parathyroid
operations. Arch Surg 124:911-914, 1989.
for the first week only.
Mulligan LM, et al: Specific mutations of the RET proto-
Patients with PTH level less than 10 pg/mL are sup-
oncogene are related to disease phenotype in MEN2a and
plemented with 0.25 mcg of calcitriol twice daily and FMTC. Nat Genet 6:70-74, 1994.
2 g of elemental calcium three times daily (greater than National Institute of Health Guidelines, 2010. Available at
70-kg patients or PTH level less than 1 pg/mL, are www.nih.gov.
medicated with 0.5 mcg calcitriol twice daily). For Pollack G, Pollack A, Delfiner J, Fernandez J: Parathyroid
patients with PTH level less than 10, repeat PTH and surgery and methylene blue: a review with guidelines for
serum calcium, magnesium, and phosphorus levels are safe intraoperative use. Laryngoscope 119:1941-1946,
obtained prior to discharge and if normalized, no further 2009.
testing is required. Rothmund M, Wagner PK, Schark C: Subtotal parathyroidec-
tomy versus total parathyroidectomy and autotransplanta-
tion in secondary hyperparathyroidism: a randomized trial.
World J Surg 15:745-750, 1991.
However, patients are instructed in the signs, Takagi H, et al: Subtotal parathyroidectomy versus total para-
symptoms, and management of hypocalcemia, which thyroidectomy and autotransplantation in secondary hyper-
may develop more than 24 hours after surgery. Even parathyroidism: A randomized trial. Ann Surg 200:18-22,
1984.
CHAPTER
Video-Assisted Parathyroidectomy
Commentary by Celestino Pio Lombardi, Paolo Miccoli, and David J. Terris
This chapter focuses on technique rather than indications

Another advantage of this approach is the possibility
for this procedure. Video-assisted parathyroidectomy is
to perform a concomitant thyroid resection, when
commonly associated with targeted parathyroidectomy
necessary and when the selection criteria for video-
but can be equally employed for both subtotal and
assisted thyroidectomy are respected. As a
total parathyroidectomy procedures. In video-assisted
consequence, the indications for video-assisted
multiple-gland surgery, the simplicity of the approach is
parathyroidectomy can be extended, especially in
one of its greatest strengths.
regions with a high prevalence of goiter. CPLombardi
This is a very important advantage of this technique

over those relying on a lateral approach: a conversion Another important point: when a conversion is needed
to traditional open surgery is not necessary when a for any reason, simple bilateral enlargement of the
bilateral parathyroid exploration is indicated. PMiccoli starting incision is required. The final cosmetic result is
that of a traditional Kocher incision. PMiccoli
Through the central incision, this approach allows

exploration of both sides of the neck, and even
ectopic sites (i.e., anterior mediastinum, carotid sheet),
Preoperative Evaluation
differently from other minimally invasive techniques and Surgical Planning
(i.e., open and video-assisted lateral approaches) that Preoperative Considerations
allow only a focused or unilateral procedure.
CPLombardi Preoperative evaluation, localization, and imaging
studies have been discussed in depth in the chapters on
targeted and open parathyroidectomy. The application
of the video-assisted technique to parathyroidectomy
does not affect my evaluation of these patients. I avoid
Benefits of Video-Assisted the use of video-assisted parathyroidectomy (and thy-
roidectomy) in morbidly obese patients.
Parathyroidectomy
Video-assisted parathyroidectomy minimizes patient
Preoperative Calcitriol Supplementation
discomfort, offers improved visualization over loupe
magnification, and is an excellent teaching tool for Especially in patients with long-standing primary hyper-
residents and fellows because the teaching surgeon can parathyroidism and significant bone demineralization,
visualize all aspects of the surgery equally as the training initiate vitamin D supplementation at 0.25 mcg twice
surgeon. daily 4 days prior to surgery to prevent a precipitous
In multiple-gland surgery, the simplicity of the drop in serum calcium and prolonged hospitalization
approach is one of its greatest strengths. Through the due to hungry bone syndrome.
small 2-cm incision, all glands can be visualized and
removed (if so indicated). The decreased incision length We totally agree about this issue: in Western
results in patient cosmetic satisfaction; however, the countries, vitamin D supplementation is often much
incision must be able to accommodate the placement of more important than oral calcium replacement and
retractors and scope, as well as provide the atraumatic indeed more tolerated by patients. PMiccoli
delivery of the parathyroid gland(s).
543
This author’s attitude underlines the need to measure TABLE 54-1 Video-Assisted Thyroidectomy and
serum levels of vitamin D during the preoperative Parathyroidectomy Specialized
Instrumentation
workup of patients with suspected primary
hyperparathyroidism. It is very important to know • Telescope lens (Karl Storz Instruments): 30- and
vitamin D levels in order to treat patients with 70-degree wide-angle/7 mm × 35 cm
deficiency and to confirm diagnosis of • Dissector optical w/large fenestrated spatula
• Suction elevator Miccoli: blunt
hyperparathyroidism versus vitamin D deficiency in
• Elevator Miccoli: blunt 2 mm
mild cases. In my practice, vitamin D supplementation
• Elevator Miccoli: blunt 4 mm
should be avoided in patients with high serum calcium • Hook Hermann
levels. CPLombardi • Scissor Belucci: straight 7 mm × 5.4 inches
• Forceps grasp: serrated/rough jaw 1 mm × 5.75 inches
• Rake small: 3 prong/sharp
Anesthetic Choice • Retractor Miccoli: double end 45 mm/21 mm × 10 mm
• Retractor Miccoli: double end 35 mm/21 mm × 10 mm
Video-assisted parathyroidectomy can be performed • Retractor army-navy
with local anesthesia, conscious sedation, and general • Clamp micro-Halsted: mosquito-curved 5 inches
anesthesia. In most circumstances I prefer general • Clamp Carmal: 7.5 inches
anesthesia. Recurrent laryngeal nerve monitoring can • Harmonic instrumentation
be used for those patients under general anesthesia,
although it is not routinely required.
Subtle laryngeal dysfunction may require videostro-

Although I routinely use laryngeal nerve monitoring
for thyroid surgery, I only use it in parathyroid
issues.
surgery when it is reoperative surgery, or in
anticipated four-gland surgery (for example, renal
hyperparathyroidism or nonlocalizing primary Specialized Instrumentation
hyperparathyroidism). In primary localizing cases in
The basic instruments are included in Table 54-1. The
which a single-gland surgery is anticipated, I believe
critical nature of the special instrumentation allows for
the benefits are reduced. DJTerris
adequate visualization and safety.
The 7-mm, 30- and 70-degree, wide-angle telescope
(Storz Instruments), Harmonic instrumentation (Ethicon
Intraoperative Localization division of Johnson & Johnson), and Miccoli suction
I do not routinely use intraoperative localization in and blunt dissectors as well as retractors are the work-
parathyroid surgery, and a more detailed discussion is horses of the procedure.
found in the targeted and open parathyroidectomy
chapters. Video-assisted parathyroidectomy should not
be used in patients with prior failed open procedures,
The standard procedure for video-assisted
although video-assisted techniques can be used to visu-
parathyroidectomy implies the use of the 5-mm,
alize and excise ectopic parathyroid disease in superior
30-degree endoscope. A 7-mm endoscope is large
mediastinal locations.
and may impede the dissection, reducing the small
operative space. Moreover, a 30-degree angle is
In fact, we consider reoperative surgery for primary sufficient for the procedure because the absence of a
hyperparathyroidism an absolute contraindication to fixed point allows the surgeon to change the position
video-assisted parathyroidectomy, whereas a previous of the endoscope whenever is necessary. CPLombardi
operation on the thyroid gland is only a “relative”
contraindication. Relative means that it only depends
on the surgeon’s attitude and experience. PMiccoli We have found 5-mm telescopes to provide adequate
visualization, and prefer the thyroidectomy
instrumentation provided by Medtronic-ENT (see
Table 54-2). DJTerris
Preoperative Examination
Preoperative evaluation of vocal cord function and Do not try to use the endoscopic sinus scopes for this
laryngeal positioning (rotation) should be performed surgery. These scopes are too short and create conflict
in all patients by either indirect or fiberoptic ex with the instruments the primary surgeon is using for
amination. dissection and delivery.
CHAPTER 54 Video-Assisted Parathyroidectomy 545
TABLE 54-2 Alternative List of Video-Assisted

Thyroidectomy and Parathyroidectomy
Specialized Instrumentation
• Terris elevator: 4 mm
• Terris suction elevator
• Terris peanut holder
• Terris retractors
• Terris malleable atraumatic suction
Hyoid bone
A valid alternative is using a 3- or 5-mm endoscope, Thyroid cartilage

similar to those used by the urologists for cystoscopy:
Just remember that you will have to cope with much
less light to the operative field. PMiccoli
Incision
Trachea
Patient Positioning
A soft gel head donut is used with the chin in the FIGURE 54-1. Ideal location and approximate size of incision
extended position without the use of a shoulder roll for video-assisted parathyroidectomy.
(patient is not hyperextended). The operative table is in
a straight position with the primary surgeon standing
to the right of the patient. Monitors should be placed healing and time, the scar localizes to the immediate
on both sides of the patient such that the assistants can suprasternal depression, which is the most desired cos-
appreciate the adequacy of the retraction and maximally metic location.
facilitate visualization. The ventilation tubing must be
in low profile, passing over the top of the head and then
below the table level to the ventilation apparatus. Place This high incision level indeed allows excellent
the table approximately 2 feet away from the standard cosmetic results. Nonetheless, one should also keep
anesthesia position to allow for an assistant to stand in mind that in focused parathyroid procedures the
directly at the head of the bed. level of this incision can be “modulated” in relation to
the parathyroid gland position as evaluated by
surgeon-performed, bedside ultrasonography.
An alternative is to rotate the bed 180 degrees from CPLombardi
the anesthesiologist to allow ample room for
assistants to stand at the head of the bed. DJTerris
The incision size, location, and orientation (horizon-
tal) are akin to that of a tracheotomy, inferior to the
cricoid, best located in a cervical crease or approxi-
Two U-shaped disposable adhesive drapes are placed mately 2 cm cephalad to the sternal notch.
in a cephalad and then caudad opposing position such
that the cervical area is the only area exposed. It is
rapidly and easily applied. It is also akin to that of the traditional thyroidectomy,
so that if you have to convert the operation to
traditional open surgery, a slight bilateral enlargement
Operative Technique of the small incision is required. PMiccoli

Incision length is ultimately 2 cm. The incision must
locaudal location with the patient awake and in a seating
be adequate to place retractors and the 7-mm scope, and
automatically deliver the parathyroid gland(s). Despite
The horizontal incision is drawn at a level approximat- your operative experience, I have generally recom-
ing the subcricoid area and the first tracheal ring. mended that surgeons early in their video-assisted expe-
Warn the patient prior to surgery that it will appear riences plan slightly larger incisions until their comfort
that the incision is high in the cervical area. With level has been attained.
I also use rubberized guards to protect against

This is a good point. Surgeons who have not had
thermal injury from the shaft of the Harmonic
adequate experience with video-assisted procedures
instrumentation.
can start with larger incisions at the beginning and
reduce them progressively to acquire a progressive
confidence with the procedure. It is very easy to learn
It is also very important to use electrocautery with a
because it is very similar to the conventional
protected tip, in order to avoid burn injury of the
operation, but a progressive experience with shorter
border of the skin incision. CPLombardi
incision may allow a less stressing, and maybe
shorter, learning curve. CPLombardi
1 : 200,000 epinephrine.
In our opinion this is a very important suggestion. A
slightly larger incision is required at the very beginning This provides both postoperative pain management and
of every surgeon’s experience because it allows a incision hemostasis without cautery. An anesthetic also
proper learning curve with the handling of all the allows postoperative pain management with anti
instruments and the endoscope in such a narrow inflammatory medication only, and outpatient surgery
space. It may also allow decreasing the conversion facilitation.
rate in the first cases performed. PMiccoli

STEP 2. The patient is positioned with the back section the subcutaneous tissues.
of the table elevated to reduce venous congestion and
the table placed in Trendelenburg to facilitate superior
cicatrix hypertrophy. Treat the skin edges kindly.
pedicle visualization (a lounge chair position).
In my practice I prefer a neutral position. Indeed, the Techniques for helping avoid skin edge trauma include
elevated back may create an obstacle when the complete avoidance of 4 × 4 sponges, which are very
position of the endoscope is changed, if exploration of abrasive when inserted and removed through the
the anterior or posterior superior mediastinum is incision, and use of an extended length low-profile
required. The same relates to the Trendelenburg Bovie tip, which is less likely to catch on the skin
position: It is not mandatory because the 30-degree edge. DJTerris
endoscope allows a good visualization of the superior
thyroid pole. CPLombardi
ous tissues deep to the platysma to the fascia investing
The legs are lowered and compression stockings
the strap musculature and the communicating anterior
placed on all patients. The patient is slightly hyperex-
jugular veins.
tended in the neck. I leave the patient with the head
toward the anesthesiologist and simply request space Although skin flap elevation is generally immediate sub-
around the head by moving the table about 2 feet away platysmal in neck dissections, in central compartment
from the anesthesia machine. surgery, especially in obese individuals, elevating at the
level of the investing fascia eliminates the potential for
lipectomy or searching for the linea alba.
Do not hyperextend the neck. Inquire of your patients, STEP 8. The flaps are elevated superiorly to the level of
and the frank absence of posterior neck discomfort will the thyroid cartilage and inferiorly, approximating the
become self-evident as compared to the frequently dis- sternal notch. For inferior parathyroid targeted video-
covered discomfort in the “standard” hyperextended assisted surgery, the superior flap need only be mini-
approaches. mally elevated.
This step is of utmost importance in order to provide

STEP 4. A sterile Adaptic dressing may be applied over adequate exposure of the operative field and to
the planned incision site to protect the wound edges allow adequate placement of the endoscope.
from potential thermal injury due to the Harmonic CPLombardi
instrumentation.
We tend to minimize the superior and inferior flaps We suggest limiting the dissection of the linea alba to
dissection for cosmetic reasons. In our opinion, if 3 to 4 cm so that the muscles themselves will absorb
you limit the flap dissection, the tension will be equally most of the tension from the retractors, thus
distributed on the skin edges and the deeper muscles, preserving the skin edges. PMiccoli
allowing for less trauma on the skin edges themselves.
PMiccoli
veins may be encountered and controlled with the Har-
Skin rake tension on the flaps elevated primarily monic scalpel or similar type of ultrasonic device.
perpendicular allows the plane above the anterior
jugular veins and strap musculature to be readily visual-
ized and opened with the electrocautery. In my practice the Harmonic scalpel for video-assisted
The flaps need only be elevated primarily in the parathyroid procedures is not routinely used. It is used
midline overlying the median raphe of the strap muscu- only for associated thyroid procedures. Indeed,
lature. This, then, avoids creation of significant dead because Harmonic is expensive, in order to reduce
space and is efficient. costs of the procedure, small clips, bipolar cautery,
and even conventional ligature are sufficient to achieve
hemostasis during video-assisted parathyroidectomy.
We have completely abandoned the use of flap CPLombardi
elevation at all during thyroid and parathyroid
surgery. The only exception is when a lateral
neck dissection is anticipated. The wound healing
is therefore more rapid and drains are not necessary. My approach to hemostasis has also evolved to
DJTerris bipolar as well as electrocautery and rare use of
suture ligatures. GLClayman
Note: From incision through this point in surgery,
I perform the surgery with loupe magnification only
a moistened sponge to keep from drying.
and do not use endoscopes whatsoever.
I do not use nor recommend silk sutures to keep I do not use loupe magnification, even if it can be
the flaps suspended. Indeed, a fixed retraction does useful. Nonetheless, it is well underlined that this step
not seem so useful in this procedure. We need to of the procedure is done under direct vision. Only after
retract the thyroid and the strap muscles, and not medial retraction of the thyroid lobe and lateral
the skin. Moreover, the retraction of the skin may retraction of the strap muscles, which allows
reduce the freedom of the dissection maneuvers. maintaining the operative space, can the endoscope
CPLombardi be inserted, and the procedure is accomplished under
endoscopic vision. CPLombardi
Although some individuals prefer self-retaining

retractors, I have not used them and prefer suture sus-
pension to anchored drapes on the patient. The absence Targeted Video-Assisted
of lateral dissection of the flaps reduces dead space and
improves efficiency.
Parathyroidectomy
STEP 11. The sternohyoid and sternothyroid strap

STEP 10. The linea alba is identified inferiorly and incised muscles are elevated off of the anterior and lateral
with the use of electrocautery. thyroid gland surfaces and the fibrolymphatic contents
of the central compartment with the use of electrocau-
In most patients the linea alba or median raphe of the
tery solely on the side of the anticipated targeted para-
strap musculature is self-evident. The linea alba is
thyroid gland.
neck. Gentle lateral tension of the sternothyroid muscle As the muscles are laterally retracted with Miccoli
with application of electrocautery on the raphe from the retractors, the muscles are separated from the anterior
immediate suprasternal area to the thyroid notch is and lateral surfaces of the thyroid gland as well as the
performed to separate these muscles. central compartment fibrolymphatics in the immediate
submuscular fascial plane. It is very rare that the ster-

Blunt dissection can usually be accomplished with the
nothyroid muscle origination needs to be released for
use of small spatulas and spatula-shaped aspirator
access, unlike thyroid surgery.
that are included in the kit for the video-assisted
procedure (see following). One again, during sole
parathyroid procedure the use of Harmonic scalpel is
STEP 12. The anterior and medial surfaces of the common
expensive and not mandatory. CPLombardi
carotid artery are dissected from approximately 2 cm
cephalad to the anticipated targeted parathyroid gland
location toward its superior mediastinal origin.
From incision to this point in surgery, I perform the Often, an “energy device” is not necessary for a
surgery with loupe magnification only and do not use parathyroidectomy because we refer to it as a “single
the endoscopes whatsoever. I use the Miccoli or freer clip operation.” When the middle thyroid vein or other
dissector to dissect along the anterior and medial significant vessels are not encountered or can be
surface of the vessel in a longitudinal fashion. Once the spared because of the particularly favorable position
carotid has been identified and dissected, a 7-mm, of the adenoma, a few titanium clips or bipolar
30-degree telescope is used throughout the remainder of electrocautery only can be sufficient. PMiccoli
the procedure.
Although the Harmonic device can be beneficial during

STEP 13. A Miccoli retractor is placed laterally to retract these cases, I do not use it for single-gland
the freed strap musculature while the other Miccoli parathyroid surgery because there is only a single
retractor superiomedially distracts the thyroid and tra- substantial vessel that is ligated during the operation,
cheal apparatus. namely the branch of the inferior thyroid artery
supplying the adenoma. When a four-gland exploration
is anticipated, particularly in patients with renal
Take notice that the retractor on the thyroid lobe
hyperparathyroidism, I do find the Harmonic device
plays the role of the assistant’s hands during the
useful enough to justify its expense. DJTerris
traditional procedure. It should not only pull
medially but also “hook” and load the lobe to
allow a proper visualization of the posterior aspect
Small perforating vessels are coagulated. Vessels
of the thyroid bed, where the eutopic parathyroids are.
greater than 1 mm are controlled with Harmonic instru-
PMiccoli
mentation. The middle thyroid vein frequently is tran-
sected with the harmonic instrument as well to provide
ready visualization of inferior and superior parathyroid
The importance of placing a retractor directly on abnormalities in a bloodless field.
the thyroid gland itself cannot be overemphasized.
In fact, it is desirable to actually hook the thyroid
gland to pull it up and out of the tracheoesophageal STEP 15. A cottonoid, held rigidly with a heavy hemostat,
groove, particularly for identification of superior is used to displace the central compartment tissues
parathyroid adenomas, which are usually found medial to the carotid artery and lateral to the thyroid
on the posterior surface of the thyroid gland. gland.
DJTerris
I do not use a cottonoid hemostat. Rather, the

spatula-shaped aspirator is a very useful instrument to
The retraction and countertraction of the thyroid accomplish dissection in my experience. CPLombardi
gland and trachea medially, create the space required
to perform video-assisted surgery (Figure 54-2). The
30-degree telescope provides the necessary visualization Medtronic-ENT provides a device specifically designed
of the anticipated parathyroid abnormality location. to hold a peanut cottonoid. It has a low-profile shaft
and a cup tip design, and is therefore superior to the
use of a standard hemostat. DJTerris
is dissected with a mosquito hemostat and incised
with Harmonic instrumentation, cautery, or similar This displacing force generally allows visualization
methodology. of the pathologic parathyroid gland.
Thyroid
gland
Recurrent
Adenoma
laryngeal n.
FIGURE 54-2. A, The depicted left superior

Adenoma
parathyroid adenoma is identified within the
space created by the countertraction of the
strap musculature laterally, and the thyroid
Thyroid gland medially. B, The scope view of the
gland same left superior parathyroid adenoma. The
Recurrent recurrent laryngeal nerve is depicted
laryngeal n.
posterior to the adenoma and its vascular
supply still intact.
B
STEP 16. A capsular excision of the gland is performed The insulated portion of the Harmonic blade must
and the arterial and venous contributions controlled with be carefully observed and be directed toward critical
Harmonic instrumentation. structures such as the recurrent laryngeal nerve, carotid
artery, trachea, and esophagus.
Creating space to allow an area of air “insulation”
As an alternative to the use of the Harmonic device, is always beneficial whenever feasible.
some glands with small vessels can be ligated with I prefer bipolar electrocautery for any small vessels
unipolar electrocautery. If the vessels are larger, a with intimate proximity to the recurrent laryngeal nerve.
small clip can be applied at a very low cost. DJTerris If necessary, a micro titanium clip can be used to protect
a nervous branch or the recurrent nerve.
For targeted video-assisted parathyroidectomy, I do

not inspect or dissect any of the other parathyroid gland
predicted locations. This minimizes dissection and
potential trauma to the normal retained parathyroid
glands (unless intraoperative parathyroid hormone
[IOPTH] level predicts a single gland operative failure). Thyroid
Recurrent
gland
laryngeal n.
Another very important technical issue is that limiting
the dissection to a single parathyroid is responsible for Adenoma
the limited morbidity of the operation both in terms of
postoperative hypoparathyroidism and recurrent nerve
injury. PMiccoli
STEP 17. The recurrent laryngeal nerve may require dis-

section based on the pathologic gland location. Some of
the anatomic course and issues pertaining to nerve dis- A
section and visualization are discussed in Chapter 47
(Figure 54-3).
I recommend proper recurrent laryngeal nerve Sterno- Sternohyoid m.

thyroid m.
identification and preparation as a first step of all the
parathyroid procedures, in order to avoid any nerve
injury during parathyroid gland dissection and vascular
Thyroid
pedicle section. The enlarged parathyroid gland, gland
especially superior ones, can be intimately attached to
the laryngeal nerve, due to their position and migration
displacement related to enlargement. CPLombardi
Adenoma
STEP 18. Video-assisted subtotal and total parathyroid-
ectomy is performed through the identical central
approach, identifying at least four glands prior to pro-
ceeding with any gland excisions.
The sites of anticipated normal and ectopic gland loca-

tions are detailed in Chapter 53. The indications and
approach to subtotal and total parathyroidectomy B
and autotransplantation are discussed in Chapter 53
as well. FIGURE 54-3. A, A left inferior parathyroid adenoma is
depicted in a midparatracheal location with the recurrent
laryngeal nerve immediately posterior to the isolated abnormal
Once again it should be stressed that the endoscope gland. B, The scope visualization of the left inferior
through the single central access allows the surgeon parathyroid adenoma during excision. Notice again the
created space by the traction and countertraction forces of
to explore all the normal and ectopic cervical
the Miccoli retractors.
parathyroid site. A formal bilateral neck exploration
can be easily accomplished. When exploring the upper
mediastinum the assistant handling the endoscope
should be positioned at the head of the patient, to
direct the endoscope toward the upper mediastinum. Although PTH half-life should allow for earlier sam-
CPLombardi pling, I prefer a single serum analysis rather than mul-
tiple samples over 5 and 10 minutes. A 50% or greater
drop in PTH level and within normal range predicts a
STEP 19. Fifteen minutes after complete removal of the successful single-gland surgery. The patient is kept
gland(s), a serum sample is drawn for rapid PTH sedated and surgical field maintained until the labora-
analysis. tory results are received.
Intraoperative PTH assay is mandatory in all the

parathyroid procedures. Also in our experience the sam-
Postoperative Care
pling time should be delayed to obtain the best results. Video-assisted targeted parathyroidectomy is performed
For our interpretation criteria refer to Di Stasio and as an outpatient procedure. The patient is discharged
colleagues (2007) or Lombardi and associates (2008) on antiinflammatory pain medication, with narcotics
(see Suggested Readings list). only for breakthrough discomfort. The patient is sup-
plemented with calcitriol 0.25 mcg twice daily and
elemental calcium 1 g twice daily unless signs or symp-
STEP 20. The wound is irrigated, and meticulous hemo- toms of hypocalcemia present. No laboratory studies
stasis verified. are required following intraoperative verification of
serum PTH normalization. The patient’s first outpatient
No drains are required. Powdered Avitene is placed
follow-up is at 1 week for pathology review, wound
within the wound. Surgicel is an alternative in this area.
inspection, and further instruction on wound care.
I similarly put patients on a 3-week taper of calcium,

STEP 21. The strap musculature is reapproximated with
although I do not use calcitriol except in renal
a single 3-0 Vicryl suture.
hyperparathyroid patients. My first and only
postoperative visit is at 1 month after surgery, when
the patient is no longer under calcium taper, and that
STEP 22. The wound is closed with a subcutaneous
is an optimum time to measure the calcium and
Vicryl suture and Dermabond or a subcuticular absorb-
parathyroid hormone. DJTerris
able suture.
Duration and extent of vitamin D and calcium sup-

plementation are based on preoperative bone mineral
A quarter-inch horizontal Steri-strip placed on top of density determination and interdisciplinary manage-
the dried glue covers up any slight appearance of ment with endocrinology.
blood, and facilitates glue removal 2 to 3 weeks
following surgery. DJTerris Suggested Readings
Di Stasio E, Carrozza C, Pio Lombardi C, Raffaelli M, Traini
E, Bellantone R, et al: Parathyroidectomy monitored by
Although traction trauma to the wound edges is intra-operative PTH: the relevance of the 20 min end-point.
much more commonly identified in video-assisted thy- Clin Biochem 40:595-603, 2007.
roidectomy, careful inspection of the wound edges Lombardi CP, Raffaelli M, Traini E, De Crea C, Corsello SM,
should be performed. If trauma is noted, I have adopted Bellantone R: Video-assisted minimally invasive parathy-
approaches to freshen 1 to 2 mm of the incision edges roidectomy: benefits and long-term results. World J Surg
prior to closing to minimize the risk of hypertrophic 33:2266-2281, 2009.
wound healing. Lombardi CP, Raffaelli M, Traini E, Di Stasio E, Carrozza C,
De Crea C, et al: Intraoperative PTH monitoring during
parathyroidectomy: the need for stricter criteria to detect
multiglandular disease. Langenbecks Arch Surg 393:639-
Another option when the skin edges appear too 645, 2008.
damaged is the resection of the necrotic tissue. Miccoli P, Berti P, Materazzi G, Ambrosini CE, Fregoli L,
Although the idea may seem too aggressive, this Donatini G: Endoscopic bilateral neck exploration versus
remodeling of the incision gives a better cosmetic quick intraoperative parathormone assay (qPTHa) during
outcome in the long term. PMiccoli endoscopic parathyroidectomy: a prospective randomized
trial. Surg Endosc 22:398-400, 2008.
SECTION A Skin Grafts
CHAPTER
Split-Thickness Skin Graft
55 Author Mark K. Wax
Commentary by Peter A. Hilger and David B. Hom
Preoperative Considerations n Surface coverage of a vascularized (pedicled or free)

myofascial flap
The majority of defects of the head and neck can be n Large mucosal defects not amenable to primary
repaired by either simple closure with generous under- closure
mining or a local pedicled cutaneous flap. Occasionally,
local tissues are insufficient and regional tissue transfer
would bring in too much tissue. In these cases skin graft- Full-thickness skin grafts have the ability to:
ing may be a reconstructive option. Although many of n Provide superior texture and color match
these wounds heal on their own, the process can take n Provide a more durable result than a split-
many months. Use of the split-thickness skin graft facili- thickness skin graft in areas of friction
tates the healing process. n Have less contraction than a split-thickness skin
graft and thus create less distortion
n Have a survival rate nearly equivalent to a split-
Over the past decades, patients’ and surgeons’
thickness skin graft
expectations regarding the aesthetic quality of facial
n Have far less donor site morbidity (a split-thickness
reconstruction have escalated. Perhaps this is most
skin graft donor site can take 3 weeks to heal and
graphically exemplified by the development of
is associated with significant discomfort, and these
techniques and public notoriety associated with
sites always have color and texture changes that
transplantation of composite facial tissues. Over the
are an aesthetic distraction)
past 20 years our indications for and use of split-
n Provide an equivalent opportunity for tumor
thickness skin grafts have diminished remarkably. As
surveillance at the site of reconstruction
noted by the authors, most soft-tissue defects can be
PAHilger
repaired with local or regional vascularized tissue
transfer. Occasionally, second-intention healing in
areas that permit soft-tissue contraction without
A full-thickness skin graft instead of split-thickness
distortion of adjacent anatomy provides a high-quality
skin graft should be considered if one is concerned
result, but is a useful option in a limited number of
that skin graft contracture location could compromise
circumstances, usually in an anatomic concavity.
facial function (i.e., proximity to the eyelid, mouth, and
When a skin graft is an appropriate choice, we almost
nose) because full-thickness skin grafts contract less.
always use a full-thickness skin graft. Rarely is a
DBHom
defect so large that a full-thickness skin graft, with or
without mobilization of local flaps, does not suffice.
Perhaps a very large scalp defect is an exception. In our practice, split-thickness skin grafts are useful
PAHilger for:
n Very large defects
The indications for a split-thickness skin graft include n Replacement of visceral lining such as the oral or
the following: nasal cavities when a thinner lining is desired.

n Cutaneous defect not amenable to primary closure However, in the nasal cavity, structural grafts,
or local flap usually of cartilage, are required to avoid
555
556 UNIT VII Basic Reconstructive Flaps
postoperative contraction with aesthetic distortion To maximize skin graft survival, a healthy wound
and physiologic compromise. These cartilage grafts bed is optimal for maximal revascularization such
must be placed deep to the vascular tissue that as underlying fascia, muscle, periosteum, or
will nourish the skin graft. In addition, intranasal perichondrium and not bare bone or cartilage. DBHom
stenting may be valuable for several weeks to
months following surgery.
n Temporary reconstruction of defects that includes Special Surgical Requirements
a plan for resection of the split-thickness skin graft for Obtaining the Skin Grafting
and further refinement with techniques such as
The most common donor site for a skin graft is from
tissue expansion to improve the quality of repair.
the lateral thigh. This area can be prepped and draped
This is similar to the excision of a skin paddle in
at the beginning of the case and then covered while the
free-flap reconstruction in which the skin paddle is
primary procedure is taking place. Care should be taken
used to monitor the viability of the free-tissue
not to use DuraPrep because it will stick to the skin and
transfer.
a graft will not be harvestable.
PAHilger
The split-thickness skin graft donor site that is most

In some circumstances a split-thickness skin graft
concealed is the buttocks region. A donor site for
may not be warranted and a different reconstructive
which repeated split-thickness skin grafts can be
method should be used. The circumstances most often
taken over intervals from the same region is the
encountered are:
scalp. DBHom
Cutaneous loss resulting in vascular exposure, which
is best managed with pedicled or free-flap coverage
rather than a split-thickness skin graft. The presence of
Our preferred donor site for a split-thickness skin graft
an active pharyngocutaneous fistula may result in dis-
is the scalp. We have found that:
solution of the skin graft. n There is less patient discomfort at the donor site.
n The donor site is often within the surgical field.
When a grossly contaminated or infected wound is n The scalp is thicker and can be a better donor site
encountered, it may be helpful to use a wound due to a more favorable epidermal-dermal

vacuum-assisted closure (VAC) device to expedite interface. This is especially true in older patients
recipient site preparation for a skin graft. This is not whose skin thins over time.
true when there is vascular exposure. PAHilger n The donor site is hidden by hair regrowth and the
color and texture changes of the skin are thus
masked.
The presence of an active wound infection may result
Technical details to be considered when using the
in dissolution of the skin graft. The presence of a chyle
scalp as a donor site include shaving the hair, the use
fistula prevents the skin graft from adhering to the
of tumescent fluid to aid in hemostasis, and the
underlying tissue.
soft-tissue inflation with fluid, which allows the
In general, patients who have significant cutaneous
surgeon to compress the donor site with a cutting
or mucosal defects who have received prior radiother-
board producing a flat surface for skin graft
apy should be allowed to develop a healthy bed of
harvest. PAHilger
granulation tissue prior to placement of a skin graft.
The lack of development of granulation tissues indicates
poor wound bed healing potential and is a prognostic Placement of the Bovie pad and taping of the Foley
indicator of poor graft take. catheter should be on the contralateral leg. Occasion-
ally, preoperative shaving is necessary. A Zimmer der-
In our practice we agree that immature wounds should matome is our dermatome of choice. A variety of blade
be allowed to develop granulation tissue prior to widths (2, 3, and 4 inches) is available. We usually do
placement of the graft. We find that this approach not harvest the skin graft until we know the size of the
increases not only graft survival but also the wound defect.
contour, and volume replacement enhances the
aesthetic result. PAHilger To confirm correct calibration of the skin graft
thickness to be taken, the space between the cutting
Another contraindication for a split-thickness skin blade and dermatome plate can be checked by sliding
graft is a surface area that is mobile and shearing may the beveled edge of a No. 15 scalpel along the space
take place. If the graft is not immobile with respect to to check for evenness. This is to ensure that the
the underlying surface, it will not stick and survive.
CHAPTER 55 Split-Thickness Skin Graft 557
FIGURE 55-1. Patient positioning is

important in being able to effortlessly
take the skin graft. The patient is
positioned on the back with a roll under
the ipsilateral hip. The knee is flexed at
90 degrees and a template applied.
STEP 4. While the assistant holds pressure with the

cutting blade has been properly engaged in the tongue depressor and advances away from the blade,
dermatome and to confirm if a homogeneous skin the operator pushes the blade forward until the
graft thickness will be obtained. It is also important to appropriate-size graft has been harvested. At this point
turn on and test the dermatome before placing it on the dermatome is removed from the leg like a plane
the patient. DBHom taking off of a runway (Figure 55-2A and B).
A blade that is 20% larger than the width of the

defect is chosen because the graft shrinks once it is STEP 5. Using a pair of gerald with teeth, the skin graft
removed from the patient. Tongue depressors, mineral is removed from the dermatome. If it is not to be used
oil, and toothed forceps are required. Meshing of the for any period of time, it must be kept moist. We prefer
skin graft can increase the surface area of the defect that to place it in a cup of saline.
can be covered by up to threefold. We rarely use meshing.
Surgical Technique I prefer wrapping the skin graft in a cool normal saline
gauze to minimize its metabolic demands while it is in
the ex-vivo state. DBHom
STEP 1. The patient is supine with a bolster under the
hips and lateral hip (Figure 55-1). The table is rotated so
that the donor leg is facing away from the anesthesia When it is time to lay it on the wound bed, the
machine. This allows for unencumbered access to the keratinizing surface is easily distinguished and is placed
thigh. The leg is prepped and draped with a povidone- facing up on top of the donor’s recipient site. A pair of
iodine (Betadine) solution. DuraPrep should not be used gerald with teeth is used to flatten out the split-thickness
because it causes the skin to stick and the graft cannot skin graft so that no buckling or wrinkling is present.
be harvested. The graft should fit loosely and cover the entire surface
area of the wound. It should overlap the edges and fit
into all the nooks and crannies. Any tenting or tension
STEP 2. The size of the defect in the head and neck is will result in a non-take at that area. The skin graft is
measured with a ruler and a template is cut out to simu- sutured to the periphery of the wound bed using a 5-0
late the defect. fast suture in a running fashion. Multiple tacking sutures
are placed in the skin graft itself to hold it to the bed
using a 5-0 fast suture. In cases in which meshing is not
STEP 3. Mineral oil is applied liberally to the thigh skin. used, multiple pie-crusting incisions are placed at 1-cm
The blade is adjusted to provide on average a thickness intervals through the skin graft to ensure the egress of
of 0.014 to 0.018 inch of skin. We routinely use the cutting serous fluid (Figure 55-3).
surface of a No. 15 scalpel to ensure that the thickness
is adequate. The blade should fit between the blade of
the Zimmer and the bevel. The skin graft is harvested by Small fenestrations of the skin graft are preferred over
turning the dermatome on. I approach the skin at a meshing if possible to decrease hematoma formation
90-degree angle. After the initial incision, the derma- for better cosmetic appearance. I prefer 5-0 chromic,
tome is rotated downward at 90 degrees to become or at times 5-0 Vicryl, to secure the graft if slow
parallel with the skin. healing is anticipated. DBHom
FIGURE 55-2. The graft is taken with a Zimmer dermatome. A, The initial “cut” is made with
the Zimmer at 90 degrees to the patient, and then, B, the Zimmer blade is turned parallel to
the skin of the thigh.
We prefer to suture the graft into place with is easily and efficiently applied, conforms to any
interrupted fast gut suture rather than a running suture surface contour whether it be convex or concave, and
because it provides less of a pursestring effect and is easy for patients to care for after surgery. PAHilger
distortion of the graft recipient site perimeter, and the
interrupted sutures can favor the escape of any fluid
that would develop between the graft and recipient STEP 6. Occasionally, meshing of the skin graft is
site and interfere with graft take. We often use a required. Meshing is performed by placing the skin graft
similar suture to tack the graft into concavities, onto a mesher, either a 1.5, 2.0, or 3.0 times plate. It is
improving graft recipient site tissue contact and important to keep the split-thickness skin graft well
resistance to shear forces. Skin grafts placed on lubricated by dripping saline onto it in a continuous
surface defects, in our practice, are routinely stented fashion to prevent the skin from getting caught up in the
with Aquaplast. Telfa or Adaptic is coated with an roller (Figure 55-4).
antibiotic ointment and placed over the graft,
overlapping the suture line by approximately 1 cm.
Aquaplast, a bithermal plastic, is then heated in a STEP 7. The wound is dressed appropriately and immo-
warm basin of water until it becomes clear and bilized depending on its location.
malleable and it is then draped over the graft and
adjacent skin to provide a properly contoured and Split-thickness skin graft splinting is essential to
stable stent. The stent can be fixed in place with an maximize take and to minimize shearing of the graft
interrupted 4-0 or 5-0 nylon suture, or in some for least 5 days to ensure proper revascularization. I
circumstances stapled into place. This stent technique prefer using a Xeroform sheet covered with a cotton
CHAPTER 55 Split-Thickness Skin Graft 559
Pie crusting
Tacking suture
FIGURE 55-3. The split-thickness skin graft is sewn onto the wound bed with 5-0 fast suture.
The periphery is done with a locking running stitch. The middle parts are individual tacking
sutures. Pie crusting is performed.
FIGURE 55-4. The mesher consists of the actual device and a plate. The skin is laid on the
plate and fed into the mesher. Copious irrigation is used to keep the skin from becoming
attached to the turning blade.
removed. We initially apply a piece of Telfa soaked in

bolster soaked in mineral oil and secured with 3-0 silk.
1 : 100,000 epinephrine to the donor site wound bed in
Another option is to use an Aquaplast splint that can
order to obtain hemostasis. At the end of the procedure
be molded after it is immersed in hot water to secure
we spray the donor site with a fibrin glue and cover it
the cotton bolster with 3-0 silk suture. Using an
with an Opsite dressing. This stays in place for 5 days
Aquaplast bolster is especially helpful in securing
and is then removed. An antibacterial ointment with
grafts over areas with various surface contours (i.e.,
Telfa is used to facilitate wound healing for 3 weeks.
supra-ala nasal crease, auricle, posterior auricular
The wound needs to be carefully managed for up to
region). DBHom
8 weeks because any trauma to the wound bed may
result in an abrasion that requires reapplication of the
dressings.
For wounds that are on the donor site of free tissue
transfer, such as the forearm, we routinely use a Xero-
form gauze applied to the wound with 4×4 gauze packed A recent method to immobilize a skin graft is to use a
loosely into the wound bed. A Kerlix gauze is then VAC device in patients with delayed healing. The VAC
applied to allow for proper occlusion. We immobilize device is most useful over regions that can be secured
the donor site using a splint for 5 days. A Xeroform over flat surfaces. In its current state, the VAC device
gauze is then used for 3 more weeks and the splint worn is more difficult to keep attached over several days to
to protect the site. surfaces with various contours on the face and neck.
If the graft is used in an intraoral setting a bolster is Despite these shortcomings, its use will continue to
made by tucking cotton balls soaked in bacitracin zinc increase and benefit patients in the future. DBHom
and polymyxin B sulfate (Polysporin) inside a Xeroform
gauze, which is then molded to fit to the defect; 0-silk Both the donor and recipient site will need to be
sutures are used in a circumferential fashion to immo- protected from the environment and trauma for up to
bilize the packing. They are tied over top. The bolster 2 months to ensure adequate healing.
is kept in place for 5 days, then removed.
Occasionally a split-thickness skin graft is used to
cover the muscle of a pedicled or free flap that has been EDITORIAL COMMENT: Skin grafting as a means
used for reconstructive purposes. The neck skin is of head and neck reconstruction is performed with
unable to be closed over the muscle without risk of significantly less frequency than in the past as a
vascular compromise. In these instances we apply the result of an increased variety of better options in
split-thickness skin graft to the muscle and secure it in terms of reliability and quicker healing. There are,
the usual fashion. A Xeroform dressing is applied to however, still circumstances in which it represents
protect it. No other dressing is necessary. the best option, and unfortunately, the relative
rarity with which the technique is used has meant
If a skin graft donor site is not available or cannot be
that many of the technical details that make up the
done, cadaveric freeze-dried skin (Alloderm) can be
“art” of its application have been lost. Dr. Wax and
used for temporary coverage on raw skin surfaces to
his commentators describe a variety of techniques
minimize oozing (i.e., first-stage paramedian skin
and variations that should allow even the
forehead flap to the nose). Another option is to use
occasional operator to successfully perform this
commercially available bioengineered skin (Apligraf)
operation in a variety of different settings. JICohen
that can be shipped overnight to be used as a thin
skin graft coverage. DBHom
Suggested Readings
Again our preferred reconstructive choice in this
construction is a full-thickness skin graft. PAHilger Ghanem TA, Wax MK: A novel split-thickness skin graft
donor site: the radial skin paddle. Otolaryngol Head Neck
Surg 141:390-394, 2009.
Postoperative Management Kim PD, Fleck T, Heffelfinger R, Blackwell KE: Avoiding
secondary skin graft donor site morbidity in the fibula free
When a skin graft is used an intraoral location, antibiot- flap harvest. Arch Otolaryngol Head Neck Surg 134:1324-
ics are routinely administered until the bolster is 1327, 2008.
SECTION B Pedicled Flaps
CHAPTER
Cervicofacial Rotation Flap
Commentary by Ted A. Cook and Eben L. Rosenthal
Preoperative Considerations relieve tension on our cutaneous flap itself. And the
The cervicofacial rotation flap is a random fasciocutane- SMAS flap has separate and equally dependable
ous flap in the face, and a musculocutaneous flap in the vascularity. TACook
neck. It is a random pattern flap that receives its vascu-
lar supply from interconnecting vessels that anastomose
to perforating vessels of the contralateral neck. Although Soft-tissue defects created below the level of the
this form of blood supply is usually unreliable, the vas- mandible can be reconstructed using the pectoralis
cular supply of the skin in the head and neck area is major myofascial flap. ELRosenthal
rich with interconnections of an ipsilateral and bilateral
nature. Consequently, this rotation flap can be elevated Notwithstanding the limitation of volume, this flap
with great reliability based on a random blood supply provides the best cosmetic match for surface area in the
from the subdermal plexus. head and neck. Proper planning of incisions is of para-
This flap is ideal for resurfacing cutaneous defects in mount importance.
the head and neck region. It supplies tissue with similar Extending this flap in a bilobed fashion to the post-
elasticity and cosmetic appearance to the resected skin. auricular area allows reconstruction up to the lateral
For primary reconstruction of cutaneous defects in canthus and temporal region.
untreated patients this is an excellent and reliable flap.
Patients that have been pretreated with radiation therapy
This second, postauricular, flap may add up to 2.5 cm
or neck dissection of either the ipsilateral or contralat-
of width to the flap, but it is somewhat thinner and
eral side may exhibit compromise of the most distal
less sun-exposed skin. So it’s not a perfect match.
parts of the flap. Planning should take this into account,
TACook
and consideration of a different modality of reconstruc-
tion should be undertaken.
The postauricular portion of the flap is most at risk for
Thinning of the subcutaneous aspect of the flap during
necrosis, particularly in smokers. ELRosenthal
tumor extirpation is also a relative contraindication to
a cervicofacial rotation flap because it commonly
results in distal necrosis. ELRosenthal
Technique of Flap Elevation
Patients with composite tissue defects involving more
than skin and subcutaneous tissue will be unable to be STEP 1. The most critical aspect of raising a cervicofa-
reconstructed with a similar volume of tissue with the cial rotation advancement flap is proper design of the
use of this flap. This flap only transfers skin and subcu- skin incision. It is incumbent on the reconstructive
taneous tissue, thus tissue volumes are limited. surgeon to be present prior to the ablative surgeon
marking the incision. A poorly placed incision does not
We have, over the past 10 years, become very allow for proper rotation advancement and closure with
aggressive in creating and mobilizing separate SMAS a tension-free suture line. A generous curvilinear inci-
(subcutaneous musculoaponeurotic system) layer flaps sion traced in a relaxed skin line down into the supra-
beneath our cervicofacial cutaneous flaps. We can clavicular area or even down onto the chest is required
thus fill in soft-tissue deficits and simultaneously depending on the degree of rotation that is needed
(Figure 56-1).
561
Extending the incision inferiorly in males improves

developing a larger flap (called the cervicothoracic
rotation flap). The incision can be placed just above
Defect the level of the areola or to the level of the mammary
xyphoid and then elevated to the midline with
preservation of the internal mammary perforators.
ELRosenthal
Scar
Several points are helpful in visualizing these flaps and

maximally using them:
1. Try to fashion the original defect, even to the
extent of excision of noninvolved skin, as a triangle
whose base is superior and whose medial side is
parallel to the nasofacial groove extending down
into the melolabial crease.
2. Ideally the base incision should be in the subciliary
line, 2 mm below the ciliary line itself. Any tissue
A between the border of the flap and the ciliary line
will become edematous and very visible.
3. Similarly, ideally camouflaged medial borders are
precisely in the nasofacial groove.
The overall length of the superior margin of the flap
should be four times the length of the base of the
Defect triangle. This 4 : 1 ratio provides a flap that is fully
mobile and usually obviates the need for a “Burrow’s
triangle” on the outer margin of the donor side.
TACook
Scar
To provide for an ectropion-free repair, the arc of the

flap should begin in the subciliary line and arc up to
above the level of the lateral canthal tendon just
beyond the margin of the lid itself. The arc should then
go directly posterior to the preauricular crease in
males (in females it should extend to the preauricular
tuft of hair and then curve around the tuft into the
preauricular crease). It should continue down the
preauricular crease, into the tragal notch (posttragal
incisions here are always visible), down to and around
the lobular notch, upward in the postauricular crease
to the level of the conchal bowl, and then curved back
to the hairline and down just anterior to the hairline
B and across the neck in one of the deep cervical
creases—usually the second one is ideal. The closure
FIGURE 56-1. A, A circular defect of the cheek is then begins with two critical subcuticular sutures, the
demonstrated here. Incision for a cervicofacial advancement first at the medial corner (ideally just at and into the
flap is depicted. Note the sweep posteriorly to encompass a medial canthal tendon), and the second at the
parotidectomy incision with generous undermining. B, A much periosteum above the attachment of the lateral canthal
larger defect is demonstrated that will require a larger transfer tendon on the lateral bony orbital rim. These two
of skin. Consequently, the inferior incision is carried into the
sutures should result in an upward force on the lid
supraclavicular area and across the midline.
margin itself. The remainder of the closure should then
easily line up. In patients older than 70 years, it is
probably best to also perform a simultaneous lower lid
canthal shortening procedure. TACook
CHAPTER 56 Cervicofacial Rotation Flap 563
Tension on the suture line can result in distal flap

necrosis. The postauricular portion of the wound
can be difficult to close because the scalp tissue
is relatively inelastic. This postauricular
wound demonstrated in IB can be closed with a
split-thickness skin graft. ELRosenthal
STEP 2. The incision is carried down through skin sub- Flap

cutaneous tissue and through the SMAS in the face and
through the platysma in the neck. The flap is raised in a
subplatysmal or sub-SMAS layer anteriorly to allow for
rotation advancement (Figure 56-2).
Platysma m.
I prefer raising the facial portion of the flap in the
subcutaneous (supra-SMAS) plane and then the
cervical portion in the sub-SMAS plane. This allows
me to preserve the vascularity afforded by the A
platysma but to use the SMAS as a separate flap.
TACook
Raising the flap in the sub-SMAS layer allows for a

thicker flap with improved vascularity, but makes the
dissection more technically difficult and puts branches
of the facial nerve at risk. ELRosenthal
STEP 3. The incision could be carried farther inferiorly

or a small back-cut performed to improve rotation
(Figure 56-3). Generous undermining posteriorly allows Flap
for closure of the inferior aspect. The flap is then rotated
and sutured in place using a 3-0 Vicryl deep layer to the
SMAS or platysma and a 5-0 fast for the skin. Suction
drains are placed more often than not because of the
concomitant parotidectomy or neck dissection should it Platysma m.
be performed (Figure 56-4).
It is important, however, to ensure that the drains be

as soft as possible, and that they not extend forward
under the arc of the flap itself. TACook
B
A heavy suture should be placed at the superior lateral
aspect of the flap at the level of the zygoma to secure FIGURE 56-2. The skin incision is performed, and the flap is
the flap superiorly and to prevent gravitational pull on elevated in a subplatysmal fashion inferiorly and a sub-SMAS
layer superiorly. A short flap is demonstrated in A, and longer
the eyelid, which can often result in ectropion. The
flap is demonstrated in B.
suture should be secured to the deep periosteum of
the lateral orbital wall or zygoma. ELRosenthal
STEP 4. No dressings are placed and care is taken to

ensure that there is no pressure dressing applied to the
skin or subcutaneous tissues.
Flap
A
A
Flap
B B
FIGURE 56-3. The flap has been completely elevated and FIGURE 56-4. The flap is sutured in place with undermining
rotation is shown demonstrating closure of the superior and rotation and advancement of the inferior flap for primary
aspect of the wound. A short flap is demonstrated in A, and closure. A short flap is demonstrated in A, and longer flap is
longer flap is demonstrated in B. demonstrated in B.
CHAPTER 56 Cervicofacial Rotation Flap 565
Suggested Readings
At times a bulky facelift-type dressing may be of help
in avoiding seroma formation. TACook Austen WG Jr, Parrett BM, Taghinia A, Wolfort SF, Upton J:
The subcutaneous cervicofacial flap revisited. Ann Plast
Surg 62:149-153, 2009.
Blackwell KE, Buchbinder D, Biller HF, Urken ML: Recon-
EDITORIAL COMMENT: Although the concept of a struction of massive defects in the head and neck: the role
cervical rotation flap for closure is well of simultaneous distant and regional flaps. Head Neck
recognized, the execution of the operation often is 19:620-628, 1997.
not. Properly designed and elevated, this flap is a Moore BA, Wine T, Netterville JL: Cervicofacial and cervico-
very versatile and reliable method of thoracic rotation flaps in head and neck reconstruction.
Head Neck 27:1092-1101, 2005
reconstruction of defects in the face and upper
Tan ST, MacKinnon CA: Deep plane cervicofacial flap: a
neck which can cover a large surface area with
useful and versatile technique in head and neck surgery.
excellent cosmetic results. The details of this are Head Neck 28:46-55, 2006.
well outlined in the text and commentary, with
some variations for specialized situations. JICohen
CHAPTER
Deltopectoral Flap
Commentary by Fred G. Fedok and Eric M. Genden
Preoperative Considerations Unless the flap is extended via a delay technique,

The deltopectoral flap is a fasciocutaneous flap that its utility is limited to the anterior-lateral lower neck.
achieves its neurovascular supply from the perforating FGFedok
branches of the internal mammary artery. The flap was
originally described as requiring transfer of the first,
second, and third intercostal perforators, but now is Technique of Flap Elevation
based on the second and third intercostal perforators
(Figure 57-1).
The medial part of the deltopectoral flap up to the STEP 1. The second and third intercostal perforators are
junction of the pectoral muscle and deltoid muscle is marked on the patient’s skin. A flap is marked with
extremely reliable and can be transferred with a high careful attention being paid so that the tip of the recon-
certainty of survival. Once the flap is extended past this struction will rotate based on its inferior attachment to
point, the degree of reliability starts to decrease. The the chest wall into the field where the reconstruction is
farther laterally one raises the flap, the more random required (Figure 57-2).
the vascular supply and the less likely survival will
occur. In order to improve distal flap survival, delay can Traditionally the location of the perforators was
be used (see Figure 57-1). surmised based on the anatomy of the ribs. A Doppler
can be used to verify the patency. FGFedok
Beyond the deltopectoral junction the flap is extended

A Doppler can be used to identify the perforating
to another angiosome and is thus less reliable.
vessels in an effort to improve the reliability and
FGFedok
capture of all three perforators. EMGenden
Flap delay, if previously performed, allows distal

Because patients afflicted with head and neck cancer
portions of the skin to be incorporated into the flap.
may require more than one surgery for recurrent
Flap delay is performed by outlining the length of the
disease or secondary reconstruction, we recommend
flap required. The area over the deltoid muscle is identi-
that when raising a pectoralis flap, the incisions be
fied. This distal portion of the flap is elevated on three
made to stage the deltopectoral flap so that in the
sides down to the fascia over the deltoid muscle. The
event that a deltopectoral flap is required in the future,
medial attachment is left intact. A piece of Silastic sheet-
the flap has been staged. EMGenden
ing is placed under it and then the wound is dressed.
Minimally tacking Prolene sutures are used to hold it in
place (Figure 57-3).
One must always be aware of the potential for distal
tip necrosis in this flap. Any procedure that has sacri- The use of the Silastic sheeting is optional. FGFedok
ficed the internal mammary artery or interfered with the
second and third intercostal perforators does not allow
for successful transfer of a flap. Diabetes, wound infec- We delay the deltopectoral flap by merely making the
tion, and a radiated recipient bed have all been reported lateral-most incisions and carry them medially to the
as contributing to a higher morbidity with this flap deltopectoral groove. The flaps are then sutured down
technique. without Silastic sheeting interposed. EMGenden
The deltopectoral flap is limited in arc.
566
CHAPTER 57 Deltopectoral Flap 567
Flap
Deltoid
muscle
FIGURE 57-3. This illustration demonstrates how delay of a

distal portion of the flap can be performed. An incision has
been carried down through the skin subcutaneous tissue, the
fascia overlying the deltoid. The flap has been elevated and a
piece of Silastic sheeting has been laid underneath the flap to
X Perforators
allow for in growth of a vascular supply from the pedicle that
Pectoral will be transferred.
muscle
FIGURE 57-1. The deltopectoral flap is based over the

pectoral muscle with variable extension onto the deltoid. The A delay of 1 week is used in our practice. The patient
second and third intercostal perforators supply the skin is taken back to the operating room after 1 week, and
paddle. The distal part of the deltopectoral flap is a random the entire elevation of the flap is executed. FGFedok
segment.
A suction drain may be placed to help prevent fluid

collection. FGFedok
Deltoid
muscle STEP 2. The flap is then elevated in a medial direction
in a subfascial plane. As one approaches the midline, the
Pectoral
muscle intercostal perforators can be visualized. This usually
occurs approximately 2 cm lateral to the sternal border.
Caution must be taken to avoid injury to these vessels
(Figure 57-4).
I usually carry the incision through the fascia to include

it with the flap. FGFedok
STEP 3. The flap is then secured into its recipient site in

two layers.
FIGURE 57-2. The intercostal area has been marked with X’s
to depict where the intercostal perforators originate. The flap STEP 4. The ability to close the chest wall in primary
design has been marked and an incision carried down fashion is not possible, so split-thickness skin grafting
through skin and subcutaneous tissue to the fascia overlying is used. A bolster is placed for 5 days on the skin graft
the deltoid and pectoral muscle. and then removed (Figure 57-5).
Deltoid
muscle Flap
Pectoral
muscle
Perforators
FIGURE 57-4. The deltopectoral flap

has been elevated. The arrow
demonstrates the arc of rotation with
use of the flap to resurface the neck of
the skin.
Flap
Bolster
FIGURE 57-5. This illustration depicts the

deltopectoral flap sewn into place to
reconstruct a defect of the neck. A split-
thickness skin graft has been applied to the
donor site over the pectoral and deltoid
muscles and is held in place by a bolster.
CHAPTER 57 Deltopectoral Flap 569
I usually leave the bolster in place for up to 12 days in reconstruction, the combination of both flaps can
order to allow maximal time for graft revascularization prove quite useful. In addition, the deltopectoral
and to reduce the amount of wound care after the flap remains a reliable “backup” option when other
bolster is removed. FGFedok methods have failed or are not available. JICohen
EDITORIAL COMMENT: The need for skin grafting

of the donor site and cutaneous pedicle of this Suggested Readings
flap, has resulted in it being largely abandoned for Andrews BT, McCulloch TM, Funk GF, Graham SM, Hoffman
the pectoralis major myocutaneous flap, which HT: Deltopectoral flap revisited in the microvascular era: a
avoids both of these problems. However, in single-institution 10-year experience. Ann Otol Rhinol Lar-
instances when major resurfacing of the neck is yngol 115:35-40, 2006.
necessary in addition to mucosal defect Mortensen M, Genden EM: Role of the island deltopectoral
flap in contemporary head and neck reconstruction. Ann
Otol Rhinol Laryngol 115:361-364, 2006.
CHAPTER
Pectoralis Major Myocutaneous Flap
Commentary by Patrick J. Gullane and David E. Schuller
Preoperative Considerations STEP 3. An unfolded sponge is placed on the chest wall

using a pivot point at the clavicle (Figure 58-1). The tem-
The pectoralis major myocutaneous flap is a fan-shaped plate is laid at the end of the sponge, which allows for
pedicled muscular cutaneous flap that originates from appropriate rotation of the pectoralis muscle with the
the clavicle, sternum, and manubrium that may be skin from the template. The flap is usually designed
transferred plus or minus its skin component. Inferiorly inferomedial to the nipple line. A line is carried out in an
it attaches to the external oblique’s tendon. The pecto- inframammary crease circling up on the anterior axillary
ralis muscle inserts onto the lateral lip of the bicipital line to allow for mobilization of skin for closure, as well
groove of the humerus. as access to the clavicle.
The myogenous flap is very reliable and can be trans-
ferred in almost all individuals. Congenital absence of
the muscle has been reported but is extremely rare and STEP 4. Monopolar cautery is used to dissect directly
easily detected on physical examination. down to the pectoralis major muscle (Figure 58-2).
Relative contraindications include the interruption
of the ipsilateral thoracoacromial vessels or when the Flaps are elevated from the remaining chest wall skin,
muscle itself has been divided. The flap may be bulky both laterally and medially, to facilitate closure. At this
and consideration of other flaps should be considered point, we secure the skin to the fascia overlying the
when large tissue volumes are not necessary. This flap muscle with 3-0 Vicryl to prevent shearing of the skin
will deform the breast and nipple. Consideration to paddle. Once the muscle has been exposed with the skin
other methods should be given in women. paddle, we transect the muscles inferiorly to identify the
space between the inferior pectoralis muscle and the
The standard approach to this flap will indeed alter the intercostal muscles.
position of the breast. When this becomes a cosmetic
issue for either women or men, there is a modification In female patients I use an inframammary incision to
to flap elevation that minimizes or even totally negates minimize the deformity to the breast. The incision is
the breast position alteration. The alteration involves carried laterally, leaving a wide base. PJGullane
placing the skin island as far medially as possible and
then making an inframammary incision from the skin
island that extends as far laterally as necessary in the I prefer to use scalpel incision through the skin and
inframammary crease. Flap elevation is more difficult subcutaneous tissues of the skin paddle rather than
and time consuming with this approach, but it does monopolar cautery to hopefully minimize the tissue
achieve the stated goal of minimizing or negating the damage via thermal necrosis to the surrounding
alteration of the breast position. DESchuller microvasculature to support healing of the skin paddle
to its transferred location. I do use monopolar cautery
for the elevation of the surrounding chest skin and
Surgical Technique subcutaneous tissue from the underlying pectoralis
major muscle. DESchuller
STEP 1. The patient is prepped and draped to expose
the entire breadth and width of the muscle, across the I do not use dermal sutures to the muscle to prevent
midline to the contralateral manubrium, and then inferi- shearing as shown in Figure 58-2. I used to, but I have
orly down to the edge of the costal margin. The anterior abandoned this. PJGullane
axillary line all the way is exposed, as well as the top of
the shoulder. This is in continuity with the head and neck
field. STEP 5. The lateral border of the pectoralis muscle is
incised and separated from the pectoralis minor muscle.
Dissecting from an inferior approach, the muscle is
STEP 2. A template of the required cutaneous portion of freed up and reflected superiorly. Medially, the muscle
the reconstruction is made. is divided from the sternal attachment (Figure 58-3).
570
CHAPTER 58 Pectoralis Major Myocutaneous Flap 571
Clavicle
Defect
Pectoralis
major m.
Sponge
Skin
paddle
FIGURE 58-2. The flap has been designed and the tissues
incised through to the fascia overlying the muscle. The dermis
is secured to the underlying muscle to ensure that there is no
shearing of the muscle.
FIGURE 58-1. The technique used to measure the arc of

rotation of the flap to ensure that the skin paddle will reach
the furthest extent of the resected area. The sponge is placed
on the clavicle and then measured to the superior aspect of
the defect. It is then rotated to the lower chest to mark out
the inferior-most aspect of the pectoralis flap.
In order to reduce some of the bulk of the skin paddle

attached to the underlying muscle, one can just use
the actual amount of the muscle that is directly below
the skin paddle rather than incorporating the entire
transverse length of the inferior end of the pectoralis
major muscle with the flap elevation. The important
perforating vessels are those that are directly below Skin
Pectoralis
the skin paddle and represent a sufficient blood paddle
major m.
supply to support the paddle. DESchuller
STEP 6. Medially the intercostal perforators from the

internal mammary artery and vein are large and are cau-
FIGURE 58-3. The pectoralis muscle is divided from its
terized prior to division because when divided they
medial attachment and its lateral attachments with cautery.
retract into the chest and cauterization can be more dif- Care is taken medially to identify and control the intercostal
ficult. Dissection continues cephalad. The plane of dis- perforators and laterally to preserve the pedicle.
section between the pectoralis major and the pectoralis
minor is avascular and can be done using blunt or sharp
dissection. The medial attachment is dissected up to the
level of the clavicle.
STEP 7. The thoracoacromial artery, which comprises

the vascular pedicle, is easily identified on the undersur-
face of the muscle (Figure 58-4).
STEP 8. The lateral dissection commences by putting

one finger in to protect the vascular pedicle, then using
the cautery to divide the attachment of the pectoralis
muscle to the humerus. The large branch coming off the
Pectoralis thoracoacromial trunk passes in the middle portion of
major m.
the muscle going laterally and must be controlled. We
Pectoral banch
of cephalic v. use cautery or medium clips.
Once again, the bulk of the flap can be reduced by

Pectoral branch of
thoracoacromial a. directing the medial and lateral muscle incisions so
that they protect the flap’s vascular pedicle without
Pectoralis
including any unnecessary muscle tissue that does
minor m.
not contain the thoracoacromial vascular pedicle.
DESchuller
STEP 9. At this point, the flap is rotated over the top of

the clavicle into the head and neck region. If the chest
FIGURE 58-4. The muscle has been rotated superiorly and or neck skin is intact, a tunnel is burrowed in a subcu-
the vascular pedicle is visible on its deep surface. taneous subplatysmal fashion. The pectoralis muscle is
then put through this tunnel, ensuring that it is large
enough and adequate so as to not put tension on, or
compress, the pedicle (Figure 58-5).
Skin
paddle
Pectoralis
major m.
Thoracoacromial a.
Pectoral branch of
thoracoacromial a.
Pectoral banch
of cephalic v.
Cephalic v.
FIGURE 58-5. The flap has been
transposed to the head and neck
through a generous tunnel of
connecting skin.
CHAPTER 58 Pectoralis Major Myocutaneous Flap 573
I divide the pectoral nerve because it tends to

compress the vascular pedicle when the muscle is
elevated. This minimizes the potential of vascular
compression by the nerve as it crosses the pedicle
like a bow-string. PJGullane
When the flap is being transposed to be used in

the reconstruction of an internal (i.e., oral cavity or
pharyngeal) defect, the flap rotation is merely an
approximate 180-degree rotation of the pedicle with
the skin island attached. However, when the flap is
being used to reconstruct an external defect, the flap
pedicle is rotated twice: once superiorly and then
rotated around the axis of the muscle pedicle. This
second rotation can inadvertently result in occluding
the artery and/or vein of the vascular pedicle by the
crossing of the nondistensible motor nerve, which
is also a part of this neurovascular pedicle. When
external resurfacing is being done with this flap, it is
advisable to transect the motor nerve to negate this
possibility. It is also advisable to try to identify the
multiple motor nerves to the pectoralis muscle and
transect them because the denervated muscle will
atrophy more and decrease, once again, some of the
bulk of the entire muscle pedicle over time. DESchuller
FIGURE 58-6. The chest wall can almost always be closed
primarily. We use towel clips to approximate the tissues. We
use 2-0 Vicryl on pop offs and then 5-0 fast for the skin.
STEP 10. The chest wall is then closed in two layers with
appropriate drain placement (Figure 58-6).
EDITORIAL COMMENT: Although the bulk of the

skin paddle and pedicle make this flap a less than
When closing the flap donor site, it is important ideal option for many defects, its reliability and
to prioritize the closure with any approach that is ease of design and elevation have preserved its
efficient. A time-consuming multilayered closure that major role in head and neck reconstruction both as
may improve the likelihood of a better cosmetic result a primary and a backup option when better options
may not be in the patient’s best interests if it adds have either failed or are not available. All head-and-
time to an already long operative procedure. We tend neck surgeons should be familiar with the basics
to close the flap donor site with no subcutaneous of this flap design and elevation so that it will be
closure and approximate the skin and subcutaneous available to them should the need arise. JICohen
tissue with 2-0 silk that is supplemented with staples.
We also place drains along the cut edges of the
medial and lateral pectoralis muscle edges to Suggested Readings
maximize drainage of the flap donor site. DESchuller
Ethier JL, Trites J, Taylor SM: Pectoralis major myofascial flap
in head and neck reconstruction: indications and outcomes.
STEP 11. Occasionally, because of the length required J Otolaryngol Head Neck Surg 38:632-641, 2009.
Ramakrishnan VR, Yao W, Campana JP: Improved skin
to pivot the muscle over the clavicle to reach the defect,
paddle survival in pectoralis major myocutaneous flap
it is tempting to base the skin paddle distal to the mus-
reconstruction of head and neck defects. Arch Facial Plast
cular attachment. This is a random portion of the skin, Surg 11:306-310, 2009.
and the failure rate of the skin paddle increases the Zbar RI, Funk GF, McCulloch TM, Graham SM, Hoffman
farther from the muscle that one proceeds. With an HT: Pectoralis major myofascial flap: a valuable tool in
abundance of other flaps available for reconstruction, contemporary head and neck reconstruction. Head Neck
we do not use this as an alternative. 19:412-418, 1997.
CHAPTER
Trapezius Flap
Commentary by Stephen W. Bayles and Joseph Valentino
Preoperative Considerations neck dissection (RND) improves the reliability of the

The trapezius has three distinct musculocutaneous flaps lateral angiosomes; additionally, there is little added
that can be harvested. Two have little practical value in morbidity from loss of upper trapezius shoulder
most head and neck reconstructions and is discussed function when the spinal accessory nerve was
only briefly. The third, the lower island musculocutane- previously sacrificed. The paraspinous supply is
ous flap, has more value and is discussed in depth. generally adequate to perfuse this flap and many
The upper part of the trapezius muscle is supplied authors divide the transverse cervical vessels in
by the transverse cervical artery and transverse cervical elevation of the flap. However, if the transverse
vein. The vascular anatomy is variable, with the transcervical vessels are easily preserved, do so—the distal
verse cervical artery running a variable course laterally angiosomes will be more reliable. JValentino
before entering the trapezius. The artery may travel
through or around the brachial plexus. It is this variable
vascular anatomy that limits the use of this rotation The superior trapezius incorporates the based at the
flap. When conditions are ideal, this flap can be used superior nuchal line and down to four or five of the
based on its arc of rotation for some defects in the ret- paraspinal perforators. Its anterior limit is the anterior
romolar trigone, and lateral and anterior floor of mouth. border of the trapezius muscle and distally the middle
and lateral part of the clavicle. This flap is excellent for
The transverse cervical artery (TCA) anatomy can coverage of posterolateral defects of the neck and is
inhibit the arc of rotation of this flap as well as the extremely reliable.
transverse cervical vein (TCV) anatomy. The venous
anatomy of the TCV is variable and does not always Although the superior trapezius flap is an extremely
follow the TCA. It must be carefully preserved as well reliable piece of vascularized tissue with limited arc of
for the flap to remain viable. Always begin this flap rotation, the sacrifice of upper trapezius function can
with careful dissection of the transverse cervical only be accepted in someone who has already had his
vessels in the supraclavicular fossa to assess for flap or her function sacrificed out of oncologic necessity.
limitations. JValentino However, because the blood supply is not dependent
on the transverse cervical vessels, this flap may
be used in patients who have had radical neck
The superior trapezius flap is based on the paraspinal dissections and are limited in other available coverage
perforators that supply the superior aspect of the trape- options. The secondary defect created may require
zius muscle. It is based on the midline of the back and skin grafting, and resultant skin graft contracture may
can be transferred as a skin muscle flap. Again, its arc additionally affect shoulder function. SWBayles
of rotation is limited by the contribution of the thyro-
cervical artery to the middle portion of the trapezius
muscle. Its use is primarily in the resurfacing of cutane- The donor site defect may require skin grafting.
ous defects of the posterior and lateral aspects of the JValentino
neck (Figure 59-1).
The lateral island trapezius flap is based on an
I typically use this flap in patients who have undergone island of skin overlying the trapezius muscle in the pos-
radical neck dissection. It is most useful for carotid terior triangle of the neck. It requires a thyrocervical
artery coverage. It typically reaches to the midline of artery that does not run in an intimate relationship to
the neck. Previous division of the TCA with radical the brachial plexus. Its arc of rotation limits its use
(Figure 59-2).
574
CHAPTER 59 Trapezius Flap 575
Donor site morbidity is minimal. It is best used for

reconstruction of lateral skull base or cheek defects.
Previous history of a radical neck dissection precludes
the use of this flap.
Technique of Flap Elevation
STEP 1. Elevation commences with defining the medial

border of the scapula. The approximate position of the
DSA that enters the deep fascial surface of the trapezius
is marked. The skin paddle incorporating the distal
DSA and spreading inferiorly is then marked on the back.
It should not extend beyond the trapezius muscle
Spinal a./v.
(Figure 59-3).
Donor flap
Deltoid m.
With the patient in lateral decubitus position, the

Trapezius m. scapula has a tendency to medially rotate.
Adduction and internal rotation with an assistant
distracting the arm facilitate opening the space
between the medial scapula and spine for flap design.
Designing the skin elliptically over the full length of the
lower trapezius offers the ability to capture more
superior musculocutaneous perforators than if the skin
island is only centered over the distal portion of
muscle. Even if the proximal portion of skin is not
FIGURE 59-1. The superior trapezius flap is based on the
paraspinal perforators and, according to the angiosome needed, it may be deepithelialized and buried once
concept, has a limited arc of rotation. It can be delayed but transferred. This design preserves additional
is useful for resurfacing the lateral and anterior aspects of subdermal blood supply to the distal aspect of the
the neck. skin and therefore potentially enhances any random
territory. The extended ellipse can be closed primarily,
similar to an isolated distal island that is harvested
Lower Island Trapezius with a subsequent vertical incision limb up the back.
SWBayles
Musculocutaneous Flap
The lower island trapezius musculocutaneous flap is the
most versatile of the trapezius musculocutaneous flaps.
It is based on the dorsoscapular artery (DSA), which
The most reliable skin paddle is entirely over the
enters the deep surface of the muscle at the upper border
muscle, but many times a minority of the flap
of the rhomboid major just below the rhomboid minor.
extends lateral to the muscle, and typically survives.
The vessel extends for a variable distance below the
JValentino
lower part of the trapezius muscle. In order to provide
for mobilization of the skin muscle island, a cuff of
rhomboid minor on either side of the vessel is divided
STEP 2. Dissection begins by incising the skin down
to improve its arc of rotation. The distal branch of the
through the skin and subcutaneous tissue in a vertical
DSA must be ligated. With division of the rhomboid
line on the lateral border of the skin paddle.
minor muscle, the arc of rotation of this flap allows it
to reach almost any area in the head and neck on the
ipsilateral side. STEP 3. Dissection is then carried out on the medial
surface of the skin paddle and the trapezius identified.
This flap typically reaches above the superior limits of The lateral border of the trapezius muscle is then ele-
the pectoralis myocutaneous flaps and provides vated and divided in a superior fashion, the same pro-
excellent coverage well above the ear. JValentino cedure being carried out on the medial attachments to
the vertebra (Figure 59-4).
Defect
Donor flap with
trapezius m. section
Transverse cervical a.
Trapezius m. Deltoid m.
A B
Trapezius m.
FIGURE 59-2. A, The lateral island trapezius flap is
designed as a paddle of skin overlying the superior
aspect of the trapezius muscle. B, The skin paddle is
incised to the fascia overlying the trapezius and the
muscle transected to encompass the skin paddle. The
vascular pedicle entering the flap is identified and
carefully preserved. C, The flap’s arc of rotation is
C limited by the origin of the transverse cervical vessels.
The inferior trapezius along its lateral surface is not territory if initial skin design position is too lateral. It is
intimately associated with the chest wall. The plane best to err on being more lateral on the initial cuts
between the chest wall and undersurface may be because territory can be regained by subsequently
developed bluntly with care to allow for visualization positioning the medial cut once the muscle edges are
of the dorsoscapular pedicle on the muscle’s defined. The flap then gets elevated inferiorly to
undersurface prior to making committed medial superiorly as described. SWBayles
muscle cuts. Identifying the lateral inferior extent of
the muscle is also useful prior to making medial cuts.
The skin island may be altered in width or shape to
STEP 4. Paraspinous perforators on the medial insertion
some degree if necessary to incorporate more muscle
of the trapezius muscle are identified and ligated.
Subclavian a.
Trapezius m.
Deltoid m.
Dorsal scapular a.
Rhomboid minor m.
Rhomboid major m.
Latissimus dorsi m.
FIGURE 59-3. A skin paddle has been designed to lie over

the distal portion of the trapezius muscle. It incorporates the
dorsoscapular artery as it enters the undersurface of the
trapezius muscle between the rhomboid major and minor
muscles.
Trapezius m. Trapezius m.
Dorsoscapular a.
Trapezius m.
Rhomboid minor m.
Dorsoscapular a.
Rhomboid major m.
Rhomboid major m.
A C
FIGURE 59-4. A, The skin paddle has been dissected to reveal the underlying trapezius
muscle. The lateral border of the muscle is elevated to reveal the dorsoscapular artery.
B, The medial border of the trapezius has been divided and the undersurface of the trapezius
examined to reveal the dorsoscapular pedicle. C, Continuing the elevation, the pedicle is seen
to emerge from between the rhomboid major and minor muscles.
STEP 6. Care is taken to preserve the cuff of the rhom-

boid minor muscle as one proceeds superiorly, dividing
the muscle on either side of the DSA. Dissection is con-
tinued superiorly until the thyrocervical artery and vein
are identified and preserved as they enter on the under-
surface of the trapezius muscle.
The dorsoscapular pedicle is variable in its ultimate

relationship with the transverse cervical vessels that
Dorsoscapular a. typically exit into the trapezius above the levator
scapula muscle. Regardless of the relationship
between the DSVs and transverse cervical vessels,
both vessel supplies should be maintained because
Rhomboid minor m. (cut) it is difficult to assess preoperatively which may
dominate in its blood supply to the lower trapezius.
Rhomboid major m. On occasion the surgeon may feel tempted to ligate a
communication between the DSV and the transverse
cervical vessel, if it exists, because this may improve
pedicle freedom and increased arc of rotation;
however, this should be avoided because it may
represent a loss of the more dominant vessel
supplying the flap. Visually this may be apparent to
the surgeon by relative caliber of the vessels and at
times the dorsoscapular may seem very meager in
comparison to the transverse cervical. Given this
potential variability, every effort should be made to
maintain both blood supplies. SWBayles
FIGURE 59-5. This drawing demonstrates the lower trapezius
flap that has been elevated superiorly. The rhomboid muscle
has been divided to preserve the dorsoscapular artery and
the dorsoscapular vessels.
EDITORIAL COMMENT: The lower island
trapezius myocutaneous flap is often overlooked
in consideration of reconstructive options for head
and neck defects, perhaps because of the need
for patient repositioning in its design and
STEP 5. The junction between the rhomboid major and elevation. However, conceptually its design
rhomboid minor is identified in the lateral aspect. This and principles of elevation are very similar to that
helps because the flap is dissected superiorly, to identify of the pectoralis myocutaneous flap. It is a
the emergence of the dorsoscapular pedicle from reliable option in situations in which the
between the two muscles. During the elevation of the pectoralis major flap is not available and a
flap superiorly, the DSA and the dorsoscapular vessels pedicled flap is the best option for reconstruction.
(DSVs) are identified as they enter the undersurface of JICohen
the trapezius muscle. In order to increase the arc of
rotation of the pedicled flap, the rhomboid minor muscle
must be divided and the descending branch of the DSA/
DSVs is divided (Figure 59-5). Suggested Readings
Chen WL, Li JS, Yang ZH, Huang ZQ, Wang JQ: Extended
vertical lower trapezius island myocutaneous flap for repair-
ing extensive oropharyngeal defects. J Oral Maxillofac Surg
The DSVs may give off a descending branch inferiorly 67:1349-1353, 2009.
that travels deep to the rhomboid major muscle. Maves MD, Netterville JL, Boozan JA, Keenan MJ: Superiorly
If this branch is encountered, it needs to be ligated based trapezius flap for emergency carotid artery coverage.
distally beyond the branch entering the trapezius Am J Otolaryngol 13:342-348, 1992.
muscle to take full advantage of pedicle mobilization. Netterville JL, Wood DE: The lower trapezius flap. Vascular
SWBayles anatomy and surgical technique. Arch Otolaryngol Head
Neck Surg 117:73-76, 1991.
CHAPTER
Latissimus Dorsi Myocutaneous Flap
Commentary by D. Gregory Farwell and Gady Har-El
Preoperative Considerations facilitate the axillary dissection. The prepping and

draping then take place and the beanbag is inflated
The latissimus dorsi myocutaneous flap (LDMF) can be (Figure 60-1).
harvested either with or without a cutaneous portion,
pedicled or as a free tissue transfer. The myocutaneous
unit provides high-volume tissue that has a large surface Because of the long nature of many of these cases,
area. It is a triangular-shaped muscle that is relatively an axillary roll or inflatable pillow underneath the
thin throughout. Its apex where it becomes narrower contralateral chest and axilla may be considered to
and thicker and inserts into the humerus is bulkier and reduce the postoperative discomfort and risk of
inconsistent in volume. The skin and subcutaneous brachial plexus injury. DGFarwell
tissues of the back are thicker than that of the head and
neck area.
The ability to harvest skin on one side, and to have One factor that has limited the popularity of LDMF in
muscles serve as either a granulating mucosalizing head and neck surgery is the need for repositioning of
surface, or a surface that will readily take a skin graft, the patient. However, after one repositioning following
allows its use for complex multidimensional reconstruc- the ablative surgery that had been done in a supine
tion involving two surface areas. position, both the harvest and the inset of the flap can
Previous axillary dissection and vascular compromise often be accomplished with the patient remaining in
to the blood supply of the muscle are contraindications. the lateral decubitus position. GHar-El
The LDMF has a very long pedicle that provides STEP 2. The arm and axilla are included in the prep. It is
an extensive arc of rotation. This allows the important to drape the patient in a way that the patient
reconstruction of virtually any defect in the head and may be rotated onto the back for the ablative surgeon,
neck area including the scalp. The large surface area then rotated onto the side for the reconstructive surgeon.
enables the surgeon to use the flap as a “double-
paddle” flap, reconstructing two surfaces such as skin
and mucosa. The vascular supply of the LDMF is not STEP 3. A template is modeled to estimate the size of
affected by neck dissection. The LDMF has minimal the defect. A skin paddle is designed to approximate this
donor site morbidity. GHar-El and marked out on the skin of the back overlying the
muscle (Figure 60-2).
Technique Use of the pencil Doppler may assist in finding the

myocutaneous perforators and design of the
cutaneous portion of the flap. DGFarwell
STEP 1. The patient is placed in a lateral decubitus posi-
tion with the back facing away from the anesthesia
machine. The table is positioned to accommodate the STEP 4. A vertical incision parallel to the anterior border
ablative surgeon’s preferences. A beanbag is placed of the latissimus is then drawn from the anterosuperior
under the patient. Once the patient is in the appropriate aspect of the skin paddle superiorly into the axilla and
position, the beanbag is pushed up to provide support then inferiorly and posteriorly to allow for adequate
to the patient’s spine and maintain the patient in his or harvest of the latissimus muscle. Harvesting starts with
her lateral position. The spine is palpable and within the incision of the skin paddle and elevation of the anterior
sterile field. The arm is positioned on an airplane to and posterior skin flaps over the latissimus muscle. The
579
Airplane
Latissimus dorsi m.
Beanbag
FIGURE 60-1. The patient is placed in a semiprone position with the axilla and spine in the
sterile field. The arm is positioned on an airplane to facilitate the axillary dissection.
Outline of latissimus dorsi m.

Muscle insertion
Skin paddle
Muscle origin
FIGURE 60-2. The skin paddle is designed to lie directly over the middle third of the muscle.
A template is used to decide on the paddle size and shape.
CHAPTER 60 Latissimus Dorsi Myocutaneous Flap 581
Latissimus dorsi m.
Skin paddle
FIGURE 60-3. The skin paddle is kept on the muscle. Anterior skin flaps are elevated to the
anterior border of the muscle. Posterior skin flaps are elevated to the spinous processes.
dissection plane is in the fascia just on top of the muscle

(Figure 60-3).
STEP 5. The anterior border of the latissimus muscle is

then identified and incised. Dissection is carried out in Circumflex Subscapular a./v.
scapular a./v.
an inferior to superior fashion. The pedicle is identified
in the upper third of the muscle traversing into the axilla Thoraco-
(Figure 60-4). dorsal a./v.
STEP 6. Once the pedicle has been identified, the muscle

is harvested. The amount of muscle that is required for
both tissue volume, or for coverage of the defect, is
estimated. The skin paddle can be used for both internal Latissimus
dorsi m.
and external lining. The inferior attachment of the muscle
is thinner than the muscle is superiorly. Serratus
anterior m.
If the defect is too large for the cutaneous paddle that

can be harvested with the latissimus dorsi, the raw
muscle may be transferred to cover large defects of
the scalp and skin grafted. DGFarwell
As one dissects the posterior spinal attachments, the

perforators from the thoracolumbar region are encoun-
tered. These can be large and should be either clipped
or cauterized. The anterior border of the latissimus is FIGURE 60-4. The pedicle is identified superiorly where it
enters into the muscle. From here it travels cephalad into the
then identified and dissection beneath the muscle above
axilla.
the fascial plane surrounding the muscle is performed.
Proceeding superiorly, the pedicle is identified on the
Latissimus dorsi m. (inferior origin)
Skin paddle
Skin paddle
Latissimus
dorsi m.
(superior
origin)
B
A
Latissimus Teres major m.
dorsi m.
(insertion)
Thoracodorsal a./v.
FIGURE 60-5. A, Once the pedicle has been identified, the muscle is harvested. The amount
of muscle that is removed depends on the volume of tissue required. B, The muscle is divided
posteriorly and inferiorly from its attachments. Once these muscle attachments are divided, the
insertion into the humerus is divided. C, Care is taken to preserve the vascular pedicle.
undersurface of the latissimus muscle and protected. the humerus is circumferentially identified and divided
The pedicle, as it exits the anterior aspect of the muscle, by cautery. Care is taken to protect the vascular supply
is preserved. to the muscle (Figure 60-5).
As a safety measure I perform the medial and inferior STEP 8. Dissection of the vascular pedicle as it enters
elevation of the skin/muscle component only after the axilla is commenced. It is helpful to have an assistant
identifying the thoracodorsal vessels. GHar-El elevate and rotate the arm. Tenotomy scissors and
Gerald forceps with teeth are used to dissect the pedicle
into the axilla. Vessels to the serratus anterior are identi-
fied and clipped, and the vessel to the circumflex scapu-
The skin paddle may be stabilized by anchoring its lar artery is also identified and clipped. The two venae
dermal layer to the surrounding muscle fascia with fine comitantes almost always join into a single vein. Once
absorbable sutures. This may prevent shearing forces a single vein has been identified, the vascular pedicle
compromising the blood supply to the skin, especially can be ligated (Figure 60-6).
in older adult patients with loose subcutaneous tissue.
GHar-El
When the LDMF is used as a pedicled flap, and when
the flap is not needed to reconstruct a very distal
STEP 7. When the inferior and posterior attachments are recipient site, the circumflex scapular artery may be
divided, the attachment to the humerus is the only thing preserved. It helps in maintaining flap orientation.
that holds the muscle in place. Once the pedicle has GHar-El
been identified, the muscular tendinous insertion into
Latissimus Skin
dorsi m. paddle
Thoraco-
Circumflex dorsal a./v.
scapular a./v.
Teres
Thoraco- major m.
dorsal a./v.
Serratus
anterior m.
Circumflex
Pectoralis
scapular a./v.
minor m.
Latissimus
dorsi m.
Pectoralis
major m.
A B
FIGURE 60-6. A, The vascular pedicle is followed into the axilla. Pedicle length is maximized
by dividing the branches to the serratus muscle and the angular vessels of the scapula. If
more length is required, the circumflex scapular artery and vein can be ligated. B, When the
muscle is transferred as a pedicle flap, a tunnel is created between the pectoralis minor and
the pectoralis major muscle.
Care should be taken at the anterior aspect of the laparotomy pads; infiltrating the soft tissues around
dissection to avoid the long thoracic nerve that runs the pedicle with 2% lidocaine; tagging the medial
superficially along the serratus anterior muscle. The and lateral aspects of the skin paddle to assist with
thoracodorsal artery can be somewhat redundant and orientation; and avoiding rotation of the flap more than
the branching pattern can be variable. Care should be 180 degrees, will prevent accidental kinking and/or
taken to ensure ligation of the distal branches of the spasm. GHar-El
artery to the adjacent muscles and tissue and not the
main pedicle as you dissect proximally along the
artery toward the axilla. DGFarwell STEP 9. If the tissue is to be transferred as a free flap,
the artery is clipped with medium clips or ligated and
tied. The vein is treated in the same fashion (Figure 60-7).
Unlike the pectoralis major pedicled flap, the LDMF

vascular pedicle is not protected with a cuff of muscle STEP 10. If the flap is to be pedicled into the head and
throughout its length. Therefore, once the humeral neck region, blunt dissection through the head of the
tendon of the latissimus dorsi muscle is transected, pectoralis major muscle overlying the pedicle is under-
the pedicle remains exposed and must be handled taken. Blunt dissection in the region of the inferior skin
with extreme care. Excessively skeletonizing the flap of the neck is also undertaken in order to have these
vessels puts them at increased risk for vasospasm. two tunnels meet. Once an adequate tunnel has been
Wrapping the pedicle and the flap with warm, moist formed, the muscle and the skin is transferred up into
the head and neck region.
Sternocleidomastoid
m. insertion
Latissimus dorsi m.
skin
paddle
Sternocleidomastoid
m. origin
FIGURE 60-7. The muscle has been transferred to the head and neck region for
reconstruction.
FIGURE 60-8. Closure consists of 2-0 Vicryl interrupted sutures with 5-0 fast for the skin. Two
10 flat Jackson-Pratt drains are used and secured.
Jackson-Pratt drains are inserted and secured with 0

Care must be taken to avoid hyperabducting or silk. The wound is then closed using 2-0 Vicryl popoffs
overrotating the arm during transfer maneuvers, which with a 5-0 fast or staples for the skin (Figure 60-8).
may result in brachial plexus injury. GHar-El
STEP 12. Drains are left in place for 2 to 3 weeks. The

STEP 11. The anterior and posterior skin flaps are then latissimus muscle bed, because of constant movement
mobilized and towel clips are applied to pull the skin of the muscles and skin of the back, will produce serous
together in the best cosmetic fashion. Two 10 flat fluid for a long time.
Rarely the subcutaneous tunnel to the neck may (muscle with or without skin) that is unparalleled
become swollen, risking flap viability. Making a skin compared with other pedicled flaps in the region,
incision (or opening a small segment of the original and therefore for appropriate defects it remains
incision) over the clavicle decompresses this “tight” the best option available. The potential to use this
area and allows for appropriate pedicle blood flow. flap as either a pedicled flap or free-tissue transfer
GHar-El increases its versatility especially for defects that
are distant enough from the donor site so as to
potentially compromise its blood supply if used in
In an effort to minimize the high risk of seroma in a pedicled fashion. In either case, protection of the
these patients, a thoracic corset may be used to pedicle, which exists without a protective
encourage the widely undermined flaps to stick down muscular cuff of tissue, and appropriate dissection
to the wound bed. DGFarwell and selective ligation of its proximal branches
are critical to its success as discussed by the
authors. JICohen
The use of LDMF may add to shoulder dysfunction
if the spinal-accessory nerve has been sacrificed.
GHar-El Suggested Readings
Quillen CG: Latissimus dorsi myocutaneous flaps in head and
neck reconstruction. Plast Reconstr Surg 63:664-670, 1979.
EDITORIAL COMMENT: As with the trapezius Sabatier RE, Bakamjian VY: Transaxillary latissimus dorsi flap
flap patient, the need for repositioning is a reconstruction in head and neck cancer. Limitations and
disadvantage in terms of the use of the latissimus refinements in 56 cases. Am J Surg 150:427-434, 1985.
flap. However, this flap offers a volume of tissue Schuller DE: Latissimus dorsi myocutaneous flap for massive
facial defects. Arch Otolaryngol 108:414-417, 1982.
SECTION C Neural Reconstruction
CHAPTER
Neural Reconstruction
Commentary by Daniel G. Deschler and Neal Futran
Preoperative Considerations inability to properly reconstruct the defect, or the nerve

Reinnervation of structures following surgical ablation repair may be disrupted.
is of paramount importance to ensure adequate postop-
erative function and rehabilitation. This applies when
This issue of geometry is a critical point. Efforts for
either sensory nerves are divided or when motor nerves
sensory reinnervation could place the reconstructive
are divided. The ability to rehabilitate patients to a great
effort at risk. If a free-tissue transfer technique is to be
extent is dependent on restoration of intraoral or other
used, care must be taken so that the neural repair or
sensory function.
nerve graft does not alter the vascular pedicle
Neural continuity may be disrupted in one of three
geometry adversely. Nerve repair should remain deep
ways (Figure 61-1).
■ The nerve may be cleanly divided and the tissue that
to the vascular pedicle so that no kinking or
constriction of the pedicle could occur in the
the nerve supplies is still intact.
■ There exists a discontinuity in the nerve and the local
postoperative period. Consideration of postoperative
positioning and swelling needs to be taken into
tissues that the nerve innervates are still present.
■ The nerve has been resected along with the local
consideration. DGDeschler
tissue that it innervates.
Whenever a nerve is divided, it should be done in an Instrumentation for neural reanastomosis is fairly
atraumatic way. Use of cold steel is recommended. standard, and can be found on the microvascular
Cautery or other methods damage the nerve to a vari- tray. Some form of magnification is needed by most
able extent. Most nerves are accompanied by a vascular surgeons.
plexus. This plexus bleeds when the nerve is divided and
can make obtaining hemostasis troublesome. Pressure
and judicious use of bipolar cautery allows for hemo- At least 3.5× magnification is preferred for accurate
stasis with no neural damage. We have also found it reanastomosis. The use of a dual-head operating
useful to tag the nerve prior to division with 4-0 silk microscope allows for even greater magnification and
sutures to allow for identification later in the case. the ability of an assistant to properly aid in the
procedure. NFutran
Tagging the nerve with medium HemaClips is an

alternative to 4-0 silk because it is also easily
identifiable and preserves maximum nerve length. Although otolaryngologist–head-and-neck surgeons
NFutran have great facility with the microscope and it is useful
for neural anastomosis, I have found that magnification
using 3.5× wide-field loupe is more than adequate for
We find it useful to approximate the tissues to deter- successful epineural reanastomosis. Advantages of
mine if the nerve should be reconstructed prior to using loupes include easy accessibility; no need for
the soft-tissue reconstruction or after it. This is impor- another bulking instrument in the room, which requires
tant because soft-tissue reconstruction first may make added cost with draping; and greater ease in obtaining
neural reconstruction impossible. Conversely, in some adequate binocular view. DGDeschler
circumstances repairing the nerve first may result in an
587
Tongue
Defect
Lingual n.
Mandible (divided)
A
Distal lingual n.
Tongue
Defect
Tongue
Free
tissue
Lingual n.
FIGURE 61-1. A, In this instance the nerve has been divided to allow access to the tumor.
The tissues that the nerve innervates are intact. B, Here we see that reconstruction of the
ablative defect has inserted tissue between the cut ends of the nerve. Although no nerve was
resected and the distal tissue remains intact, it is not possible to reconnect the two ends of
the nerve. C, Finally, the nerve will be resected with the soft tissue that it supplies.
CHAPTER 61 Neural Reconstruction 589
Tongue
Free
tissue
Lingual n.
FIGURE 61-2. A, The divided nerve has been loosely approximated and a single suture has
been placed in the posterior aspect. B, The nerve has been rotated and the remaining three
sutures have been placed.
Neural Reconstruction Technique STEP 3. The nerve ends are rotated, and two lateral
sutures and an anterior suture are placed so as to obtain
Nerve Divided and Reapproximation Possible adequate coadaptation. There should be no tension
(See Figure 61-2A) (Figure 61-2B).
STEP 1. The two ends of the nerve are identified and The nerve ends can be freshened by placing them on
gently co-opted together. If there is any tension or a sterile tongue depressor and trimming with a No. 15
pulling, a nerve graft is used. scalpel blade. For small nerves a 10 nylon suture can
accurately co-opt the nerve with less disruption of the
fibers. An epineural approach is preferred. Background
material under the nerve also aids in accuracy of the
repair. NFutran
This point of avoiding tension cannot be
overemphasized: it is probably the single factor most
likely to adversely affect success in reinnervation.
One must also consider tension not only at the
Neural Grafting
time of anastomosis but also after the soft-tissue When there is a gap between the cut nerve ends, a nerve
reconstruction is complete, as well as the potential graft must be harvested. Sites include:
effects of postoperative edema. DGDeschler ■ The greater auricular nerve (limited in length,
branching, and occasionally resected with the
specimen)
STEP 2. The neural ends are freshened up using straight ■ The same site where the composite reconstructive
microvascular scissors. The ends of the nerves are care- tissue is being harvested.
fully aligned and then a posterior 9-0 tacking suture is ❏ The medial antebrachial nerve (radial forearm
placed. flap)
Rather than measuring or estimating adequate length

and then cutting the nerve graft to size prior to
Tongue insetting, it is recommended that one anastomosis
Nerve
graft be completed first (usually the more challenging
anatomically). The graft can then be draped in the
field, assessing position and allowing for avoidance of
tension. With the position optimized, the graft can be
readily trimmed and prepared for the second
Lingual
n. anastomosis. DGDeschler
Technique of Sural Nerve Harvest
STEP 1. The lower limb is prepped and draped in a cir-

cumferential manner from just below the popliteal fossa
to the ankle. The lateral malleolus is included in the field.
FIGURE 61-3. A nerve graft has been harvested and is
placed between the two ends of the divided nerve.
Anastomosis is performed as described. Care must be taken
to ensure that an adequate length of graft has been used to STEP 2. The nerve is identified in the distal part of the
ensure no tension on either end of the anastomosis. leg, where it lies in close association to the short saphe-
nous vein posterior to the lateral malleolus.
The nerve runs in a compartment between the lateral

malleolus of the tendon of the calcareous. As one pro-
❏ The sural nerve (fibular flap). This is also prob- ceeds more proximal up the leg, it leaves its association
ably the most common distant donor site for with the lesser saphenous vein and pierces the fascia to
nerve grafting in which a flap is not otherwise run closer to the muscular sheath.
being done and there is no available head and
neck nerve to be used.
❏ A segment of the motor branch of the anterolat- STEP 3. The nerve is bluntly dissected from an inferior
eral thigh flap accompanying the vascular pedicle to superior fashion until the desired length is reached.
Care must be taken not to damage the lesser saphenous
vein (Figure 61-4).
The appropriate site should be prepped and draped at Special attention is paid to placement of drains and
the start of the procedure. Adequate graft length and final insetting and closure so as not to put undue tension
caliber match to the recipient nerve is critical. NFutran or disrupt the anastomosis.
A useful method to identify the nerve is to find it 1 cm

posterior and superior to the lateral malleolus. A
All these options are excellent and take into account vertical incision along the lateral aspect of the leg can
the myriad potential sites especially in the setting also be used, but the stepladder incisions illustrated in
of free-tissue reconstruction. Yet the neck remains Figure 61-4 provide less patient discomfort. A nerve
the single greatest source of potential nerve grafts, stripper can be used to safely dissect it away from the
especially in the setting of a nonbranching nerve lesser saphenous vein. NFutran
requirement. As such, ablation procedures are often
done in conjunction with some form of neck
dissection; the sensory branches of the cervical The technique described is excellent and avoids a
rootlets in the posterior triangle provide excellent longitudinal, lengthy incision, yet the patient’s position
options as does the ansa cervicalis. DGDeschler or body habitus may make an incision limiting
technique more challenging. Examples include obese
patients or those with varicosities. In such cases, a
traditional longitudinal incision may be best. There
The technique of neural anastomosis is the same as is also evolving experience using an endoscopic
for when primary anastomosis is performed. The nerve technique through a single incision in cases without
graft must be of sufficient length to make both anasto- contraindication. DGDeschler
moses loose (Figure 61-3).
CHAPTER 61 Neural Reconstruction 591
Sural n.
FIGURE 61-4. The first incision is placed posterior to the lateral malleolus and the nerve
identified. It is followed superior through a series of horizontal incisions until the desired length
is obtained.
Care must be taken with this technique to avoid

Tongue causing significant denervation of the otherwise
normally innervated tongue to achieve limited sensory
Nerve
graft
innervation of a skin flap on the lateral tongue, which
may have little ultimate functional value. DGDeschler
EDITORIAL COMMENT: Neural reconstruction,

Lingual
n. either separately or as part of a larger
reconstruction, is probably underused by head-
and-neck surgeons in their reconstructive efforts.
There is ample evidence that when properly done,
FIGURE 61-5. The lingual nerve is identified and a small nerve reanastomosis or grafting has a high chance
enterotomy is made. The donor nerve is anastomosed with of restoring neural function. Whether restoration of
three or four 9-0 sutures in an end-to-side fashion. neural function necessarily improves the overall
functional result, particularly in larger defects with
major tissue transfer, remains more controversial.
Technique of End–to-Side Nevertheless, although conceptually
straightforward, the technical details of nerve
Anastomosis
grafting are critical to its success and require
The free tissue that is used to reconstruct the defect is special attention as noted in this chapter. JICohen
harvested with its sensory supply. The lingual nerve is
identified. A small enterotomy is made into the lingual
nerve and the nerve from the free flap is anastomosed
in an end-to-side fashion (Figure 61-5). We usually use Suggested Readings
three or four sutures for the anastomosis.
Falcioni M, Taibah A, Russo A, Piccirillo E, Sanna M: Facial
nerve grafting. Otol Neurotol 24:486-489, 2003.
I do not commonly use this technique because Humphrey CD, Kriet JD: Nerve repair and cable grafting for
sensation may be decreased to the tongue, and facial paralysis. Facial Plast Surg 24:170-176, 2008.
innervation into the free-tissue transfer is limited. Wax MK, Kaylie DM: Does a positive neural margin affect
NFutran outcome in facial nerve grafting? Head Neck 29:546-549,
2007.

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Atlas of

HEAD & NECK

Gary L. Clayman, MD, DMD, FACS

ATLAS OF HEAD & NECK SURGERY ISBN: 978-1-4160-3368-4

Copyright © 2011 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Library of Congress Cataloging-in-Publication Data

Acquisitions Editor: Stefanie Jewell-Thomas

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Ehab Hanna, MD, FACS Joshua S. Schindler, MD

Mihir K. Bhayani, MD F. Christopher Holsinger, MD, FACS

Gary L. Clayman, MD, DMD, FACS Ollivier Laccourreye, MD

Neil D. Gross, MD, FACS Raul Pellini, MD

Greg Reece, MD Mark K. Wax, MD, FACS, FRCSC

Mark S. Courey, MD Jeremy L. Freeman, MD, FRCSC, FACS

D. Gregory Farwell, MD, FACS Andrew N. Goldberg, MD, MSCE, FACS

Gady Har-El, MD, FACS Jonas T. Johnson, MD

Frans J. M. Hilgers, MD, PhD Ronald B. Kuppersmith, MD, MBA, FACS

Jeffery Scott Magnuson, MD Tanya K. Meyer, MD

Robert H. Ossoff, MD, DMD John A. Ridge, MD, PhD

William W. Shockley, MD, FACS David J. Terris, MD, FACS

James D. Smith, MD Stephen J. Wang, MD, FACS

Robert A. Sofferman, MD Randal S. Weber, MD

Positioning Fiberoptic Nasopharyngoscopy

FIGURE 1-1. Indirect mirror nasopharyngoscopy.

inspection of the choana, the eustachian tube orifice, the

Superior meatal passage

Inferior meatal passage

FIGURE 1-2. A, Flexible fiberoptic nasopharyngoscopy. B, Fiberoptic

FIGURE 1-3. Nasopharynx view through flexible fiberoptic scope.

Positioning Telescopic Examination

Transoral laryngopharyngoscopy may be performed

FIGURE 2-1. Indirect mirror laryngoscopy.

FIGURE 2-2. Indirect rigid telescope laryngoscopy.

FIGURE 2-3. Flexible fiberoptic laryngoscopy.

Comprehensive flexible fiberoptic laryngoscopic

The glottis is generally quite easy to see in relaxed

General Considerations The role of preoperative communication and planning

The usual and customary sequence of performing

Equipment for Laryngoscopy

Although a thorough discussion of all available

supraglottis, glottis, subglottis, or hypopharynx; trauma

Having a selection of operative microlaryngoscopes is A Hunsaker jet-ventilation catheter can be valuable

Direct Laryngoscopy and

FIGURE 3-3. Room configuration.

First, the anesthesiologist must have immediate

With wet gloves to facilitate examination, digital palpa-

Preparation for direct laryngoscopy and pharyngoscopy

FIGURE 3-4. Bimanual examination.

laryngoscope against the teeth and uses them as a

Direction of scope advance

FIGURE 3-5. Patient positioning for laryngoscopy and pharyngoscopy.

Proper head positioning for direct laryngoscopy is

Remarkably, the sniffing position is widely espoused

Direction of scope advance

FIGURE 3-8. Examination of the oropharynx.

STEP 7. Perform hypopharyngeal examination.

With the uvula in view, the distal tip of the laryngoscope

False vocal fold

into the anterior glottis (Figure 3-12). The immediate

An operative diagram of the larynx should be used in

A posterior ledge about 3 mm surrounds the graft.