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Surgery_Schwartz_4302 | Surgery_Schwartz | staging format which was recently updated in the 8th edition in 2017.105 The T stage for each subsite incorporates relevant anatomy; for instance, T3 lesions of the glottis are associated with vocal cord immobility. Recent changes have incorporated HPV/P16 status for oropharynx cancer (Tables 18-1 and 18-2) and depth of invasion for oral cavity cancers (Table 18-3).The N classification for head and neck sites is nearly uni-form for all sites (Tables 18-4 and 18-5) except for the nasophar-ynx and for HPV-associated (p16-positive) oropharynx cancer. Recent changes have also incorporated extracapsular extension into this nodal staging to improve the discrimination and prog-nostication of the classification.Upper Aerodigestive TractThere are similarities in the initial assessment and manage-ment of all patients with a newly diagnosed upper aerodiges-tive tract malignancy. The frequently reviewed clinical practice guidelines (National Comprehensive Cancer Network; NCCN) provide valuable | Surgery_Schwartz. staging format which was recently updated in the 8th edition in 2017.105 The T stage for each subsite incorporates relevant anatomy; for instance, T3 lesions of the glottis are associated with vocal cord immobility. Recent changes have incorporated HPV/P16 status for oropharynx cancer (Tables 18-1 and 18-2) and depth of invasion for oral cavity cancers (Table 18-3).The N classification for head and neck sites is nearly uni-form for all sites (Tables 18-4 and 18-5) except for the nasophar-ynx and for HPV-associated (p16-positive) oropharynx cancer. Recent changes have also incorporated extracapsular extension into this nodal staging to improve the discrimination and prog-nostication of the classification.Upper Aerodigestive TractThere are similarities in the initial assessment and manage-ment of all patients with a newly diagnosed upper aerodiges-tive tract malignancy. The frequently reviewed clinical practice guidelines (National Comprehensive Cancer Network; NCCN) provide valuable |
Surgery_Schwartz_4303 | Surgery_Schwartz | of all patients with a newly diagnosed upper aerodiges-tive tract malignancy. The frequently reviewed clinical practice guidelines (National Comprehensive Cancer Network; NCCN) provide valuable information by site and stage with regard to workup and management and should be used to direct care.106 After a thorough history that should include assessment of the previously discussed risk factors, a comprehensive physical examination should follow. A full head and neck examination including inspection and palpation is critical for nearly all head and neck cancers. Oral cavity and oropharyngeal cancers should be palpated when possible to provide additional tactile informa-tion regarding depth of invasion, mobility, and invasion into adjacent structures. A cranial nerve (CN) examination with a focus on the assessment of trigeminal (V2/V3) parasthesia/Table 18-1Clinical and pathologic T category for HPV-associated (p16-positive) oropharyngeal cancerT CATEGORYT CRITERIAT0No primary | Surgery_Schwartz. of all patients with a newly diagnosed upper aerodiges-tive tract malignancy. The frequently reviewed clinical practice guidelines (National Comprehensive Cancer Network; NCCN) provide valuable information by site and stage with regard to workup and management and should be used to direct care.106 After a thorough history that should include assessment of the previously discussed risk factors, a comprehensive physical examination should follow. A full head and neck examination including inspection and palpation is critical for nearly all head and neck cancers. Oral cavity and oropharyngeal cancers should be palpated when possible to provide additional tactile informa-tion regarding depth of invasion, mobility, and invasion into adjacent structures. A cranial nerve (CN) examination with a focus on the assessment of trigeminal (V2/V3) parasthesia/Table 18-1Clinical and pathologic T category for HPV-associated (p16-positive) oropharyngeal cancerT CATEGORYT CRITERIAT0No primary |
Surgery_Schwartz_4304 | Surgery_Schwartz | with a focus on the assessment of trigeminal (V2/V3) parasthesia/Table 18-1Clinical and pathologic T category for HPV-associated (p16-positive) oropharyngeal cancerT CATEGORYT CRITERIAT0No primary identifiedT1Tumor 2 cm or smaller in greatest dimensionT2Tumor larger than 2 cm but not larger than 4 cm in greatest dimensionT3Tumor larger than 4 cm in greatest dimension or extension to lingual surface of epiglottisT4Moderately advanced local diseaseTumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible or beyond**Mucosal extension to lingual surface of epiglottis from primary tumors of the base of the tongue and vallecula does not constitute invasion of the larynx.Used with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Table 18-2Clinical and pathologic T category for non–HPV-associated (p16-negative) oropharyngeal cancerT CATEGORYT | Surgery_Schwartz. with a focus on the assessment of trigeminal (V2/V3) parasthesia/Table 18-1Clinical and pathologic T category for HPV-associated (p16-positive) oropharyngeal cancerT CATEGORYT CRITERIAT0No primary identifiedT1Tumor 2 cm or smaller in greatest dimensionT2Tumor larger than 2 cm but not larger than 4 cm in greatest dimensionT3Tumor larger than 4 cm in greatest dimension or extension to lingual surface of epiglottisT4Moderately advanced local diseaseTumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible or beyond**Mucosal extension to lingual surface of epiglottis from primary tumors of the base of the tongue and vallecula does not constitute invasion of the larynx.Used with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Table 18-2Clinical and pathologic T category for non–HPV-associated (p16-negative) oropharyngeal cancerT CATEGORYT |
Surgery_Schwartz_4305 | Surgery_Schwartz | Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Table 18-2Clinical and pathologic T category for non–HPV-associated (p16-negative) oropharyngeal cancerT CATEGORYT CRITERIATXPrimary tumor cannot be assessedTisCarcinoma in situT1Tumor 2 cm or smaller in greatest dimensionT2Tumor larger than 2 cm but not larger than 4 cm in greatest dimensionT3Tumor larger than 4 cm in greatest dimension or extension to lingual surface of epiglottisT4Moderately advanced or very advanced local disease T4aModerately advanced local diseaseTumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible* T4bVery advanced local diseaseTumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or skull base or encases carotid artery*Mucosal extension to lingual surface of epiglottis from primary tumors of the base of the tongue and vallecula does not constitute invasion of the larynx.Used with the permission of the | Surgery_Schwartz. Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Table 18-2Clinical and pathologic T category for non–HPV-associated (p16-negative) oropharyngeal cancerT CATEGORYT CRITERIATXPrimary tumor cannot be assessedTisCarcinoma in situT1Tumor 2 cm or smaller in greatest dimensionT2Tumor larger than 2 cm but not larger than 4 cm in greatest dimensionT3Tumor larger than 4 cm in greatest dimension or extension to lingual surface of epiglottisT4Moderately advanced or very advanced local disease T4aModerately advanced local diseaseTumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible* T4bVery advanced local diseaseTumor invades lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, or skull base or encases carotid artery*Mucosal extension to lingual surface of epiglottis from primary tumors of the base of the tongue and vallecula does not constitute invasion of the larynx.Used with the permission of the |
Surgery_Schwartz_4306 | Surgery_Schwartz | artery*Mucosal extension to lingual surface of epiglottis from primary tumors of the base of the tongue and vallecula does not constitute invasion of the larynx.Used with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Brunicardi_Ch18_p0613-p0660.indd 63201/03/19 5:23 PM 633DISORDERS OF THE HEAD AND NECKCHAPTER 18anesthesia, CN VII, CN XI, and CN XII function. Flexible fiber-optic nasolaryngoscopy should be carried out to better charac-terize tumor extent, assess vocal cord mobility in laryngeal cancers, assess airway patency, and rule out any synchronous second primary tumors, as previously discussed.Investigations should include a diagnostic laryngoscopy and esophagoscopy to rule out second primaries and obtain tis-sue of any concerning lesions. A pathologic specimen is nearly always required before initiation of treatment. A metastatic work up including a CT of the neck | Surgery_Schwartz. artery*Mucosal extension to lingual surface of epiglottis from primary tumors of the base of the tongue and vallecula does not constitute invasion of the larynx.Used with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Brunicardi_Ch18_p0613-p0660.indd 63201/03/19 5:23 PM 633DISORDERS OF THE HEAD AND NECKCHAPTER 18anesthesia, CN VII, CN XI, and CN XII function. Flexible fiber-optic nasolaryngoscopy should be carried out to better charac-terize tumor extent, assess vocal cord mobility in laryngeal cancers, assess airway patency, and rule out any synchronous second primary tumors, as previously discussed.Investigations should include a diagnostic laryngoscopy and esophagoscopy to rule out second primaries and obtain tis-sue of any concerning lesions. A pathologic specimen is nearly always required before initiation of treatment. A metastatic work up including a CT of the neck |
Surgery_Schwartz_4307 | Surgery_Schwartz | rule out second primaries and obtain tis-sue of any concerning lesions. A pathologic specimen is nearly always required before initiation of treatment. A metastatic work up including a CT of the neck and chest with contrast is indicated in all patients with a newly diagnosed head and neck cancer. In certain jurisdictions, a positron emission tomography (PET)-CT is used to rule out any distant metastases; however, this approach does lead to a high false positive rate.107Patients are then assessed in a multidisciplinary manner with radiation and surgical oncology. A dental evaluation is initiated before treatment because many patients undergoing primary or adjuvant radiotherapy require dental extraction to decrease the risk of osteoradionecrosis in the posttreatment period. Assessment by speech language pathology in the pre-operative period is imperative in all patients, but it is especially important in patients with laryngeal/hypopharyngeal pathology because speech and swallowing | Surgery_Schwartz. rule out second primaries and obtain tis-sue of any concerning lesions. A pathologic specimen is nearly always required before initiation of treatment. A metastatic work up including a CT of the neck and chest with contrast is indicated in all patients with a newly diagnosed head and neck cancer. In certain jurisdictions, a positron emission tomography (PET)-CT is used to rule out any distant metastases; however, this approach does lead to a high false positive rate.107Patients are then assessed in a multidisciplinary manner with radiation and surgical oncology. A dental evaluation is initiated before treatment because many patients undergoing primary or adjuvant radiotherapy require dental extraction to decrease the risk of osteoradionecrosis in the posttreatment period. Assessment by speech language pathology in the pre-operative period is imperative in all patients, but it is especially important in patients with laryngeal/hypopharyngeal pathology because speech and swallowing |
Surgery_Schwartz_4308 | Surgery_Schwartz | speech language pathology in the pre-operative period is imperative in all patients, but it is especially important in patients with laryngeal/hypopharyngeal pathology because speech and swallowing dysfunction needs to be charac-terized and often helps drive management. Smoking cessation is initiated as early as possible.Lip. The lips starting at the vermillion border represent a tran-sition between external skin to internal mucosa. The sphincter function of the lip is created by activation of the circumferen-tial musculature of the orbicularis oris, a critical structure in lip form and function. Lip cancers are most common in men and are often seen in those with fairer complexions. In addition to tobacco use and immunosuppression, UV exposure is an addi-tional important risk factor unique to this head and neck subsite. The majority (>90%) of lip cancers present on the lower lip due to its increased protrusion and increased sun exposure.108 Although the vast majority of lip cancers | Surgery_Schwartz. speech language pathology in the pre-operative period is imperative in all patients, but it is especially important in patients with laryngeal/hypopharyngeal pathology because speech and swallowing dysfunction needs to be charac-terized and often helps drive management. Smoking cessation is initiated as early as possible.Lip. The lips starting at the vermillion border represent a tran-sition between external skin to internal mucosa. The sphincter function of the lip is created by activation of the circumferen-tial musculature of the orbicularis oris, a critical structure in lip form and function. Lip cancers are most common in men and are often seen in those with fairer complexions. In addition to tobacco use and immunosuppression, UV exposure is an addi-tional important risk factor unique to this head and neck subsite. The majority (>90%) of lip cancers present on the lower lip due to its increased protrusion and increased sun exposure.108 Although the vast majority of lip cancers |
Surgery_Schwartz_4309 | Surgery_Schwartz | to this head and neck subsite. The majority (>90%) of lip cancers present on the lower lip due to its increased protrusion and increased sun exposure.108 Although the vast majority of lip cancers are SCC, other cuta-neous malignancies such as basal cell carcinoma and malignant melanoma are not uncommon at this subsite.Basal cell carcinoma presents more frequently on the upper lip than lower.Negative prognostic factors for lip cancers include peri-neural invasion, invasion into bone (maxilla or mandible), upper Table 18-3Clinical and pathologic T category for oral cavity cancerT CATEGORYT CRITERIATXPrimary tumor cannot be assessedTisCarcinoma in situT1Tumor ≤2 cm, ≤5 mm depth of invasion (DOI)DOI is depth of invasion and not tumor thickness.T2Tumor ≤2 cm, DOI >5 mm and ≤10 mmor tumor >2 cm but ≤4 cm, and DOI ≤10 mmT3Tumor >4 cmor any tumor with DOI >10 mm but ≤20 mmT4Moderately advanced or very advanced local disease T4aModerately advanced local diseaseTumor invades adjacent structures | Surgery_Schwartz. to this head and neck subsite. The majority (>90%) of lip cancers present on the lower lip due to its increased protrusion and increased sun exposure.108 Although the vast majority of lip cancers are SCC, other cuta-neous malignancies such as basal cell carcinoma and malignant melanoma are not uncommon at this subsite.Basal cell carcinoma presents more frequently on the upper lip than lower.Negative prognostic factors for lip cancers include peri-neural invasion, invasion into bone (maxilla or mandible), upper Table 18-3Clinical and pathologic T category for oral cavity cancerT CATEGORYT CRITERIATXPrimary tumor cannot be assessedTisCarcinoma in situT1Tumor ≤2 cm, ≤5 mm depth of invasion (DOI)DOI is depth of invasion and not tumor thickness.T2Tumor ≤2 cm, DOI >5 mm and ≤10 mmor tumor >2 cm but ≤4 cm, and DOI ≤10 mmT3Tumor >4 cmor any tumor with DOI >10 mm but ≤20 mmT4Moderately advanced or very advanced local disease T4aModerately advanced local diseaseTumor invades adjacent structures |
Surgery_Schwartz_4310 | Surgery_Schwartz | but ≤4 cm, and DOI ≤10 mmT3Tumor >4 cmor any tumor with DOI >10 mm but ≤20 mmT4Moderately advanced or very advanced local disease T4aModerately advanced local diseaseTumor invades adjacent structures only (e.g., through cortical bone of the mandible or maxilla, or involves the maxillary sinus or skin of the face) or extensive tumor with bilateral tongue involvement and/or DOI >20 mm.Note: Superficial erosion of bone/tooth socket (alone) by a gingival primary is not sufficient to classify a tumor as T4. T4bVery advanced local diseaseTumor invades masticator space, pterygoid plates, or skull base and/or encases the internal carotid arteryUsed with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Table 18-4Clinical N category for non–HPV-associated (p16-negative) oropharyngeal cancerN CATEGORYN CRITERIANXRegional lymph nodes cannot be assessedN0No regional lymph node | Surgery_Schwartz. but ≤4 cm, and DOI ≤10 mmT3Tumor >4 cmor any tumor with DOI >10 mm but ≤20 mmT4Moderately advanced or very advanced local disease T4aModerately advanced local diseaseTumor invades adjacent structures only (e.g., through cortical bone of the mandible or maxilla, or involves the maxillary sinus or skin of the face) or extensive tumor with bilateral tongue involvement and/or DOI >20 mm.Note: Superficial erosion of bone/tooth socket (alone) by a gingival primary is not sufficient to classify a tumor as T4. T4bVery advanced local diseaseTumor invades masticator space, pterygoid plates, or skull base and/or encases the internal carotid arteryUsed with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Table 18-4Clinical N category for non–HPV-associated (p16-negative) oropharyngeal cancerN CATEGORYN CRITERIANXRegional lymph nodes cannot be assessedN0No regional lymph node |
Surgery_Schwartz_4311 | Surgery_Schwartz | Springer New York, 2017.Table 18-4Clinical N category for non–HPV-associated (p16-negative) oropharyngeal cancerN CATEGORYN CRITERIANXRegional lymph nodes cannot be assessedN0No regional lymph node metastasisN1Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest dimension and ENE(-)N2Metastasis in a single ipsilateral node larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-); or metastases in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-); or in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-) N2aMetastasis in a single ipsilateral node larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-) N2bMetastasis in multiple ipsilateral nodes, none larger than 6 cm in greatest dimension and ENE(-) N2cMetastasis in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-)N3Metastasis in a lymph node larger | Surgery_Schwartz. Springer New York, 2017.Table 18-4Clinical N category for non–HPV-associated (p16-negative) oropharyngeal cancerN CATEGORYN CRITERIANXRegional lymph nodes cannot be assessedN0No regional lymph node metastasisN1Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest dimension and ENE(-)N2Metastasis in a single ipsilateral node larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-); or metastases in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-); or in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-) N2aMetastasis in a single ipsilateral node larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-) N2bMetastasis in multiple ipsilateral nodes, none larger than 6 cm in greatest dimension and ENE(-) N2cMetastasis in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-)N3Metastasis in a lymph node larger |
Surgery_Schwartz_4312 | Surgery_Schwartz | larger than 6 cm in greatest dimension and ENE(-) N2cMetastasis in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-)N3Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE(-); or metastasis in any node(s) and clinically overt ENE(+) N3aMetastasis in a lymph node larger than 6 cm in greatest dimension and ENE(-) N3bMetastasis in any node(s) and clinically overt ENE(+)ENE = extranodal extension.Used with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Brunicardi_Ch18_p0613-p0660.indd 63301/03/19 5:23 PM 634SPECIFIC CONSIDERATIONSPART IIlip or oral commissure involvement, positive regional metasta-sis, and young age at diagnosis.The primary management of lip cancer is a surgical resection of the primary site with an adequate margin (1 cm). This provides margin analysis and additional pathologic information that can | Surgery_Schwartz. larger than 6 cm in greatest dimension and ENE(-) N2cMetastasis in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-)N3Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE(-); or metastasis in any node(s) and clinically overt ENE(+) N3aMetastasis in a lymph node larger than 6 cm in greatest dimension and ENE(-) N3bMetastasis in any node(s) and clinically overt ENE(+)ENE = extranodal extension.Used with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Brunicardi_Ch18_p0613-p0660.indd 63301/03/19 5:23 PM 634SPECIFIC CONSIDERATIONSPART IIlip or oral commissure involvement, positive regional metasta-sis, and young age at diagnosis.The primary management of lip cancer is a surgical resection of the primary site with an adequate margin (1 cm). This provides margin analysis and additional pathologic information that can |
Surgery_Schwartz_4313 | Surgery_Schwartz | diagnosis.The primary management of lip cancer is a surgical resection of the primary site with an adequate margin (1 cm). This provides margin analysis and additional pathologic information that can help stratify which patients may benefit from adjuvant treatment. The primary regional nodal drainage basin for lip cancers is the submandibular, submental, and perifacial nodes (level I), and metastases occur in <10% of patients with a higher incidence in those with upper lip cancers.109 When there are clinical evident notes, a neck dissection is indicated. Otherwise, in the clinically and radiographically negative neck observation is acceptable.109 Unfortunately, many lip cancers are not appropriately staged, and advanced regional failure is not infrequently seen. Adjuvant (postoperative) radiotherapy is indicated in patients with close (<5 mm) or positive margins, lymph node metastases, tumors with perineural invasion, and in thick (>4 mm) tumors.110 The overall 10-year survival rate | Surgery_Schwartz. diagnosis.The primary management of lip cancer is a surgical resection of the primary site with an adequate margin (1 cm). This provides margin analysis and additional pathologic information that can help stratify which patients may benefit from adjuvant treatment. The primary regional nodal drainage basin for lip cancers is the submandibular, submental, and perifacial nodes (level I), and metastases occur in <10% of patients with a higher incidence in those with upper lip cancers.109 When there are clinical evident notes, a neck dissection is indicated. Otherwise, in the clinically and radiographically negative neck observation is acceptable.109 Unfortunately, many lip cancers are not appropriately staged, and advanced regional failure is not infrequently seen. Adjuvant (postoperative) radiotherapy is indicated in patients with close (<5 mm) or positive margins, lymph node metastases, tumors with perineural invasion, and in thick (>4 mm) tumors.110 The overall 10-year survival rate |
Surgery_Schwartz_4314 | Surgery_Schwartz | radiotherapy is indicated in patients with close (<5 mm) or positive margins, lymph node metastases, tumors with perineural invasion, and in thick (>4 mm) tumors.110 The overall 10-year survival rate is 84% to 92% for early stage disease but drops precipitously (11%–28%) for advanced stage disease predicted by regional and distant metastases.111The goals of lip reconstruction include providing oral competence, maintaining dynamic function, and achieving acceptable cosmesis, while avoiding severe microstomia. The proportion of the lip excised and whether the defect involves the oral commissure determines the reconstructive options. Regardless of the reconstructive technique, realignment of the vermilion border and reapproximation of the orbicularis oris are critical steps to a successful outcome. Defects of less than one-third of the lip are closed primarily, while defects between one-third and two-thirds of the lip borrow tissue from surrounding regions, mainly the upper lip and cheek | Surgery_Schwartz. radiotherapy is indicated in patients with close (<5 mm) or positive margins, lymph node metastases, tumors with perineural invasion, and in thick (>4 mm) tumors.110 The overall 10-year survival rate is 84% to 92% for early stage disease but drops precipitously (11%–28%) for advanced stage disease predicted by regional and distant metastases.111The goals of lip reconstruction include providing oral competence, maintaining dynamic function, and achieving acceptable cosmesis, while avoiding severe microstomia. The proportion of the lip excised and whether the defect involves the oral commissure determines the reconstructive options. Regardless of the reconstructive technique, realignment of the vermilion border and reapproximation of the orbicularis oris are critical steps to a successful outcome. Defects of less than one-third of the lip are closed primarily, while defects between one-third and two-thirds of the lip borrow tissue from surrounding regions, mainly the upper lip and cheek |
Surgery_Schwartz_4315 | Surgery_Schwartz | Defects of less than one-third of the lip are closed primarily, while defects between one-third and two-thirds of the lip borrow tissue from surrounding regions, mainly the upper lip and cheek to recreate the lip. This can be accomplished using an Abbe (lip switch) (Fig. 18-23) or Karapandzic flap (Fig. 18-24), if the commissure is preserved, or an Estlander flap (lip switch) if the commissure is resected. If there is insufficient lip tissue, rectangular excisions can be closed using upper Burrow’s triangles in combination with bilateral advancement flaps made possible by mental crease relaxing incisions; this technique is called Bernard-Burrow (Fig. 18-25).112 When more than two-thirds of the lip is excised, the Karapandzic can still be used when the defect is up to 80% as this provides a sensate lip with sphincter-like function; however, microstomia becomes a serious concern, and larger defects require free flap reconstruction. This typically does not achieve sphincter function even | Surgery_Schwartz. Defects of less than one-third of the lip are closed primarily, while defects between one-third and two-thirds of the lip borrow tissue from surrounding regions, mainly the upper lip and cheek to recreate the lip. This can be accomplished using an Abbe (lip switch) (Fig. 18-23) or Karapandzic flap (Fig. 18-24), if the commissure is preserved, or an Estlander flap (lip switch) if the commissure is resected. If there is insufficient lip tissue, rectangular excisions can be closed using upper Burrow’s triangles in combination with bilateral advancement flaps made possible by mental crease relaxing incisions; this technique is called Bernard-Burrow (Fig. 18-25).112 When more than two-thirds of the lip is excised, the Karapandzic can still be used when the defect is up to 80% as this provides a sensate lip with sphincter-like function; however, microstomia becomes a serious concern, and larger defects require free flap reconstruction. This typically does not achieve sphincter function even |
Surgery_Schwartz_4316 | Surgery_Schwartz | sensate lip with sphincter-like function; however, microstomia becomes a serious concern, and larger defects require free flap reconstruction. This typically does not achieve sphincter function even when a sling is used. Microstomia can be a problem in patients that are edentulous who then cannot insert their dentures and in the dentulous who may not be able to get dental work performed with significant negative impact on their dental health.Oral Cavity. As previously mentioned, the oral cavity is com-posed of several sites. The anatomy of each subsite can uniquely impact the aggressiveness of disease, the function after resec-tion, and the surgical approach. We therefore in this next section briefly review each subsite with a focus on the relevant anatomy and treatment options.The preferred approach to management of these tumors is a surgical resection with adequate (1 cm) surgical margins with management of the regional nodal basin. In general, tumors of the oral cavity metastasize | Surgery_Schwartz. sensate lip with sphincter-like function; however, microstomia becomes a serious concern, and larger defects require free flap reconstruction. This typically does not achieve sphincter function even when a sling is used. Microstomia can be a problem in patients that are edentulous who then cannot insert their dentures and in the dentulous who may not be able to get dental work performed with significant negative impact on their dental health.Oral Cavity. As previously mentioned, the oral cavity is com-posed of several sites. The anatomy of each subsite can uniquely impact the aggressiveness of disease, the function after resec-tion, and the surgical approach. We therefore in this next section briefly review each subsite with a focus on the relevant anatomy and treatment options.The preferred approach to management of these tumors is a surgical resection with adequate (1 cm) surgical margins with management of the regional nodal basin. In general, tumors of the oral cavity metastasize |
Surgery_Schwartz_4317 | Surgery_Schwartz | approach to management of these tumors is a surgical resection with adequate (1 cm) surgical margins with management of the regional nodal basin. In general, tumors of the oral cavity metastasize to the submandibular, submental, and upper cervical nodes and are almost always treated with a supra-omohyoid neck dissection at the time of primary resection with a few rare exceptions (T1 oral tongue lesions that have less than 4 mm depth of invasion). In the “Neck” section of this chapter, we will discuss this in more detail. Adjuvant radiotherapy is indicated in patients with close margins, regional lymphade-nopathy, advanced stage tumors (T3/T4), perineural invasion, and lymphovascular invasion, while adjuvant chemoradiother-apy is reserved for those with positive margins or extracapsular invasion.113,114Oral Tongue The oral tongue is a muscular structure composed of intrinsic (longitudinal, vertical, and transverse muscle fibers) and extrinsic (genioglossus, hyoglossus, styloglossus, | Surgery_Schwartz. approach to management of these tumors is a surgical resection with adequate (1 cm) surgical margins with management of the regional nodal basin. In general, tumors of the oral cavity metastasize to the submandibular, submental, and upper cervical nodes and are almost always treated with a supra-omohyoid neck dissection at the time of primary resection with a few rare exceptions (T1 oral tongue lesions that have less than 4 mm depth of invasion). In the “Neck” section of this chapter, we will discuss this in more detail. Adjuvant radiotherapy is indicated in patients with close margins, regional lymphade-nopathy, advanced stage tumors (T3/T4), perineural invasion, and lymphovascular invasion, while adjuvant chemoradiother-apy is reserved for those with positive margins or extracapsular invasion.113,114Oral Tongue The oral tongue is a muscular structure composed of intrinsic (longitudinal, vertical, and transverse muscle fibers) and extrinsic (genioglossus, hyoglossus, styloglossus, |
Surgery_Schwartz_4318 | Surgery_Schwartz | invasion.113,114Oral Tongue The oral tongue is a muscular structure composed of intrinsic (longitudinal, vertical, and transverse muscle fibers) and extrinsic (genioglossus, hyoglossus, styloglossus, and pala-toglossus) muscles separated by a midline raphe and has overly-ing nonkeratinizing squamous epithelium. The posterior limit of the oral tongue is the circumvallate papillae beyond which the oropharynx begins while the ventral portion is contiguous with the anterior floor of mouth.Table 18-5Clinical N category for oral cavity, larynx, and hypopharynx cancerN CATEGORYN CRITERIANXRegional lymph nodes cannot be assessedN0No regional lymph node metastasisN1Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest dimension ENE(-)N2Metastasis in a single ipsilateral node larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-); or metastases in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-); or in bilateral | Surgery_Schwartz. invasion.113,114Oral Tongue The oral tongue is a muscular structure composed of intrinsic (longitudinal, vertical, and transverse muscle fibers) and extrinsic (genioglossus, hyoglossus, styloglossus, and pala-toglossus) muscles separated by a midline raphe and has overly-ing nonkeratinizing squamous epithelium. The posterior limit of the oral tongue is the circumvallate papillae beyond which the oropharynx begins while the ventral portion is contiguous with the anterior floor of mouth.Table 18-5Clinical N category for oral cavity, larynx, and hypopharynx cancerN CATEGORYN CRITERIANXRegional lymph nodes cannot be assessedN0No regional lymph node metastasisN1Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest dimension ENE(-)N2Metastasis in a single ipsilateral node larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-); or metastases in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-); or in bilateral |
Surgery_Schwartz_4319 | Surgery_Schwartz | larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-); or metastases in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-); or in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension, and ENE(-) N2aMetastasis in a single ipsilateral node larger than 3 cm but not larger than 6 cm in greatest dimension, and ENE(-) N2bMetastasis in multiple ipsilateral nodes, none larger than 6 cm in greatest dimension, and ENE(-) N2cMetastasis in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension, and ENE(-)N3Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE(-); or metastasis in any node(s) and clinically overt ENE(+) N3aMetastasis in a lymph node larger than 6 cm in greatest dimension and ENE(-) N3bMetastasis in any node(s) and clinically overt ENE(+)ENE = extranodal extension.Used with the permission of the American College of Surgeons. Amin MB, Edge SB, | Surgery_Schwartz. larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-); or metastases in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-); or in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension, and ENE(-) N2aMetastasis in a single ipsilateral node larger than 3 cm but not larger than 6 cm in greatest dimension, and ENE(-) N2bMetastasis in multiple ipsilateral nodes, none larger than 6 cm in greatest dimension, and ENE(-) N2cMetastasis in bilateral or contralateral lymph nodes, none larger than 6 cm in greatest dimension, and ENE(-)N3Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE(-); or metastasis in any node(s) and clinically overt ENE(+) N3aMetastasis in a lymph node larger than 6 cm in greatest dimension and ENE(-) N3bMetastasis in any node(s) and clinically overt ENE(+)ENE = extranodal extension.Used with the permission of the American College of Surgeons. Amin MB, Edge SB, |
Surgery_Schwartz_4320 | Surgery_Schwartz | cm in greatest dimension and ENE(-) N3bMetastasis in any node(s) and clinically overt ENE(+)ENE = extranodal extension.Used with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Brunicardi_Ch18_p0613-p0660.indd 63401/03/19 5:23 PM 635DISORDERS OF THE HEAD AND NECKCHAPTER 18Tumors of the tongue typically start along the epithelial surface and can be endophytic or exophytic with or without ulceration (Fig. 18-26) and are typically seen on the lateral and ventral surfaces of the tongue. Lesions on the dorsal aspect of the tongue, particularly along the midline, are less likely to be malignant. What is seen on the surface is typically the tip of the iceberg, and palpation can provide further information regarding the depth of invasion of the tumor. These tumors can be extensive, and when they cross the midline and start to involve the base of tongue an extensive surgical resection | Surgery_Schwartz. cm in greatest dimension and ENE(-) N3bMetastasis in any node(s) and clinically overt ENE(+)ENE = extranodal extension.Used with the permission of the American College of Surgeons. Amin MB, Edge SB, Greene FL, et al. (Eds.) AJCC Cancer Staging Manual, 8th Ed. Springer New York, 2017.Brunicardi_Ch18_p0613-p0660.indd 63401/03/19 5:23 PM 635DISORDERS OF THE HEAD AND NECKCHAPTER 18Tumors of the tongue typically start along the epithelial surface and can be endophytic or exophytic with or without ulceration (Fig. 18-26) and are typically seen on the lateral and ventral surfaces of the tongue. Lesions on the dorsal aspect of the tongue, particularly along the midline, are less likely to be malignant. What is seen on the surface is typically the tip of the iceberg, and palpation can provide further information regarding the depth of invasion of the tumor. These tumors can be extensive, and when they cross the midline and start to involve the base of tongue an extensive surgical resection |
Surgery_Schwartz_4321 | Surgery_Schwartz | information regarding the depth of invasion of the tumor. These tumors can be extensive, and when they cross the midline and start to involve the base of tongue an extensive surgical resection including a total glossectomy may be required. However, most tumors present at an early stage due to significant pain, otal-gia, voice change secondary to difficulties with articulation, and dysphagia, which may lead to weight loss. On history and physical examination, ipsilateral paresthesias and deviation of the tongue protrusion with fasciculations or atrophy may indicate lingual nerve and hypoglossal nerve tumor invasion respectively (Fig. 18-27).Early lesions (T1–T2) can be closed primarily, allowed to heal by secondary intention, or reconstructed with a split thickness ACBDFigure 18-23. Estlander flap. A. Intra-operative image of lower lip squamous cell carcinoma with buccal and cutaneous extension pre-excision; B. Intra-operative defect and Estlander flap design. C. Immediate | Surgery_Schwartz. information regarding the depth of invasion of the tumor. These tumors can be extensive, and when they cross the midline and start to involve the base of tongue an extensive surgical resection including a total glossectomy may be required. However, most tumors present at an early stage due to significant pain, otal-gia, voice change secondary to difficulties with articulation, and dysphagia, which may lead to weight loss. On history and physical examination, ipsilateral paresthesias and deviation of the tongue protrusion with fasciculations or atrophy may indicate lingual nerve and hypoglossal nerve tumor invasion respectively (Fig. 18-27).Early lesions (T1–T2) can be closed primarily, allowed to heal by secondary intention, or reconstructed with a split thickness ACBDFigure 18-23. Estlander flap. A. Intra-operative image of lower lip squamous cell carcinoma with buccal and cutaneous extension pre-excision; B. Intra-operative defect and Estlander flap design. C. Immediate |
Surgery_Schwartz_4322 | Surgery_Schwartz | Estlander flap. A. Intra-operative image of lower lip squamous cell carcinoma with buccal and cutaneous extension pre-excision; B. Intra-operative defect and Estlander flap design. C. Immediate post-operative flap. D. One year post-operative image.ABCFigure 18-24. A-C. Karapandzic labiaplasty for lower lip carcinoma.Brunicardi_Ch18_p0613-p0660.indd 63501/03/19 5:23 PM 636SPECIFIC CONSIDERATIONSPART IIskin graft after partial glossectomy. This procedure allows rea-sonable speech and swallowing function as long as there is not significant tethering in the floor of the mouth if this has been resected. Articulation is determined by premaxillary contact of the tongue, and dental appliances can be used in the postoperative setting to improve this. Tongue protrusion and lateral movement predicts a patient’s ability to swallow, and this is less difficult to repair secondarily. Therefore, many patients, even with small tongue cancers that require significant floor of mouth resection, | Surgery_Schwartz. Estlander flap. A. Intra-operative image of lower lip squamous cell carcinoma with buccal and cutaneous extension pre-excision; B. Intra-operative defect and Estlander flap design. C. Immediate post-operative flap. D. One year post-operative image.ABCFigure 18-24. A-C. Karapandzic labiaplasty for lower lip carcinoma.Brunicardi_Ch18_p0613-p0660.indd 63501/03/19 5:23 PM 636SPECIFIC CONSIDERATIONSPART IIskin graft after partial glossectomy. This procedure allows rea-sonable speech and swallowing function as long as there is not significant tethering in the floor of the mouth if this has been resected. Articulation is determined by premaxillary contact of the tongue, and dental appliances can be used in the postoperative setting to improve this. Tongue protrusion and lateral movement predicts a patient’s ability to swallow, and this is less difficult to repair secondarily. Therefore, many patients, even with small tongue cancers that require significant floor of mouth resection, |
Surgery_Schwartz_4323 | Surgery_Schwartz | predicts a patient’s ability to swallow, and this is less difficult to repair secondarily. Therefore, many patients, even with small tongue cancers that require significant floor of mouth resection, receive soft pliable fasciocutaneous free flap reconstruction to improve these functional outcomes.115 Advanced lesions that require a more radical resection require free flaps, which obliter-ate the oral cavity dead space while creating bulk in the posterior oropharynx to improve the pharyngeal swallowing phase.116ABFigure 18-25. Bernard burrow flap reconstruction for a total lower lip defect involving upper and lip advancement rotation flap and cheek advancement.Figure 18-26. Oral tongue squamous cell carcinoma.ABSubmandibular glandDigastric m.(anterior belly)Myohyoid m.Stylopharyngeus,stylohyoid andstyloglossus mm.Digastric muscle(posterior belly)Styloid processHypoglossal n.Middleconstrictor m.External carotid a.Hyoid boneHyoglossus m.Lingual n.Deep lingual a.Dorsal lingual | Surgery_Schwartz. predicts a patient’s ability to swallow, and this is less difficult to repair secondarily. Therefore, many patients, even with small tongue cancers that require significant floor of mouth resection, receive soft pliable fasciocutaneous free flap reconstruction to improve these functional outcomes.115 Advanced lesions that require a more radical resection require free flaps, which obliter-ate the oral cavity dead space while creating bulk in the posterior oropharynx to improve the pharyngeal swallowing phase.116ABFigure 18-25. Bernard burrow flap reconstruction for a total lower lip defect involving upper and lip advancement rotation flap and cheek advancement.Figure 18-26. Oral tongue squamous cell carcinoma.ABSubmandibular glandDigastric m.(anterior belly)Myohyoid m.Stylopharyngeus,stylohyoid andstyloglossus mm.Digastric muscle(posterior belly)Styloid processHypoglossal n.Middleconstrictor m.External carotid a.Hyoid boneHyoglossus m.Lingual n.Deep lingual a.Dorsal lingual |
Surgery_Schwartz_4324 | Surgery_Schwartz | andstyloglossus mm.Digastric muscle(posterior belly)Styloid processHypoglossal n.Middleconstrictor m.External carotid a.Hyoid boneHyoglossus m.Lingual n.Deep lingual a.Dorsal lingual a.Genioglossus m.Geniohyoid m.Sublingual a.Lingual n.Hyoid boneHypoglossal n.Figure 18-27. A and B. Anatomy of the floor of mouth and submandibular space. a. = artery; m. = muscle; n. = nerve.Brunicardi_Ch18_p0613-p0660.indd 63601/03/19 5:24 PM 637DISORDERS OF THE HEAD AND NECKCHAPTER 18Floor of Mouth The floor of mouth is a mucosal-covered semilu-nar area that extends from the anterior tonsillar pillar posteriorly to the frenulum anteriorly, and from the inner surface of the mandible to the ventral surface of the oral tongue. The ostia of the submax-illary and sublingual glands are contained in the anterior floor of mouth. The muscular floor of mouth is composed of the sling-like genioglossus, mylohyoid, and hyoglossus muscles, which serve as a barrier to the spread of disease. Invasion into these | Surgery_Schwartz. andstyloglossus mm.Digastric muscle(posterior belly)Styloid processHypoglossal n.Middleconstrictor m.External carotid a.Hyoid boneHyoglossus m.Lingual n.Deep lingual a.Dorsal lingual a.Genioglossus m.Geniohyoid m.Sublingual a.Lingual n.Hyoid boneHypoglossal n.Figure 18-27. A and B. Anatomy of the floor of mouth and submandibular space. a. = artery; m. = muscle; n. = nerve.Brunicardi_Ch18_p0613-p0660.indd 63601/03/19 5:24 PM 637DISORDERS OF THE HEAD AND NECKCHAPTER 18Floor of Mouth The floor of mouth is a mucosal-covered semilu-nar area that extends from the anterior tonsillar pillar posteriorly to the frenulum anteriorly, and from the inner surface of the mandible to the ventral surface of the oral tongue. The ostia of the submax-illary and sublingual glands are contained in the anterior floor of mouth. The muscular floor of mouth is composed of the sling-like genioglossus, mylohyoid, and hyoglossus muscles, which serve as a barrier to the spread of disease. Invasion into these |
Surgery_Schwartz_4325 | Surgery_Schwartz | floor of mouth. The muscular floor of mouth is composed of the sling-like genioglossus, mylohyoid, and hyoglossus muscles, which serve as a barrier to the spread of disease. Invasion into these muscles can result in decreased tongue mobility and poor articulation.The floor of mouth begins just below the lingual surface of the mandibular alveolus and ends at the ventral tongue where the frenulum connects the floor of mouth to the tongue along the mid-line and at the anterior tonsillar pillars posteriorly. Just deep to the floor of mouth mucosa is the submandibular (Wharton’s) duct and sublingual minor salivary glands followed by the genio-glossus, hyoglossus, and mylohyoid muscles. Direct invasion of these structures is not uncommon and can result in direct spread to the sublingual and submandibular spaces as well as decreased tongue mobility, leading to articulation complaints. The lingual nerve (a branch of V3) provides sensory innerva-tion to this subsite and is in close proximity | Surgery_Schwartz. floor of mouth. The muscular floor of mouth is composed of the sling-like genioglossus, mylohyoid, and hyoglossus muscles, which serve as a barrier to the spread of disease. Invasion into these muscles can result in decreased tongue mobility and poor articulation.The floor of mouth begins just below the lingual surface of the mandibular alveolus and ends at the ventral tongue where the frenulum connects the floor of mouth to the tongue along the mid-line and at the anterior tonsillar pillars posteriorly. Just deep to the floor of mouth mucosa is the submandibular (Wharton’s) duct and sublingual minor salivary glands followed by the genio-glossus, hyoglossus, and mylohyoid muscles. Direct invasion of these structures is not uncommon and can result in direct spread to the sublingual and submandibular spaces as well as decreased tongue mobility, leading to articulation complaints. The lingual nerve (a branch of V3) provides sensory innerva-tion to this subsite and is in close proximity |
Surgery_Schwartz_4326 | Surgery_Schwartz | spaces as well as decreased tongue mobility, leading to articulation complaints. The lingual nerve (a branch of V3) provides sensory innerva-tion to this subsite and is in close proximity to it, often requir-ing resection of this structure. The contiguity of the floor of mouth mucosa with the lingual surface of the mandible can lead to mandibular invasion. This needs to be carefully examined bimanually on physical examination and using imaging (CT, MRI, or Panorex) because a marginal or segmental mandibu-lectomy may be required to excise these tumors (Fig. 18-28). If the lesion is not fixed to the mandibular cortex on physical examination, then a mandible-sparing procedure is feasible.117 Extension to the sublingual and submandibular ducts and spaces requires that the neck dissection specimen be removed en bloc with the primary tumor. Invasion of the intrinsic tongue muscu-lature requires a partial glossectomy. In our experience, except for the smallest (T1) very superficial floor of | Surgery_Schwartz. spaces as well as decreased tongue mobility, leading to articulation complaints. The lingual nerve (a branch of V3) provides sensory innerva-tion to this subsite and is in close proximity to it, often requir-ing resection of this structure. The contiguity of the floor of mouth mucosa with the lingual surface of the mandible can lead to mandibular invasion. This needs to be carefully examined bimanually on physical examination and using imaging (CT, MRI, or Panorex) because a marginal or segmental mandibu-lectomy may be required to excise these tumors (Fig. 18-28). If the lesion is not fixed to the mandibular cortex on physical examination, then a mandible-sparing procedure is feasible.117 Extension to the sublingual and submandibular ducts and spaces requires that the neck dissection specimen be removed en bloc with the primary tumor. Invasion of the intrinsic tongue muscu-lature requires a partial glossectomy. In our experience, except for the smallest (T1) very superficial floor of |
Surgery_Schwartz_4327 | Surgery_Schwartz | be removed en bloc with the primary tumor. Invasion of the intrinsic tongue muscu-lature requires a partial glossectomy. In our experience, except for the smallest (T1) very superficial floor of mouth lesions, cancers at this subsite nearly always require a reconstructive procedure to separate the floor of mouth from the neck and to avoid tethering of the tongue using a pliable fasciocutaneous flap. If a segmental resection is performed, the vascularized osteocutaneous free flap is used. Given the anterior location of this tumor, a lip-splitting incision is rarely used unless resection of lip and chin skin is required as part of the resection in a select group of T4a tumors with through-and-through involvement.Mandibular Alveolus and Gingiva The alveolar mucosa overlies the bone of the mandible and extends from the gin-givobuccal sulcus to the mucosa of the floor of mouth to the second and third molar, which is the anterior border of the ret-romolar trigone subsite. Treatment of these | Surgery_Schwartz. be removed en bloc with the primary tumor. Invasion of the intrinsic tongue muscu-lature requires a partial glossectomy. In our experience, except for the smallest (T1) very superficial floor of mouth lesions, cancers at this subsite nearly always require a reconstructive procedure to separate the floor of mouth from the neck and to avoid tethering of the tongue using a pliable fasciocutaneous flap. If a segmental resection is performed, the vascularized osteocutaneous free flap is used. Given the anterior location of this tumor, a lip-splitting incision is rarely used unless resection of lip and chin skin is required as part of the resection in a select group of T4a tumors with through-and-through involvement.Mandibular Alveolus and Gingiva The alveolar mucosa overlies the bone of the mandible and extends from the gin-givobuccal sulcus to the mucosa of the floor of mouth to the second and third molar, which is the anterior border of the ret-romolar trigone subsite. Treatment of these |
Surgery_Schwartz_4328 | Surgery_Schwartz | and extends from the gin-givobuccal sulcus to the mucosa of the floor of mouth to the second and third molar, which is the anterior border of the ret-romolar trigone subsite. Treatment of these lesions requires at the very least marginal resection of the mandibular bone given the proximity and early invasion of the periosteum in this region. A marginal resection is acceptable if there is only very early bony invasion (Fig. 18-29). If the inferior alveolar canal or the medullary cavity is invaded on physical examination or preoperative imaging, a negative locoregional prognostic fac-tor, a segmental resection is recommended with appropriate reconstruction.118,119Retromolar Trigone The retromolar trigone (RMT) is bor-dered medially by the anterior tonsillar pillar, anteriorly by the ABIncisionTissue excisedFigure 18-28. A and B. Differences in the transoral resection of a floor of mouth and alveolar ridge lesion.Brunicardi_Ch18_p0613-p0660.indd 63701/03/19 5:24 PM 638SPECIFIC | Surgery_Schwartz. and extends from the gin-givobuccal sulcus to the mucosa of the floor of mouth to the second and third molar, which is the anterior border of the ret-romolar trigone subsite. Treatment of these lesions requires at the very least marginal resection of the mandibular bone given the proximity and early invasion of the periosteum in this region. A marginal resection is acceptable if there is only very early bony invasion (Fig. 18-29). If the inferior alveolar canal or the medullary cavity is invaded on physical examination or preoperative imaging, a negative locoregional prognostic fac-tor, a segmental resection is recommended with appropriate reconstruction.118,119Retromolar Trigone The retromolar trigone (RMT) is bor-dered medially by the anterior tonsillar pillar, anteriorly by the ABIncisionTissue excisedFigure 18-28. A and B. Differences in the transoral resection of a floor of mouth and alveolar ridge lesion.Brunicardi_Ch18_p0613-p0660.indd 63701/03/19 5:24 PM 638SPECIFIC |
Surgery_Schwartz_4329 | Surgery_Schwartz | excisedFigure 18-28. A and B. Differences in the transoral resection of a floor of mouth and alveolar ridge lesion.Brunicardi_Ch18_p0613-p0660.indd 63701/03/19 5:24 PM 638SPECIFIC CONSIDERATIONSPART IIsecond or third molar, posteriorly by the maxillary tuberosity, inferiorly by the posterior mandibular alveolus, superiorly by the coronoid process of the mandible, and laterally by the buc-cal mucosa. Negative margin resection often requires a mar-ginal shave mandibulectomy, even when there is no evidence of mandibular cortical invasion, because of the close proxim-ity to the mandibular periosteum. This is typically achieved through a transoral approach while carefully protecting the lips and cheek.120 Extension to adjacent subsites including the buccal mucosa, maxillary tuberosity, floor of mouth, and posterolateral tongue often requires these structures be resected as part of the margin. Trismus at this and other subsites is an advanced indica-tion of involvement of the muscles | Surgery_Schwartz. excisedFigure 18-28. A and B. Differences in the transoral resection of a floor of mouth and alveolar ridge lesion.Brunicardi_Ch18_p0613-p0660.indd 63701/03/19 5:24 PM 638SPECIFIC CONSIDERATIONSPART IIsecond or third molar, posteriorly by the maxillary tuberosity, inferiorly by the posterior mandibular alveolus, superiorly by the coronoid process of the mandible, and laterally by the buc-cal mucosa. Negative margin resection often requires a mar-ginal shave mandibulectomy, even when there is no evidence of mandibular cortical invasion, because of the close proxim-ity to the mandibular periosteum. This is typically achieved through a transoral approach while carefully protecting the lips and cheek.120 Extension to adjacent subsites including the buccal mucosa, maxillary tuberosity, floor of mouth, and posterolateral tongue often requires these structures be resected as part of the margin. Trismus at this and other subsites is an advanced indica-tion of involvement of the muscles |
Surgery_Schwartz_4330 | Surgery_Schwartz | of mouth, and posterolateral tongue often requires these structures be resected as part of the margin. Trismus at this and other subsites is an advanced indica-tion of involvement of the muscles of mastication in the masti-cator space, which can extend to the skull base. These tumors are aggressive. Infiltration into the masticator space and bony invasion (maxilla more often than mandible) significantly wors-ens the prognosis.121Buccal Mucosa The buccal mucosa includes all of the mucosal lining from the inner surface of the lips to the line of attachment of mucosa of the alveolar ridges and pterygomandibular raphe. The mucosa includes the parotid (Stenson’s) duct opening adja-cent to the first and second maxillary molars. An understanding of the layers of the cheek from medial to lateral is important because these layers are very closely adherent to the buccal mucosa. Therefore, tumors in this region have a high propensity for early deep invasion and early lymphatic spread. The layers | Surgery_Schwartz. of mouth, and posterolateral tongue often requires these structures be resected as part of the margin. Trismus at this and other subsites is an advanced indica-tion of involvement of the muscles of mastication in the masti-cator space, which can extend to the skull base. These tumors are aggressive. Infiltration into the masticator space and bony invasion (maxilla more often than mandible) significantly wors-ens the prognosis.121Buccal Mucosa The buccal mucosa includes all of the mucosal lining from the inner surface of the lips to the line of attachment of mucosa of the alveolar ridges and pterygomandibular raphe. The mucosa includes the parotid (Stenson’s) duct opening adja-cent to the first and second maxillary molars. An understanding of the layers of the cheek from medial to lateral is important because these layers are very closely adherent to the buccal mucosa. Therefore, tumors in this region have a high propensity for early deep invasion and early lymphatic spread. The layers |
Surgery_Schwartz_4331 | Surgery_Schwartz | important because these layers are very closely adherent to the buccal mucosa. Therefore, tumors in this region have a high propensity for early deep invasion and early lymphatic spread. The layers of the cheek from medial to lateral are: (a) buccal mucosa, (b) pharyngobasilar fascia, (c) buccinator muscle, (d) buccopha-ryngeal fascia, (e) buccinator fat pad, (f) masseter muscle, (g) muscles of facial expression and the superficial muscular apo-neurotic system (SMAS), (h) subcutaneous tissue, and (i) facial skin. It is not uncommon for tumors with deep invasion into the cheek to require a through-and-through resection. Reconstruc-tion aimed at providing both an internal and external lining may be accomplished with a folded fasciocutaneous free flap or a combination of a local flap for the external component and a free flap for the internal component. Marginal bone resection is often required in tumors that extend to the mandibular or maxil-lary alveolus.Maxillary Alveolus and Hard | Surgery_Schwartz. important because these layers are very closely adherent to the buccal mucosa. Therefore, tumors in this region have a high propensity for early deep invasion and early lymphatic spread. The layers of the cheek from medial to lateral are: (a) buccal mucosa, (b) pharyngobasilar fascia, (c) buccinator muscle, (d) buccopha-ryngeal fascia, (e) buccinator fat pad, (f) masseter muscle, (g) muscles of facial expression and the superficial muscular apo-neurotic system (SMAS), (h) subcutaneous tissue, and (i) facial skin. It is not uncommon for tumors with deep invasion into the cheek to require a through-and-through resection. Reconstruc-tion aimed at providing both an internal and external lining may be accomplished with a folded fasciocutaneous free flap or a combination of a local flap for the external component and a free flap for the internal component. Marginal bone resection is often required in tumors that extend to the mandibular or maxil-lary alveolus.Maxillary Alveolus and Hard |
Surgery_Schwartz_4332 | Surgery_Schwartz | the external component and a free flap for the internal component. Marginal bone resection is often required in tumors that extend to the mandibular or maxil-lary alveolus.Maxillary Alveolus and Hard Palate The hard palate and maxillary alveolus have classically been considered two sepa-rate subsites, but due to their anatomic contiguity and the simi-larities in their oncologic outcomes these two subsites should be discussed together.122 The junction between the hard palate and soft palate is the posterior border, while the maxillary tuberos-ity is the posterolateral border separating the retromolar trigone from the maxillary alveolus. The periosteum is at this subsite is closely adherent to the mucosa, and as such, superficial lesions require resection of the bone to achieve a clear margin. An infrastructure maxillectomy may be required for larger lesions involving the palate or maxillary antrum. The greater palatine nerve and foramen can be a pathway for neuropathic spread, and it | Surgery_Schwartz. the external component and a free flap for the internal component. Marginal bone resection is often required in tumors that extend to the mandibular or maxil-lary alveolus.Maxillary Alveolus and Hard Palate The hard palate and maxillary alveolus have classically been considered two sepa-rate subsites, but due to their anatomic contiguity and the simi-larities in their oncologic outcomes these two subsites should be discussed together.122 The junction between the hard palate and soft palate is the posterior border, while the maxillary tuberos-ity is the posterolateral border separating the retromolar trigone from the maxillary alveolus. The periosteum is at this subsite is closely adherent to the mucosa, and as such, superficial lesions require resection of the bone to achieve a clear margin. An infrastructure maxillectomy may be required for larger lesions involving the palate or maxillary antrum. The greater palatine nerve and foramen can be a pathway for neuropathic spread, and it |
Surgery_Schwartz_4333 | Surgery_Schwartz | An infrastructure maxillectomy may be required for larger lesions involving the palate or maxillary antrum. The greater palatine nerve and foramen can be a pathway for neuropathic spread, and it is important to identify perineural invasion on these tumors in the biopsy specimen.Although SCC continues to be the primary malignant pathology at this subsite, minor salivary gland tumors such as adenoid cystic carcinoma, mucoepidermoid carcinoma, and adenocarcinoma can also present in this location. Minor sali-vary gland tumors tend to arise at the junction of the hard and soft palate.Nonmalignant pathology includes necrotizing sialometa-plasia, which appears as a butterfly-shaped ulcer on the hard palate that otherwise looks like a neoplasm. Treatment is symp-tomatic as these lesions typical disappear with time; however, a biopsy is warranted to confirm the diagnosis. A torus palatini is a benign bony outgrowth seen on midline of the hard palate. This does not require biopsy to confirm the | Surgery_Schwartz. An infrastructure maxillectomy may be required for larger lesions involving the palate or maxillary antrum. The greater palatine nerve and foramen can be a pathway for neuropathic spread, and it is important to identify perineural invasion on these tumors in the biopsy specimen.Although SCC continues to be the primary malignant pathology at this subsite, minor salivary gland tumors such as adenoid cystic carcinoma, mucoepidermoid carcinoma, and adenocarcinoma can also present in this location. Minor sali-vary gland tumors tend to arise at the junction of the hard and soft palate.Nonmalignant pathology includes necrotizing sialometa-plasia, which appears as a butterfly-shaped ulcer on the hard palate that otherwise looks like a neoplasm. Treatment is symp-tomatic as these lesions typical disappear with time; however, a biopsy is warranted to confirm the diagnosis. A torus palatini is a benign bony outgrowth seen on midline of the hard palate. This does not require biopsy to confirm the |
Surgery_Schwartz_4334 | Surgery_Schwartz | with time; however, a biopsy is warranted to confirm the diagnosis. A torus palatini is a benign bony outgrowth seen on midline of the hard palate. This does not require biopsy to confirm the diagnosis and only requires treatment to relieve symptoms.Reconstruction of the maxillectomy defect depends on a number of variables, including patient preference, dentition, patient comorbidity, and extent of defect. A partial palatectomy or partial infrastructure palatectomy can often be reconstructed with a dental obturator or a soft tissue flap alone to separate the oral cavity from the nasal cavity and maxillary sinus. More extensive suprastructure maxillectomies can be reconstructed with a free flap composed only of soft tissue, although this will leave the patient with a significant malar asymmetry over an osseous free flap. The layered fibular free flap and the scapular tip have been recently popularized to reconstruct more extensive orbitomaxillary reconstruction.123,124 Supporting the | Surgery_Schwartz. with time; however, a biopsy is warranted to confirm the diagnosis. A torus palatini is a benign bony outgrowth seen on midline of the hard palate. This does not require biopsy to confirm the diagnosis and only requires treatment to relieve symptoms.Reconstruction of the maxillectomy defect depends on a number of variables, including patient preference, dentition, patient comorbidity, and extent of defect. A partial palatectomy or partial infrastructure palatectomy can often be reconstructed with a dental obturator or a soft tissue flap alone to separate the oral cavity from the nasal cavity and maxillary sinus. More extensive suprastructure maxillectomies can be reconstructed with a free flap composed only of soft tissue, although this will leave the patient with a significant malar asymmetry over an osseous free flap. The layered fibular free flap and the scapular tip have been recently popularized to reconstruct more extensive orbitomaxillary reconstruction.123,124 Supporting the |
Surgery_Schwartz_4335 | Surgery_Schwartz | over an osseous free flap. The layered fibular free flap and the scapular tip have been recently popularized to reconstruct more extensive orbitomaxillary reconstruction.123,124 Supporting the orbital floor when it is resected is critical in supporting the orbital contents and avoiding eventual diploplia because there can be a drop in these contents when they are not supported.Oropharynx The borders of the oropharynx start at the soft pal-ate superiorly, the hyoid (vallecular root) inferiorly, the anterior tonsillar pillar anterolaterally, and the cricumvallate papilla at the junction between the anterior two-thirds and posterior third of the tongue. There are five subsites in the oropharynx: the tonsillar region that includes the anterior and posterior tonsillar pillars, the soft palate, the posterior pharyngeal wall, the lateral pharyngeal wall, and the base of tongue. Tumors at this subsite can have direct extension laterally in the parapharyngeal space, posteriorly into the | Surgery_Schwartz. over an osseous free flap. The layered fibular free flap and the scapular tip have been recently popularized to reconstruct more extensive orbitomaxillary reconstruction.123,124 Supporting the orbital floor when it is resected is critical in supporting the orbital contents and avoiding eventual diploplia because there can be a drop in these contents when they are not supported.Oropharynx The borders of the oropharynx start at the soft pal-ate superiorly, the hyoid (vallecular root) inferiorly, the anterior tonsillar pillar anterolaterally, and the cricumvallate papilla at the junction between the anterior two-thirds and posterior third of the tongue. There are five subsites in the oropharynx: the tonsillar region that includes the anterior and posterior tonsillar pillars, the soft palate, the posterior pharyngeal wall, the lateral pharyngeal wall, and the base of tongue. Tumors at this subsite can have direct extension laterally in the parapharyngeal space, posteriorly into the |
Surgery_Schwartz_4336 | Surgery_Schwartz | the posterior pharyngeal wall, the lateral pharyngeal wall, and the base of tongue. Tumors at this subsite can have direct extension laterally in the parapharyngeal space, posteriorly into the retropharyngeal space, anteriorly into the oral cavity, superiorly into the nasopharynx, or inferiorly into Figure 18-29. Anterior mandibulotomy with mandibular swing to approach a posterior lesion.Brunicardi_Ch18_p0613-p0660.indd 63801/03/19 5:24 PM 639DISORDERS OF THE HEAD AND NECKCHAPTER 18the supraglottic larynx. Laterally, through the superior con-strictor, invasion of the jugular vein, carotid artery, and cranial nerves IX to XII, as well as the sympathetic chain, is possible. The pharyngobasilar fascia (resectable) deep to the constrictor muscles is a natural barrier from invasion into the prevertebral fascia (unresectable). The ascending ramus of the mandible can be involved when tumors invade the medial pterygoid muscle.Although SCC is the predominant pathology, minor sali-vary | Surgery_Schwartz. the posterior pharyngeal wall, the lateral pharyngeal wall, and the base of tongue. Tumors at this subsite can have direct extension laterally in the parapharyngeal space, posteriorly into the retropharyngeal space, anteriorly into the oral cavity, superiorly into the nasopharynx, or inferiorly into Figure 18-29. Anterior mandibulotomy with mandibular swing to approach a posterior lesion.Brunicardi_Ch18_p0613-p0660.indd 63801/03/19 5:24 PM 639DISORDERS OF THE HEAD AND NECKCHAPTER 18the supraglottic larynx. Laterally, through the superior con-strictor, invasion of the jugular vein, carotid artery, and cranial nerves IX to XII, as well as the sympathetic chain, is possible. The pharyngobasilar fascia (resectable) deep to the constrictor muscles is a natural barrier from invasion into the prevertebral fascia (unresectable). The ascending ramus of the mandible can be involved when tumors invade the medial pterygoid muscle.Although SCC is the predominant pathology, minor sali-vary |
Surgery_Schwartz_4337 | Surgery_Schwartz | the prevertebral fascia (unresectable). The ascending ramus of the mandible can be involved when tumors invade the medial pterygoid muscle.Although SCC is the predominant pathology, minor sali-vary gland tumors can present as submucosal lesions in the soft palate or tongue base, and lymphoma can present in the tonsils as an asymmetric enlargement, underlying the importance of a tissue diagnosis before treatment.Oropharyngeal cancers, other than those on the soft palate or tonsils, are often not obvious on oral cavity exam inspection; therefore, a high degree of suspicion should exist in patients with a muffled voice as would be experienced in tongue base tumors, patients with dysphagia and weight loss, or referred otalgia from the tympanic branches of CN IX and X. Trismus may indicate advanced disease with pterygoid involvement. As previously mentioned, because of the epidemic rise in incidence of oropharyngeal cancers, secondary to HPV-associated tumors, and the high regional | Surgery_Schwartz. the prevertebral fascia (unresectable). The ascending ramus of the mandible can be involved when tumors invade the medial pterygoid muscle.Although SCC is the predominant pathology, minor sali-vary gland tumors can present as submucosal lesions in the soft palate or tongue base, and lymphoma can present in the tonsils as an asymmetric enlargement, underlying the importance of a tissue diagnosis before treatment.Oropharyngeal cancers, other than those on the soft palate or tonsils, are often not obvious on oral cavity exam inspection; therefore, a high degree of suspicion should exist in patients with a muffled voice as would be experienced in tongue base tumors, patients with dysphagia and weight loss, or referred otalgia from the tympanic branches of CN IX and X. Trismus may indicate advanced disease with pterygoid involvement. As previously mentioned, because of the epidemic rise in incidence of oropharyngeal cancers, secondary to HPV-associated tumors, and the high regional |
Surgery_Schwartz_4338 | Surgery_Schwartz | advanced disease with pterygoid involvement. As previously mentioned, because of the epidemic rise in incidence of oropharyngeal cancers, secondary to HPV-associated tumors, and the high regional metastatic rate for these tumors, the pre-senting symptom is often a nontender cervical lymphadenopa-thy, which should be investigated with a fine-needle aspiration (FNA) biopsy. Approximately 50% of patients have metastases at the time of diagnosis. Bilateral metastases are common in patients with soft palate and base of tongue tumors. Treatment of the neck should include the upper jugulodigastric nodes to which these tumors most commonly metastasize to, followed by levels II, IV, V, and the retropharyngeal lymph nodes.A discussion about oropharyngeal cancer cannot be had without discussing the important prognostic information pro-vided by the HPV status of these tumors. The incidence of oro-pharyngeal squamous cell carcinoma has increased significantly over the last four decades secondary | Surgery_Schwartz. advanced disease with pterygoid involvement. As previously mentioned, because of the epidemic rise in incidence of oropharyngeal cancers, secondary to HPV-associated tumors, and the high regional metastatic rate for these tumors, the pre-senting symptom is often a nontender cervical lymphadenopa-thy, which should be investigated with a fine-needle aspiration (FNA) biopsy. Approximately 50% of patients have metastases at the time of diagnosis. Bilateral metastases are common in patients with soft palate and base of tongue tumors. Treatment of the neck should include the upper jugulodigastric nodes to which these tumors most commonly metastasize to, followed by levels II, IV, V, and the retropharyngeal lymph nodes.A discussion about oropharyngeal cancer cannot be had without discussing the important prognostic information pro-vided by the HPV status of these tumors. The incidence of oro-pharyngeal squamous cell carcinoma has increased significantly over the last four decades secondary |
Surgery_Schwartz_4339 | Surgery_Schwartz | important prognostic information pro-vided by the HPV status of these tumors. The incidence of oro-pharyngeal squamous cell carcinoma has increased significantly over the last four decades secondary to HPV-16 related develop-ment of this tumor.125 HPV infection can induce the production of two viral oncoproteins, E6 and E7, which inactivate tumor suppressors p53 and Rb leading to tumor promotion.126 HPV-positive tumors are more common in younger male patients and are associated with a history of a higher lifetime number of sexual partners and oral sex.127 Ang et al demonstrated that oropharyngeal cancers can be stratified on overall survival into low risk (HPV-positive tumors in patients with ≤10 pack years of smoking or >10 pack years of smoking but N0-N2a), intermediate risk (HPV-positive tumors with >10 pack years of smoking and N2b-N3 or HPV-negative tumors in patients with ≤10 pack years of smoking and T2-T3 tumors), and high risk (HPV-negative tumors in patients with ≤10 pack | Surgery_Schwartz. important prognostic information pro-vided by the HPV status of these tumors. The incidence of oro-pharyngeal squamous cell carcinoma has increased significantly over the last four decades secondary to HPV-16 related develop-ment of this tumor.125 HPV infection can induce the production of two viral oncoproteins, E6 and E7, which inactivate tumor suppressors p53 and Rb leading to tumor promotion.126 HPV-positive tumors are more common in younger male patients and are associated with a history of a higher lifetime number of sexual partners and oral sex.127 Ang et al demonstrated that oropharyngeal cancers can be stratified on overall survival into low risk (HPV-positive tumors in patients with ≤10 pack years of smoking or >10 pack years of smoking but N0-N2a), intermediate risk (HPV-positive tumors with >10 pack years of smoking and N2b-N3 or HPV-negative tumors in patients with ≤10 pack years of smoking and T2-T3 tumors), and high risk (HPV-negative tumors in patients with ≤10 pack |
Surgery_Schwartz_4340 | Surgery_Schwartz | tumors with >10 pack years of smoking and N2b-N3 or HPV-negative tumors in patients with ≤10 pack years of smoking and T2-T3 tumors), and high risk (HPV-negative tumors in patients with ≤10 pack years of smok-ing and T4 tumors or HPV-negative tumors in patients with >10 pack years of smoking).92 The rate of distant metastases in the HPV-positive and HPV-negative tumors does not differ, and therefore the survival benefit in the HPV-positive group is due to improved locoregional control.Management of squamous cell cancers of this region includes single modality (surgery or radiotherapy alone) treat-ment for early stage disease (stage I/II) and multimodality treatment for advanced stage (stage III/IV) disease (surgery followed by postoperative radiotherapy or concurrent chemora-diotherapy).106 Historically, from 1971 to 2000, oropharyngeal cancers, at the time mostly HPV-negative, were treated hetero-geneously with surgery followed by radiotherapy or primary radiotherapy similar survival | Surgery_Schwartz. tumors with >10 pack years of smoking and N2b-N3 or HPV-negative tumors in patients with ≤10 pack years of smoking and T2-T3 tumors), and high risk (HPV-negative tumors in patients with ≤10 pack years of smok-ing and T4 tumors or HPV-negative tumors in patients with >10 pack years of smoking).92 The rate of distant metastases in the HPV-positive and HPV-negative tumors does not differ, and therefore the survival benefit in the HPV-positive group is due to improved locoregional control.Management of squamous cell cancers of this region includes single modality (surgery or radiotherapy alone) treat-ment for early stage disease (stage I/II) and multimodality treatment for advanced stage (stage III/IV) disease (surgery followed by postoperative radiotherapy or concurrent chemora-diotherapy).106 Historically, from 1971 to 2000, oropharyngeal cancers, at the time mostly HPV-negative, were treated hetero-geneously with surgery followed by radiotherapy or primary radiotherapy similar survival |
Surgery_Schwartz_4341 | Surgery_Schwartz | Historically, from 1971 to 2000, oropharyngeal cancers, at the time mostly HPV-negative, were treated hetero-geneously with surgery followed by radiotherapy or primary radiotherapy similar survival until Parsons et al demonstrated in a meta-analysis similar survival rates between the two treatment groups with improved locoregional control in the radiation-alone group and much higher complication rates in the surgery group (32% severe complications, 3.5% mortality) compared to the radiotherapy group (3.8% severe complications, 0.4% mortal-ity).128 For this reason, for many years, advanced-stage tumors were treated with primary concurrent chemoradiotherapy. How-ever, this is now a moving target given the excellent results in early and some intermediate-stage HPV-positive disease regardless of treatment. More recently, there has been a push to study de-escalation, particularly in the aforementioned low and intermediate risk groups given the excellent survival rates. The standard of care, | Surgery_Schwartz. Historically, from 1971 to 2000, oropharyngeal cancers, at the time mostly HPV-negative, were treated hetero-geneously with surgery followed by radiotherapy or primary radiotherapy similar survival until Parsons et al demonstrated in a meta-analysis similar survival rates between the two treatment groups with improved locoregional control in the radiation-alone group and much higher complication rates in the surgery group (32% severe complications, 3.5% mortality) compared to the radiotherapy group (3.8% severe complications, 0.4% mortal-ity).128 For this reason, for many years, advanced-stage tumors were treated with primary concurrent chemoradiotherapy. How-ever, this is now a moving target given the excellent results in early and some intermediate-stage HPV-positive disease regardless of treatment. More recently, there has been a push to study de-escalation, particularly in the aforementioned low and intermediate risk groups given the excellent survival rates. The standard of care, |
Surgery_Schwartz_4342 | Surgery_Schwartz | treatment. More recently, there has been a push to study de-escalation, particularly in the aforementioned low and intermediate risk groups given the excellent survival rates. The standard of care, regardless of HPV status, for advanced tumors (T3/T4 or N2b-N3 or evidence of gross ECE) continues to be concurrent chemoradiotherapy.129The high complication and mortality rate in the surgi-cal group analyzed by Parsons et al was associated not just with HPV-negative tumors but also with open resections for advanced tumors that necessitated a lip-splitting mandibulotomy approach. More recently, particularly for early stage tumors (T1, T2, N0-N2a), there has been a push towards minimally invasive transoral robotic surgery (TORS) using the da Vinci Surgical System. Oncologic outcomes are similar between surgery and radiotherapy in this group, and TORS has been demonstrated to be cost-effective in this setting.130-132 Functional outcomes related to swallowing (G-tube dependency) and airway | Surgery_Schwartz. treatment. More recently, there has been a push to study de-escalation, particularly in the aforementioned low and intermediate risk groups given the excellent survival rates. The standard of care, regardless of HPV status, for advanced tumors (T3/T4 or N2b-N3 or evidence of gross ECE) continues to be concurrent chemoradiotherapy.129The high complication and mortality rate in the surgi-cal group analyzed by Parsons et al was associated not just with HPV-negative tumors but also with open resections for advanced tumors that necessitated a lip-splitting mandibulotomy approach. More recently, particularly for early stage tumors (T1, T2, N0-N2a), there has been a push towards minimally invasive transoral robotic surgery (TORS) using the da Vinci Surgical System. Oncologic outcomes are similar between surgery and radiotherapy in this group, and TORS has been demonstrated to be cost-effective in this setting.130-132 Functional outcomes related to swallowing (G-tube dependency) and airway |
Surgery_Schwartz_4343 | Surgery_Schwartz | between surgery and radiotherapy in this group, and TORS has been demonstrated to be cost-effective in this setting.130-132 Functional outcomes related to swallowing (G-tube dependency) and airway (tra-cheotomy dependency) are also similar between the groups.130 These outcomes are heavily dependent on the surgeon’s abil-ity to achieve negative margins, which can be challenging, and on good preoperative predictive value of imaging to stage the neck, given that advanced nodal disease, particularly with ECE, continues to benefit from adjuvant chemoradiotherapy. Positive margins or ECE ultimately leads to adjuvant chemoradiother-apy. This results in triple modality treatment with its associated higher morbidity. Therefore, clinical recommendations based on these favorable early retrospective poorly controlled studies with small sample sizes is not yet possible. Meanwhile, clinical trial evidence is pending to help elucidate in which settings and patients this new approach may be | Surgery_Schwartz. between surgery and radiotherapy in this group, and TORS has been demonstrated to be cost-effective in this setting.130-132 Functional outcomes related to swallowing (G-tube dependency) and airway (tra-cheotomy dependency) are also similar between the groups.130 These outcomes are heavily dependent on the surgeon’s abil-ity to achieve negative margins, which can be challenging, and on good preoperative predictive value of imaging to stage the neck, given that advanced nodal disease, particularly with ECE, continues to benefit from adjuvant chemoradiotherapy. Positive margins or ECE ultimately leads to adjuvant chemoradiother-apy. This results in triple modality treatment with its associated higher morbidity. Therefore, clinical recommendations based on these favorable early retrospective poorly controlled studies with small sample sizes is not yet possible. Meanwhile, clinical trial evidence is pending to help elucidate in which settings and patients this new approach may be |
Surgery_Schwartz_4344 | Surgery_Schwartz | poorly controlled studies with small sample sizes is not yet possible. Meanwhile, clinical trial evidence is pending to help elucidate in which settings and patients this new approach may be beneficial.133Extensive oropharyngeal cancers that fail concurrent chemoradiotherapy are treated with resection. If the mandible is involved, a marginal mandibulectomy or segmental man-dibulectomy may be required depending on the extent of bony invasion. Tongue base resection may necessitate total glossec-tomy depending on the contralateral extent of the tumor and the ability to save the lingual artery and to a lesser extent the hypo-glossal nerve on that side. When the larynx is preserved many patients, if careful reconstruction is performed, 90% of patients can be decannulated and have acceptable voice outcomes.134 However, it is not uncommon to have to perform a total laryn-gectomy at the same time as the total glossectomy for tumors with supraglottic extent, and this is associated with poor | Surgery_Schwartz. poorly controlled studies with small sample sizes is not yet possible. Meanwhile, clinical trial evidence is pending to help elucidate in which settings and patients this new approach may be beneficial.133Extensive oropharyngeal cancers that fail concurrent chemoradiotherapy are treated with resection. If the mandible is involved, a marginal mandibulectomy or segmental man-dibulectomy may be required depending on the extent of bony invasion. Tongue base resection may necessitate total glossec-tomy depending on the contralateral extent of the tumor and the ability to save the lingual artery and to a lesser extent the hypo-glossal nerve on that side. When the larynx is preserved many patients, if careful reconstruction is performed, 90% of patients can be decannulated and have acceptable voice outcomes.134 However, it is not uncommon to have to perform a total laryn-gectomy at the same time as the total glossectomy for tumors with supraglottic extent, and this is associated with poor |
Surgery_Schwartz_4345 | Surgery_Schwartz | voice outcomes.134 However, it is not uncommon to have to perform a total laryn-gectomy at the same time as the total glossectomy for tumors with supraglottic extent, and this is associated with poor quality of life. Generally, these patients also have poorer survival.135-137The primary goal of oropharyngeal reconstruction is swal-lowing rehabilitation. For soft palate defects, palatal obturators may assist in providing a seal between the nasopharynx and the posterior pharyngeal wall. The modified Gehanno technique sutures the posterior wall of the remaining soft palate to the remaining incised pharyngeal mucosa to close off the ipsilateral hemi-nasopharyngeal port.138,139 A flap can then be inset overly-ing this defect, which has effectively separated the nasopharynx from the oropharynx. This prevents nasal regurgitation of air Brunicardi_Ch18_p0613-p0660.indd 63901/03/19 5:24 PM 640SPECIFIC CONSIDERATIONSPART IIand liquids, therefore impacting both speech and swallowing. | Surgery_Schwartz. voice outcomes.134 However, it is not uncommon to have to perform a total laryn-gectomy at the same time as the total glossectomy for tumors with supraglottic extent, and this is associated with poor quality of life. Generally, these patients also have poorer survival.135-137The primary goal of oropharyngeal reconstruction is swal-lowing rehabilitation. For soft palate defects, palatal obturators may assist in providing a seal between the nasopharynx and the posterior pharyngeal wall. The modified Gehanno technique sutures the posterior wall of the remaining soft palate to the remaining incised pharyngeal mucosa to close off the ipsilateral hemi-nasopharyngeal port.138,139 A flap can then be inset overly-ing this defect, which has effectively separated the nasopharynx from the oropharynx. This prevents nasal regurgitation of air Brunicardi_Ch18_p0613-p0660.indd 63901/03/19 5:24 PM 640SPECIFIC CONSIDERATIONSPART IIand liquids, therefore impacting both speech and swallowing. |
Surgery_Schwartz_4346 | Surgery_Schwartz | This prevents nasal regurgitation of air Brunicardi_Ch18_p0613-p0660.indd 63901/03/19 5:24 PM 640SPECIFIC CONSIDERATIONSPART IIand liquids, therefore impacting both speech and swallowing. Similarly, total glossectomy reconstruction has several goals, including filling the oral cavity dead space, allowing the neo-tongue to reach the premaxilla to assist with articulation, and, most importantly, creating posterior bulk to allow the base of tongue to touch the posterior pharyngeal wall, which assists with the pharyngeal phase of swallowing. This is often achieved with a large rectus abdominis or anterolateral thigh free flap.138 If the neotongue does not successfully touch the premaxilla and hard palate and speech is impeded, a palatal obturator can be used to bring down the palate and achieve better contact.Hypopharynx and Cervical Esophagus The hypopharynx, which extends from the vallecular to the lower border of the cricoid cartilage (Fig. 18-30), has three subsites; the pyriform | Surgery_Schwartz. This prevents nasal regurgitation of air Brunicardi_Ch18_p0613-p0660.indd 63901/03/19 5:24 PM 640SPECIFIC CONSIDERATIONSPART IIand liquids, therefore impacting both speech and swallowing. Similarly, total glossectomy reconstruction has several goals, including filling the oral cavity dead space, allowing the neo-tongue to reach the premaxilla to assist with articulation, and, most importantly, creating posterior bulk to allow the base of tongue to touch the posterior pharyngeal wall, which assists with the pharyngeal phase of swallowing. This is often achieved with a large rectus abdominis or anterolateral thigh free flap.138 If the neotongue does not successfully touch the premaxilla and hard palate and speech is impeded, a palatal obturator can be used to bring down the palate and achieve better contact.Hypopharynx and Cervical Esophagus The hypopharynx, which extends from the vallecular to the lower border of the cricoid cartilage (Fig. 18-30), has three subsites; the pyriform |
Surgery_Schwartz_4347 | Surgery_Schwartz | better contact.Hypopharynx and Cervical Esophagus The hypopharynx, which extends from the vallecular to the lower border of the cricoid cartilage (Fig. 18-30), has three subsites; the pyriform sinuses, the lateral and posterior pharyngeal walls, and the post cricoid space. SCC of the hypopharynx typically presents with progressive dysphagia, first to solids then to liquids, fol-lowed by weight loss. Similar to oropharyngeal tumors, patients can also present with voice change, referred otalgia or a neck mass. Rarely, when the larynx is involved, patients may pres-ent with stridor and airway compromise necessitating an urgent tracheotomy.Unfortunately, there is significant delay in diagnosis of patients with hypopharyngeal cancer and late presentation is common.140 Routine physical examination will not typically detect the tumor. Fiberoptic nasolaryngoscopy is important in assessing the extent of the tumor and laryngeal function. Vocal cord paralysis is a poor prognostic factor and | Surgery_Schwartz. better contact.Hypopharynx and Cervical Esophagus The hypopharynx, which extends from the vallecular to the lower border of the cricoid cartilage (Fig. 18-30), has three subsites; the pyriform sinuses, the lateral and posterior pharyngeal walls, and the post cricoid space. SCC of the hypopharynx typically presents with progressive dysphagia, first to solids then to liquids, fol-lowed by weight loss. Similar to oropharyngeal tumors, patients can also present with voice change, referred otalgia or a neck mass. Rarely, when the larynx is involved, patients may pres-ent with stridor and airway compromise necessitating an urgent tracheotomy.Unfortunately, there is significant delay in diagnosis of patients with hypopharyngeal cancer and late presentation is common.140 Routine physical examination will not typically detect the tumor. Fiberoptic nasolaryngoscopy is important in assessing the extent of the tumor and laryngeal function. Vocal cord paralysis is a poor prognostic factor and |
Surgery_Schwartz_4348 | Surgery_Schwartz | will not typically detect the tumor. Fiberoptic nasolaryngoscopy is important in assessing the extent of the tumor and laryngeal function. Vocal cord paralysis is a poor prognostic factor and indicates fixation of the cricoarytenoid joint from direct extension of the tumor or recurrent laryngeal nerve invasion. A Valsalva maneuver dur-ing laryngoscopy allows for a better evaluation of the opened pyriform sinuses and postcricoid space. Functional endoscopic evaluation of swallowing (FEES) can be useful to assess laryn-geal penetration and aspiration, but a modified barium swal-low (MBS) is better at assessing inferior extent of the disease, multifocality within the esophagus, and aspiration. A thorough metastatic workup is required, with special attention paid to paratracheal and upper mediastinal metastases.This site has the poorest survival outcomes of all head and neck subsites. There is no difference in survival when surgery is used as the primary modality of treatment followed by | Surgery_Schwartz. will not typically detect the tumor. Fiberoptic nasolaryngoscopy is important in assessing the extent of the tumor and laryngeal function. Vocal cord paralysis is a poor prognostic factor and indicates fixation of the cricoarytenoid joint from direct extension of the tumor or recurrent laryngeal nerve invasion. A Valsalva maneuver dur-ing laryngoscopy allows for a better evaluation of the opened pyriform sinuses and postcricoid space. Functional endoscopic evaluation of swallowing (FEES) can be useful to assess laryn-geal penetration and aspiration, but a modified barium swal-low (MBS) is better at assessing inferior extent of the disease, multifocality within the esophagus, and aspiration. A thorough metastatic workup is required, with special attention paid to paratracheal and upper mediastinal metastases.This site has the poorest survival outcomes of all head and neck subsites. There is no difference in survival when surgery is used as the primary modality of treatment followed by |
Surgery_Schwartz_4349 | Surgery_Schwartz | metastases.This site has the poorest survival outcomes of all head and neck subsites. There is no difference in survival when surgery is used as the primary modality of treatment followed by radio-therapy or chemoradiotherapy compared to primary radiother-apy or concurrent chemoradiotherapy followed by surgery.141 Concurrent chemoradiotherapy appears to be the modality of choice for laryngeal preservation; however, when surgical sal-vage is required, there is a low cure rate and increased wound complications.142 Early T1 lesions without clinical or radio-graphic evidence of adenopathy can be treated with primary radiotherapy, but this is relatively rare for this subsite due to a high rate of adenopathy and an advanced T stage at presentation.Surgical resection, typically in the salvage setting, involves a total laryngopharyngectomy typically with a circumferential defect or a very small strip of mucosa preserved in continuity with the cervical esophagus. A total thyroidectomy and | Surgery_Schwartz. metastases.This site has the poorest survival outcomes of all head and neck subsites. There is no difference in survival when surgery is used as the primary modality of treatment followed by radio-therapy or chemoradiotherapy compared to primary radiother-apy or concurrent chemoradiotherapy followed by surgery.141 Concurrent chemoradiotherapy appears to be the modality of choice for laryngeal preservation; however, when surgical sal-vage is required, there is a low cure rate and increased wound complications.142 Early T1 lesions without clinical or radio-graphic evidence of adenopathy can be treated with primary radiotherapy, but this is relatively rare for this subsite due to a high rate of adenopathy and an advanced T stage at presentation.Surgical resection, typically in the salvage setting, involves a total laryngopharyngectomy typically with a circumferential defect or a very small strip of mucosa preserved in continuity with the cervical esophagus. A total thyroidectomy and |
Surgery_Schwartz_4350 | Surgery_Schwartz | setting, involves a total laryngopharyngectomy typically with a circumferential defect or a very small strip of mucosa preserved in continuity with the cervical esophagus. A total thyroidectomy and cen-tral neck dissection (level VI) is simultaneously performed and removed en bloc with the specimen. Bilateral neck dissection of levels II to IV is indicated. Careful dissection of the central neck, and in some cases the upper mediastinum (level VII), is required to clear regional disease, and this is critical in prevent-ing a peristomal recurrence.Given the circumferential or near circumferential defect, reconstruction is required to prevent saliva from accumulating in the wound and to create a neopharynx. A pedicled pectoralis major flap sutured to the prevertebral fascia has been described, but advances in free flap reconstruction has popularized a num-ber of fasciocutaneous flaps for reconstruction of this defect, namely the radial forearm flap and the anterolateral thigh free | Surgery_Schwartz. setting, involves a total laryngopharyngectomy typically with a circumferential defect or a very small strip of mucosa preserved in continuity with the cervical esophagus. A total thyroidectomy and cen-tral neck dissection (level VI) is simultaneously performed and removed en bloc with the specimen. Bilateral neck dissection of levels II to IV is indicated. Careful dissection of the central neck, and in some cases the upper mediastinum (level VII), is required to clear regional disease, and this is critical in prevent-ing a peristomal recurrence.Given the circumferential or near circumferential defect, reconstruction is required to prevent saliva from accumulating in the wound and to create a neopharynx. A pedicled pectoralis major flap sutured to the prevertebral fascia has been described, but advances in free flap reconstruction has popularized a num-ber of fasciocutaneous flaps for reconstruction of this defect, namely the radial forearm flap and the anterolateral thigh free |
Surgery_Schwartz_4351 | Surgery_Schwartz | but advances in free flap reconstruction has popularized a num-ber of fasciocutaneous flaps for reconstruction of this defect, namely the radial forearm flap and the anterolateral thigh free flap.143-146 When total laryngopharyngoesophagectomy is required, a gastric pull-up may be performed for the pharyngeal reconstruction.Larynx Laryngeal carcinoma typical presents with a progres-sive voice complaint in a long-time smoker (Fig. 18-31). A thorough understanding of laryngeal anatomy is critical in the proper diagnosis, staging, and treatment of laryngeal cancers. The larynx is divided into the supraglottis, glottis, and subglottis as previously described (Fig. 18-32). The larynx starts superi-orly at the epiglottis and ends inferiorly at the inferior border of the cricoid cartilage of the larynx span from the epiglottis supe-riorly to the cricoid cartilage inferiorly. Laterally, it is separated from the hypopharynx by the aryepiglottic folds.The supraglottis includes all of the | Surgery_Schwartz. but advances in free flap reconstruction has popularized a num-ber of fasciocutaneous flaps for reconstruction of this defect, namely the radial forearm flap and the anterolateral thigh free flap.143-146 When total laryngopharyngoesophagectomy is required, a gastric pull-up may be performed for the pharyngeal reconstruction.Larynx Laryngeal carcinoma typical presents with a progres-sive voice complaint in a long-time smoker (Fig. 18-31). A thorough understanding of laryngeal anatomy is critical in the proper diagnosis, staging, and treatment of laryngeal cancers. The larynx is divided into the supraglottis, glottis, and subglottis as previously described (Fig. 18-32). The larynx starts superi-orly at the epiglottis and ends inferiorly at the inferior border of the cricoid cartilage of the larynx span from the epiglottis supe-riorly to the cricoid cartilage inferiorly. Laterally, it is separated from the hypopharynx by the aryepiglottic folds.The supraglottis includes all of the |
Surgery_Schwartz_4352 | Surgery_Schwartz | of the larynx span from the epiglottis supe-riorly to the cricoid cartilage inferiorly. Laterally, it is separated from the hypopharynx by the aryepiglottic folds.The supraglottis includes all of the laryngeal structures above the inferior half of the ventricle, and this includes the upper half of the ventricle, the false vocal cords, the arytenoids, the aryepiglottic folds, and the epiglottis. The membranes and cartilages of the larynx act as barriers to laryngeal spread: the thyroid and cricoid cartilage, conus elasticus, the quandrangular membrane, the ventricle, the hyoepiglottic ligament, thyrohyoid membrane, and cricothyroid membrane. Although the majority of tumors of the larynx are SCC, minor salivary glands, and their associated malignancies, can be found in the supraglot-tis and subglottis. Other rarer pathologies include granular cell EpiglottisNasopharynxOropharynxEustachiantube orificeSoft palateHyoid boneLarynxHypopharynxPalatine tonsilAdenoidThyroid | Surgery_Schwartz. of the larynx span from the epiglottis supe-riorly to the cricoid cartilage inferiorly. Laterally, it is separated from the hypopharynx by the aryepiglottic folds.The supraglottis includes all of the laryngeal structures above the inferior half of the ventricle, and this includes the upper half of the ventricle, the false vocal cords, the arytenoids, the aryepiglottic folds, and the epiglottis. The membranes and cartilages of the larynx act as barriers to laryngeal spread: the thyroid and cricoid cartilage, conus elasticus, the quandrangular membrane, the ventricle, the hyoepiglottic ligament, thyrohyoid membrane, and cricothyroid membrane. Although the majority of tumors of the larynx are SCC, minor salivary glands, and their associated malignancies, can be found in the supraglot-tis and subglottis. Other rarer pathologies include granular cell EpiglottisNasopharynxOropharynxEustachiantube orificeSoft palateHyoid boneLarynxHypopharynxPalatine tonsilAdenoidThyroid |
Surgery_Schwartz_4353 | Surgery_Schwartz | supraglot-tis and subglottis. Other rarer pathologies include granular cell EpiglottisNasopharynxOropharynxEustachiantube orificeSoft palateHyoid boneLarynxHypopharynxPalatine tonsilAdenoidThyroid glandCricoidcartilageFigure 18-30. Relationship of nasopharynx, oropharynx, and hypopharynx.Brunicardi_Ch18_p0613-p0660.indd 64001/03/19 5:24 PM 641DISORDERS OF THE HEAD AND NECKCHAPTER 18tumors and laryngeal framework tumors, typically arising from the cricoid, such as chondroma and chondrosarcoma.The larynx functions to (a) phonate, (b) protect the air-way during swallowing, and (c) maintain airway patency. This is a fine balance. For instance, if the glottic aperture is enlarged and/or supraglottic structures are excised, phonation and air-way protection suffer while airway patency is improved. It is therefore not surprising that patients with laryngeal tumors can present with dysphonia (hot potato voice in supraglottic tumors and hoarseness in glottic tumors), dysphagia, and airway | Surgery_Schwartz. supraglot-tis and subglottis. Other rarer pathologies include granular cell EpiglottisNasopharynxOropharynxEustachiantube orificeSoft palateHyoid boneLarynxHypopharynxPalatine tonsilAdenoidThyroid glandCricoidcartilageFigure 18-30. Relationship of nasopharynx, oropharynx, and hypopharynx.Brunicardi_Ch18_p0613-p0660.indd 64001/03/19 5:24 PM 641DISORDERS OF THE HEAD AND NECKCHAPTER 18tumors and laryngeal framework tumors, typically arising from the cricoid, such as chondroma and chondrosarcoma.The larynx functions to (a) phonate, (b) protect the air-way during swallowing, and (c) maintain airway patency. This is a fine balance. For instance, if the glottic aperture is enlarged and/or supraglottic structures are excised, phonation and air-way protection suffer while airway patency is improved. It is therefore not surprising that patients with laryngeal tumors can present with dysphonia (hot potato voice in supraglottic tumors and hoarseness in glottic tumors), dysphagia, and airway |
Surgery_Schwartz_4354 | Surgery_Schwartz | It is therefore not surprising that patients with laryngeal tumors can present with dysphonia (hot potato voice in supraglottic tumors and hoarseness in glottic tumors), dysphagia, and airway con-cerns. These patients can also present with dysphagia, weight loss, referred otalgia, and a neck mass. Vocal cord fixation can be a result of a mass effect from large obstructing masses, sec-ondary to direct extension into the paraglottic space or through direct invasion of the cricoarytenoid joint involving either the muscle or the recurrent laryngeal nerve (RLN). Although sub-glottic tumors represent <1% of laryngeal cancers, they can also present with vocal cord paralysis and/or airway compromise.Direct laryngoscopy is beneficial in the assessment of laryngeal tumors to assess the local extent of tumor spread. This is particularly important in assessing vallecula and base of tongue as there can be direct extension to the oropharynx. Simi-larly, glottic cancers can have subglottic | Surgery_Schwartz. It is therefore not surprising that patients with laryngeal tumors can present with dysphonia (hot potato voice in supraglottic tumors and hoarseness in glottic tumors), dysphagia, and airway con-cerns. These patients can also present with dysphagia, weight loss, referred otalgia, and a neck mass. Vocal cord fixation can be a result of a mass effect from large obstructing masses, sec-ondary to direct extension into the paraglottic space or through direct invasion of the cricoarytenoid joint involving either the muscle or the recurrent laryngeal nerve (RLN). Although sub-glottic tumors represent <1% of laryngeal cancers, they can also present with vocal cord paralysis and/or airway compromise.Direct laryngoscopy is beneficial in the assessment of laryngeal tumors to assess the local extent of tumor spread. This is particularly important in assessing vallecula and base of tongue as there can be direct extension to the oropharynx. Simi-larly, glottic cancers can have subglottic |
Surgery_Schwartz_4355 | Surgery_Schwartz | extent of tumor spread. This is particularly important in assessing vallecula and base of tongue as there can be direct extension to the oropharynx. Simi-larly, glottic cancers can have subglottic extension, which neces-sitates a wider radiation field and/or a more extensive resection. Esophagoscopy and bronchoscopy are also recommended to assess second primary tumors. Furthermore, when a laryngec-tomy is planned, the direct laryngoscopy provides information about the best possible site of entry into the pharynx. Entry can be achieved through (a) a suprahyoid pharyngotomy, (b) ) lat-eral pharyngotomy (lateral to the thyroid cartilage), or (c) infe-riorly through a postcricoid or hypopharyngeal pharyngotomy.Appropriate preoperative staging with a CT scan with contrast is critical in assessing cervical lymphadenopathy and extralaryngeal spread. Erosion or invasion of the thyroid and cri-coid cartilage can significantly impact outcomes and treatment as can extension into the | Surgery_Schwartz. extent of tumor spread. This is particularly important in assessing vallecula and base of tongue as there can be direct extension to the oropharynx. Simi-larly, glottic cancers can have subglottic extension, which neces-sitates a wider radiation field and/or a more extensive resection. Esophagoscopy and bronchoscopy are also recommended to assess second primary tumors. Furthermore, when a laryngec-tomy is planned, the direct laryngoscopy provides information about the best possible site of entry into the pharynx. Entry can be achieved through (a) a suprahyoid pharyngotomy, (b) ) lat-eral pharyngotomy (lateral to the thyroid cartilage), or (c) infe-riorly through a postcricoid or hypopharyngeal pharyngotomy.Appropriate preoperative staging with a CT scan with contrast is critical in assessing cervical lymphadenopathy and extralaryngeal spread. Erosion or invasion of the thyroid and cri-coid cartilage can significantly impact outcomes and treatment as can extension into the |
Surgery_Schwartz_4356 | Surgery_Schwartz | in assessing cervical lymphadenopathy and extralaryngeal spread. Erosion or invasion of the thyroid and cri-coid cartilage can significantly impact outcomes and treatment as can extension into the preepiglottic or paraglottic spaces. The supraglottic and subglottic sites are lymphatic rich, and bilateral lymphadenopathy is not uncommon, whereas the glottic site has relatively poor lymphatic drainage (1%–4% regional metasta-sis for isolated larynx cancer). The supraglottis drains through the neurovascular bundle to the thyrohyoid membrane, mainly draining to the upper and lateral cervical nodes (levels II–IV), whereas the glottis and subglottis drain through the cricothyroid membrane and can have spread to the prelaryngeal (Delphian nodes), paratracheal, and lower cervical nodes (levels IV and VI), although in these cases we still treat levels II to IV surgi-cally because of the significant occult nodes in this region.The primary management of laryngeal cancer depends on a variety of | Surgery_Schwartz. in assessing cervical lymphadenopathy and extralaryngeal spread. Erosion or invasion of the thyroid and cri-coid cartilage can significantly impact outcomes and treatment as can extension into the preepiglottic or paraglottic spaces. The supraglottic and subglottic sites are lymphatic rich, and bilateral lymphadenopathy is not uncommon, whereas the glottic site has relatively poor lymphatic drainage (1%–4% regional metasta-sis for isolated larynx cancer). The supraglottis drains through the neurovascular bundle to the thyrohyoid membrane, mainly draining to the upper and lateral cervical nodes (levels II–IV), whereas the glottis and subglottis drain through the cricothyroid membrane and can have spread to the prelaryngeal (Delphian nodes), paratracheal, and lower cervical nodes (levels IV and VI), although in these cases we still treat levels II to IV surgi-cally because of the significant occult nodes in this region.The primary management of laryngeal cancer depends on a variety of |
Surgery_Schwartz_4357 | Surgery_Schwartz | and VI), although in these cases we still treat levels II to IV surgi-cally because of the significant occult nodes in this region.The primary management of laryngeal cancer depends on a variety of factors, including tumor extent, patient comorbidi-ties, and surgeon/center experience. In general, similar to other subsites, early-stage disease can be treated with single modality treatment (surgery or radiotherapy) while advanced stage dis-ease is treated with at least two modalities, typically either sur-gery followed by radiotherapy (with or without chemotherapy) or concurrent chemoradiotherapy. Supraglottic and subglottic lesions are typically treated with primary concurrent chemo-radiotherapy in an attempt to preserve the organ; however, in patients where the primary functions of the larynx are not being fulfilled preoperatively (tracheotomy– and gastrostomy tube–dependent), primary surgical management with a total lar-yngectomy (Fig. 18-33) can be considered. The original trials | Surgery_Schwartz. and VI), although in these cases we still treat levels II to IV surgi-cally because of the significant occult nodes in this region.The primary management of laryngeal cancer depends on a variety of factors, including tumor extent, patient comorbidi-ties, and surgeon/center experience. In general, similar to other subsites, early-stage disease can be treated with single modality treatment (surgery or radiotherapy) while advanced stage dis-ease is treated with at least two modalities, typically either sur-gery followed by radiotherapy (with or without chemotherapy) or concurrent chemoradiotherapy. Supraglottic and subglottic lesions are typically treated with primary concurrent chemo-radiotherapy in an attempt to preserve the organ; however, in patients where the primary functions of the larynx are not being fulfilled preoperatively (tracheotomy– and gastrostomy tube–dependent), primary surgical management with a total lar-yngectomy (Fig. 18-33) can be considered. The original trials |
Surgery_Schwartz_4358 | Surgery_Schwartz | larynx are not being fulfilled preoperatively (tracheotomy– and gastrostomy tube–dependent), primary surgical management with a total lar-yngectomy (Fig. 18-33) can be considered. The original trials that popularized organ preservation techniques with concurrent chemoradiotherapy either excluded or had a very small sample size of large (T4) tumors.147,148 Similarly, advanced glottic can-cers (T3/T4a), even when there is no evidence of nodal disease or supraglottic tumors of all stages, have superior survival out-comes when surgery is used as the primary treatment modality.149,150 This is particularly true for tumors that extend beyond the endolarynx or with cartilage destruction, for which total Figure 18-31. Endoscopic view of a laryngeal squamous carcinoma.Figure 18-32. Total laryngectomy specimen featuring a locally invasive advanced stage glottic squamous carcinoma.Brunicardi_Ch18_p0613-p0660.indd 64101/03/19 5:24 PM 642SPECIFIC CONSIDERATIONSPART IIlaryngectomy followed | Surgery_Schwartz. larynx are not being fulfilled preoperatively (tracheotomy– and gastrostomy tube–dependent), primary surgical management with a total lar-yngectomy (Fig. 18-33) can be considered. The original trials that popularized organ preservation techniques with concurrent chemoradiotherapy either excluded or had a very small sample size of large (T4) tumors.147,148 Similarly, advanced glottic can-cers (T3/T4a), even when there is no evidence of nodal disease or supraglottic tumors of all stages, have superior survival out-comes when surgery is used as the primary treatment modality.149,150 This is particularly true for tumors that extend beyond the endolarynx or with cartilage destruction, for which total Figure 18-31. Endoscopic view of a laryngeal squamous carcinoma.Figure 18-32. Total laryngectomy specimen featuring a locally invasive advanced stage glottic squamous carcinoma.Brunicardi_Ch18_p0613-p0660.indd 64101/03/19 5:24 PM 642SPECIFIC CONSIDERATIONSPART IIlaryngectomy followed |
Surgery_Schwartz_4359 | Surgery_Schwartz | specimen featuring a locally invasive advanced stage glottic squamous carcinoma.Brunicardi_Ch18_p0613-p0660.indd 64101/03/19 5:24 PM 642SPECIFIC CONSIDERATIONSPART IIlaryngectomy followed by postoperative radiotherapy continues to be the standard of care. When primary chemoradiotherapy is used, surgical salvage is available if there is treatment failure or recurrent disease.The early glottic and supraglottic lesions can be safely treated with CO2 laser transoral microlaryngoscopic resection with excellent oncologic outcomes and laryngeal preservation rates.151,152 Patients with limited involvement of the arytenoid or anterior commissure are the best candidates for a good posttreat-ment vocal quality result with this approach. One of the benefits of this approach is that it does not burn any bridges to more inva-sive treatment. Often, multiple procedures are required to control the disease. Nonetheless, for early stage cancers of the glottis and the supraglottis, radiation therapy | Surgery_Schwartz. specimen featuring a locally invasive advanced stage glottic squamous carcinoma.Brunicardi_Ch18_p0613-p0660.indd 64101/03/19 5:24 PM 642SPECIFIC CONSIDERATIONSPART IIlaryngectomy followed by postoperative radiotherapy continues to be the standard of care. When primary chemoradiotherapy is used, surgical salvage is available if there is treatment failure or recurrent disease.The early glottic and supraglottic lesions can be safely treated with CO2 laser transoral microlaryngoscopic resection with excellent oncologic outcomes and laryngeal preservation rates.151,152 Patients with limited involvement of the arytenoid or anterior commissure are the best candidates for a good posttreat-ment vocal quality result with this approach. One of the benefits of this approach is that it does not burn any bridges to more inva-sive treatment. Often, multiple procedures are required to control the disease. Nonetheless, for early stage cancers of the glottis and the supraglottis, radiation therapy |
Surgery_Schwartz_4360 | Surgery_Schwartz | any bridges to more inva-sive treatment. Often, multiple procedures are required to control the disease. Nonetheless, for early stage cancers of the glottis and the supraglottis, radiation therapy is equally as effective as surgery in controlling disease with excellent voice outcomes.Laryngeal Preservation Techniques Beyond CO2 laser tran-soral microlaryngoscopic resection for the most early of lesions, more advanced open laryngeal preservation techniques have been developed for the resection of select, moderately advanced supraglottic and glottic tumors. These techniques can be divided into vertical and horizontal partial laryngeal procedures.Vertical partial larygnectomy (VPL) (Fig. 18-34) involves a midline thyrotomy followed by dissection of the inner peri-chondrium off of the thyroid cartilage with resection of the entire true cord and a portion of the false cords, followed by reconstruction with pedicle strap muscles and bipedicled outer perichondrial flaps. A temporoparietal | Surgery_Schwartz. any bridges to more inva-sive treatment. Often, multiple procedures are required to control the disease. Nonetheless, for early stage cancers of the glottis and the supraglottis, radiation therapy is equally as effective as surgery in controlling disease with excellent voice outcomes.Laryngeal Preservation Techniques Beyond CO2 laser tran-soral microlaryngoscopic resection for the most early of lesions, more advanced open laryngeal preservation techniques have been developed for the resection of select, moderately advanced supraglottic and glottic tumors. These techniques can be divided into vertical and horizontal partial laryngeal procedures.Vertical partial larygnectomy (VPL) (Fig. 18-34) involves a midline thyrotomy followed by dissection of the inner peri-chondrium off of the thyroid cartilage with resection of the entire true cord and a portion of the false cords, followed by reconstruction with pedicle strap muscles and bipedicled outer perichondrial flaps. A temporoparietal |
Surgery_Schwartz_4361 | Surgery_Schwartz | cartilage with resection of the entire true cord and a portion of the false cords, followed by reconstruction with pedicle strap muscles and bipedicled outer perichondrial flaps. A temporoparietal fascial free flap has also been used to reconstruct these defects with excellent voice outcomes.153 This can be extended to include a frontal verti-cal VPL where the excision crosses the midline as far laterally as to leave only the posterior commissure and one functional cricoarytenoid unit. This procedure is best reserved for recurrent glottic T1/T2 lesions involving only one vocal cord (although anterior commissure involvement is not a contraindication), <5 mm sublottic extension, with a mobile cord, and no cricoid cartilage or extralaryngeal extension. This technique leads to excellent locoregional control with improvements in voice related quality of life with advanced reconstructive techniques.153Supraglottic and supracricoid partial laryngectomies are horizontally oriented | Surgery_Schwartz. cartilage with resection of the entire true cord and a portion of the false cords, followed by reconstruction with pedicle strap muscles and bipedicled outer perichondrial flaps. A temporoparietal fascial free flap has also been used to reconstruct these defects with excellent voice outcomes.153 This can be extended to include a frontal verti-cal VPL where the excision crosses the midline as far laterally as to leave only the posterior commissure and one functional cricoarytenoid unit. This procedure is best reserved for recurrent glottic T1/T2 lesions involving only one vocal cord (although anterior commissure involvement is not a contraindication), <5 mm sublottic extension, with a mobile cord, and no cricoid cartilage or extralaryngeal extension. This technique leads to excellent locoregional control with improvements in voice related quality of life with advanced reconstructive techniques.153Supraglottic and supracricoid partial laryngectomies are horizontally oriented |
Surgery_Schwartz_4362 | Surgery_Schwartz | locoregional control with improvements in voice related quality of life with advanced reconstructive techniques.153Supraglottic and supracricoid partial laryngectomies are horizontally oriented resections. In a supraglottic laryngectomy, a laryngectomy is performed below the hyoid and includes the upper portion of the thyroid cartilage while preserving a lower portion approximately the height of the cricoid cartilage. This is reserved for lesions not involving the vocal cords, false cords, or the arytenoids. Cartilage invasion and extensive base of tongue involvement are contraindications. Most lesions amenable for resection using this procedure are typically small enough that a laser or TORS procedure is adequate for resection, and there-fore this procedure is rarely performed. For T3 glottic lesions without preepiglottic space or cricoarytenoid joint involvement, a supracricoid laryngectomy with a cricohyoidopexy or crico-hyoidoepiglottopexy (CHEP) are options. A single | Surgery_Schwartz. locoregional control with improvements in voice related quality of life with advanced reconstructive techniques.153Supraglottic and supracricoid partial laryngectomies are horizontally oriented resections. In a supraglottic laryngectomy, a laryngectomy is performed below the hyoid and includes the upper portion of the thyroid cartilage while preserving a lower portion approximately the height of the cricoid cartilage. This is reserved for lesions not involving the vocal cords, false cords, or the arytenoids. Cartilage invasion and extensive base of tongue involvement are contraindications. Most lesions amenable for resection using this procedure are typically small enough that a laser or TORS procedure is adequate for resection, and there-fore this procedure is rarely performed. For T3 glottic lesions without preepiglottic space or cricoarytenoid joint involvement, a supracricoid laryngectomy with a cricohyoidopexy or crico-hyoidoepiglottopexy (CHEP) are options. A single |
Surgery_Schwartz_4363 | Surgery_Schwartz | For T3 glottic lesions without preepiglottic space or cricoarytenoid joint involvement, a supracricoid laryngectomy with a cricohyoidopexy or crico-hyoidoepiglottopexy (CHEP) are options. A single cricoaryte-noid unit is preserved to allow for phonation through apposition with the remnant epiglottis or base of tongue. The procedure is associated with excellent oncologic outcomes, tracheostomy decannulation rates, and swallowing function.154 Phonation is reasonable after this procedure but can be characterized as breathy and coarse. Many surgeons prefer not to decannulate patients until the patient has had a significant period of time with good oral intake to allow for pulmonary toilet given the high initial rate of aspiration with this procedure.All partial laryngeal procedures are associated with a high risk of aspiration. Therefore, patients should have excellent pul-monary reserve through pulmonary function tests. When this is not possible, a simple measure includes whether | Surgery_Schwartz. For T3 glottic lesions without preepiglottic space or cricoarytenoid joint involvement, a supracricoid laryngectomy with a cricohyoidopexy or crico-hyoidoepiglottopexy (CHEP) are options. A single cricoaryte-noid unit is preserved to allow for phonation through apposition with the remnant epiglottis or base of tongue. The procedure is associated with excellent oncologic outcomes, tracheostomy decannulation rates, and swallowing function.154 Phonation is reasonable after this procedure but can be characterized as breathy and coarse. Many surgeons prefer not to decannulate patients until the patient has had a significant period of time with good oral intake to allow for pulmonary toilet given the high initial rate of aspiration with this procedure.All partial laryngeal procedures are associated with a high risk of aspiration. Therefore, patients should have excellent pul-monary reserve through pulmonary function tests. When this is not possible, a simple measure includes whether |
Surgery_Schwartz_4364 | Surgery_Schwartz | associated with a high risk of aspiration. Therefore, patients should have excellent pul-monary reserve through pulmonary function tests. When this is not possible, a simple measure includes whether patients can climb two flights of stairs without stopping.PerichondriumUnilaterallesionThyroidcartilageFigure 18-33. Example of the resection of a vertical partial laryn-gectomy for an early stage glottic carcinoma.Angle of mandibleOhngren'slineMaxillarysinusMedial canthusFigure 18-34. Example of the Ohngren’s line and the relationship to the maxilla.Brunicardi_Ch18_p0613-p0660.indd 64201/03/19 5:24 PM 643DISORDERS OF THE HEAD AND NECKCHAPTER 18Speech and Swallowing Rehabilitation Speech and lan-guage pathology (SLP) assessment is critical in the manage-ment of patients with laryngeal and hypopharyngeal cancer. It is a critical part of the preoperative assessment and counseling and postoperative therapy. In the elderly larynx cancer popula-tion, Starmer et al demonstrated that SLP | Surgery_Schwartz. associated with a high risk of aspiration. Therefore, patients should have excellent pul-monary reserve through pulmonary function tests. When this is not possible, a simple measure includes whether patients can climb two flights of stairs without stopping.PerichondriumUnilaterallesionThyroidcartilageFigure 18-33. Example of the resection of a vertical partial laryn-gectomy for an early stage glottic carcinoma.Angle of mandibleOhngren'slineMaxillarysinusMedial canthusFigure 18-34. Example of the Ohngren’s line and the relationship to the maxilla.Brunicardi_Ch18_p0613-p0660.indd 64201/03/19 5:24 PM 643DISORDERS OF THE HEAD AND NECKCHAPTER 18Speech and Swallowing Rehabilitation Speech and lan-guage pathology (SLP) assessment is critical in the manage-ment of patients with laryngeal and hypopharyngeal cancer. It is a critical part of the preoperative assessment and counseling and postoperative therapy. In the elderly larynx cancer popula-tion, Starmer et al demonstrated that SLP |
Surgery_Schwartz_4365 | Surgery_Schwartz | and hypopharyngeal cancer. It is a critical part of the preoperative assessment and counseling and postoperative therapy. In the elderly larynx cancer popula-tion, Starmer et al demonstrated that SLP care is underutilized and is largely reserved for select patients in anticipation of total laryngectomy or after the onset of impaired airway and swal-lowing function. SLP care was, however, strongly associated with improved outcomes (lower rates of dysphagia, stricture, weight loss, and pneumonia).155SLP often discusses with the patient speech rehabilita-tion options after total laryngectomy, which include esophageal speech, tracheoesophageal puncture, and use of an electrolar-ynx. Esophageal speech is produced by actively swallowing and releasing air from the esophagus, resulting in vibrations of the esophageal walls and pharynx that can then be articulated into words. This requires a very motivated patient, and unfor-tunately, <20% of postlaryngectomy patients develop fluent esophageal | Surgery_Schwartz. and hypopharyngeal cancer. It is a critical part of the preoperative assessment and counseling and postoperative therapy. In the elderly larynx cancer popula-tion, Starmer et al demonstrated that SLP care is underutilized and is largely reserved for select patients in anticipation of total laryngectomy or after the onset of impaired airway and swal-lowing function. SLP care was, however, strongly associated with improved outcomes (lower rates of dysphagia, stricture, weight loss, and pneumonia).155SLP often discusses with the patient speech rehabilita-tion options after total laryngectomy, which include esophageal speech, tracheoesophageal puncture, and use of an electrolar-ynx. Esophageal speech is produced by actively swallowing and releasing air from the esophagus, resulting in vibrations of the esophageal walls and pharynx that can then be articulated into words. This requires a very motivated patient, and unfor-tunately, <20% of postlaryngectomy patients develop fluent esophageal |
Surgery_Schwartz_4366 | Surgery_Schwartz | of the esophageal walls and pharynx that can then be articulated into words. This requires a very motivated patient, and unfor-tunately, <20% of postlaryngectomy patients develop fluent esophageal speech.The electrolarynx is a device that creates vibratory elec-tric type sounds when held against the neck or cheek that the patient can articulate into speech. This device is typically used in the postoperative inpatient setting, but it can also be used by patients who are not able to create esophageal speech.The ultimate speech rehabilitation for patients with laryn-gectomy is a tracheoesophageal puncture (TEP) with insertion of a voice prosthesis. This prosthesis is a one-way valve that allows air from the trachea to enter the upper esophagus while preventing retrograde passage of food or saliva into the trachea. Patients who undergo placement of a tracheoesophageal punc-ture have a success rate of >90% in achieving functional speech. Many surgeons do not like to place a TEP at the time | Surgery_Schwartz. of the esophageal walls and pharynx that can then be articulated into words. This requires a very motivated patient, and unfor-tunately, <20% of postlaryngectomy patients develop fluent esophageal speech.The electrolarynx is a device that creates vibratory elec-tric type sounds when held against the neck or cheek that the patient can articulate into speech. This device is typically used in the postoperative inpatient setting, but it can also be used by patients who are not able to create esophageal speech.The ultimate speech rehabilitation for patients with laryn-gectomy is a tracheoesophageal puncture (TEP) with insertion of a voice prosthesis. This prosthesis is a one-way valve that allows air from the trachea to enter the upper esophagus while preventing retrograde passage of food or saliva into the trachea. Patients who undergo placement of a tracheoesophageal punc-ture have a success rate of >90% in achieving functional speech. Many surgeons do not like to place a TEP at the time |
Surgery_Schwartz_4367 | Surgery_Schwartz | into the trachea. Patients who undergo placement of a tracheoesophageal punc-ture have a success rate of >90% in achieving functional speech. Many surgeons do not like to place a TEP at the time of the primary laryngectomy, particularly in the salvage setting after radiotherapy due to wound complication concerns. However, primary and secondary TEP patients experience similarly high complication rates, and the extent of the pharyngeal reconstruc-tion rather than preoperative exposure to radiotherapy appear to be more important factors in selection of TEP timing.156 Free flap patients used their TEP more commonly for primary com-munication after secondary versus primary TEP.Postoperative swallowing rehabilitation is another impor-tant task performed by SLPs. Modified barium swallows where the consistency and amount of food provided is varied to mini-mize aspiration can be critical particularly in the management of patients with partial laryngeal procedures. This is performed under | Surgery_Schwartz. into the trachea. Patients who undergo placement of a tracheoesophageal punc-ture have a success rate of >90% in achieving functional speech. Many surgeons do not like to place a TEP at the time of the primary laryngectomy, particularly in the salvage setting after radiotherapy due to wound complication concerns. However, primary and secondary TEP patients experience similarly high complication rates, and the extent of the pharyngeal reconstruc-tion rather than preoperative exposure to radiotherapy appear to be more important factors in selection of TEP timing.156 Free flap patients used their TEP more commonly for primary com-munication after secondary versus primary TEP.Postoperative swallowing rehabilitation is another impor-tant task performed by SLPs. Modified barium swallows where the consistency and amount of food provided is varied to mini-mize aspiration can be critical particularly in the management of patients with partial laryngeal procedures. This is performed under |
Surgery_Schwartz_4368 | Surgery_Schwartz | the consistency and amount of food provided is varied to mini-mize aspiration can be critical particularly in the management of patients with partial laryngeal procedures. This is performed under fluorosocopy in the radiology suite to allow for the assess-ment of all phases of swallowing. A more limited examination in FEES utilizes the fiberoptic nasolaryngoscope to visualize the larynx during swallow and directly visualize whether there is any laryngeal penetration.Unknown Primary Tumors Patients with cervical nodal metas-tases confirmed to be carcinoma without clinical or radiologic evidence of an upper aerodigestive tract primary tumor are referred to as having carcinoma of unknown primary (CUP). CUP comprise 2% to 5% of all head and neck cancers, although the true incidence is probably lower given advances in surgical visualization and radiological imaging to identify the primary site.157-159 Recently, there has been a rise in CUP likely related to the increase in HPV-associated | Surgery_Schwartz. the consistency and amount of food provided is varied to mini-mize aspiration can be critical particularly in the management of patients with partial laryngeal procedures. This is performed under fluorosocopy in the radiology suite to allow for the assess-ment of all phases of swallowing. A more limited examination in FEES utilizes the fiberoptic nasolaryngoscope to visualize the larynx during swallow and directly visualize whether there is any laryngeal penetration.Unknown Primary Tumors Patients with cervical nodal metas-tases confirmed to be carcinoma without clinical or radiologic evidence of an upper aerodigestive tract primary tumor are referred to as having carcinoma of unknown primary (CUP). CUP comprise 2% to 5% of all head and neck cancers, although the true incidence is probably lower given advances in surgical visualization and radiological imaging to identify the primary site.157-159 Recently, there has been a rise in CUP likely related to the increase in HPV-associated |
Surgery_Schwartz_4369 | Surgery_Schwartz | lower given advances in surgical visualization and radiological imaging to identify the primary site.157-159 Recently, there has been a rise in CUP likely related to the increase in HPV-associated oropharyngeal cancer, although CUP could also be from a primary thyroid or skin malignancy.160 After a thorough history and physical examination including fiberoptic nasolaryngoscopy, an FNA biopsy is used to confirm carcinoma in the cervical metastases. This is preferred over an open biopsy to avoid the risk of tumor spillage, challeng-ing revision surgery secondary to disruption of fascial planes, and increased risk of recurrence and distant metastases.161 If the primary is not identified on physical examination, patients should undergo a PET-CT scan. A recent systematic review of 7 studies (246 patients) demonstrates an overall sensitivity of 44% and specificity of 97% with this technique, which can often detect tumors >1 cm in size.162 This should be followed by thorough diagnostic | Surgery_Schwartz. lower given advances in surgical visualization and radiological imaging to identify the primary site.157-159 Recently, there has been a rise in CUP likely related to the increase in HPV-associated oropharyngeal cancer, although CUP could also be from a primary thyroid or skin malignancy.160 After a thorough history and physical examination including fiberoptic nasolaryngoscopy, an FNA biopsy is used to confirm carcinoma in the cervical metastases. This is preferred over an open biopsy to avoid the risk of tumor spillage, challeng-ing revision surgery secondary to disruption of fascial planes, and increased risk of recurrence and distant metastases.161 If the primary is not identified on physical examination, patients should undergo a PET-CT scan. A recent systematic review of 7 studies (246 patients) demonstrates an overall sensitivity of 44% and specificity of 97% with this technique, which can often detect tumors >1 cm in size.162 This should be followed by thorough diagnostic |
Surgery_Schwartz_4370 | Surgery_Schwartz | (246 patients) demonstrates an overall sensitivity of 44% and specificity of 97% with this technique, which can often detect tumors >1 cm in size.162 This should be followed by thorough diagnostic operative endoscopy (nasopharyngos-copy, direct laryngoscopy, esophagoscopy, and bronchoscopy). Operative manipulation of the tissues in the upper aerodiges-tive tract specifically with biopsy may lead to false positive results on the PET-CT scan, and therefore PET-CT should be performed before endoscopy. Furthermore, having the PET-CT results prior to operative endoscopy allows the surgeon to focus on specific high-risk sites for biopsy, particularly as it relates to the base of tongue.163 When the primary site is not evident, bilat-eral tonsillectomies and bilateral base of tongue biopsies can be performed to try to identify the primary site. Patients in whom a primary is identified proceed to receive appropriate treatment, and if radiotherapy is part of this treatment regimen, a more | Surgery_Schwartz. (246 patients) demonstrates an overall sensitivity of 44% and specificity of 97% with this technique, which can often detect tumors >1 cm in size.162 This should be followed by thorough diagnostic operative endoscopy (nasopharyngos-copy, direct laryngoscopy, esophagoscopy, and bronchoscopy). Operative manipulation of the tissues in the upper aerodiges-tive tract specifically with biopsy may lead to false positive results on the PET-CT scan, and therefore PET-CT should be performed before endoscopy. Furthermore, having the PET-CT results prior to operative endoscopy allows the surgeon to focus on specific high-risk sites for biopsy, particularly as it relates to the base of tongue.163 When the primary site is not evident, bilat-eral tonsillectomies and bilateral base of tongue biopsies can be performed to try to identify the primary site. Patients in whom a primary is identified proceed to receive appropriate treatment, and if radiotherapy is part of this treatment regimen, a more |
Surgery_Schwartz_4371 | Surgery_Schwartz | can be performed to try to identify the primary site. Patients in whom a primary is identified proceed to receive appropriate treatment, and if radiotherapy is part of this treatment regimen, a more limited radiation field is administered, highlighting the impor-tance of identifying a primary site. When the primary site is not identified, primary chemoradiotherapy is advocated, treating all of the mucosal sources of the upper aerodigestive tract at risk (from nasopharynx to hypopharynx) and the cervical regional basin bilaterally. For patients with advanced neck disease (N2a or greater) or with persistent lymphadenopathy after radiation, a neck dissection may be necessary. In the preradiation setting, a neck dissection is preferred over radiotherapy for patients with N1 disease, according to the NCCN guidelines, because some of these patients will be upstaged, ECE is not accurately diagnosed on imaging alone, and because some patients without ECE and a pathologically N1 node benefit | Surgery_Schwartz. can be performed to try to identify the primary site. Patients in whom a primary is identified proceed to receive appropriate treatment, and if radiotherapy is part of this treatment regimen, a more limited radiation field is administered, highlighting the impor-tance of identifying a primary site. When the primary site is not identified, primary chemoradiotherapy is advocated, treating all of the mucosal sources of the upper aerodigestive tract at risk (from nasopharynx to hypopharynx) and the cervical regional basin bilaterally. For patients with advanced neck disease (N2a or greater) or with persistent lymphadenopathy after radiation, a neck dissection may be necessary. In the preradiation setting, a neck dissection is preferred over radiotherapy for patients with N1 disease, according to the NCCN guidelines, because some of these patients will be upstaged, ECE is not accurately diagnosed on imaging alone, and because some patients without ECE and a pathologically N1 node benefit |
Surgery_Schwartz_4372 | Surgery_Schwartz | to the NCCN guidelines, because some of these patients will be upstaged, ECE is not accurately diagnosed on imaging alone, and because some patients without ECE and a pathologically N1 node benefit from radiation alone without chemotherapy.106,164 The additional prognostic information pro-vided by a neck dissection can significantly impact treatment algorithms and is also associated with lower morbidity com-pared to postoperative neck dissection.Nose and Paranasal SinusesCancers of the nasal cavity and paranasal sinuses are exceed-ingly rare, and pathology in this anatomic subsite is dominated by infectious and inflammatory sources as previously discussed in the “Sinonasal Inflammatory Disease” section of this chapter. Malignant pathology at this site is often diagnosed after failed repeated treatment of suspected benign inflammatory sinona-sal pathology. Concerning preoperative imaging findings (uni-lateral disease; extensive disease; bony, orbital or intracranial invasion) and | Surgery_Schwartz. to the NCCN guidelines, because some of these patients will be upstaged, ECE is not accurately diagnosed on imaging alone, and because some patients without ECE and a pathologically N1 node benefit from radiation alone without chemotherapy.106,164 The additional prognostic information pro-vided by a neck dissection can significantly impact treatment algorithms and is also associated with lower morbidity com-pared to postoperative neck dissection.Nose and Paranasal SinusesCancers of the nasal cavity and paranasal sinuses are exceed-ingly rare, and pathology in this anatomic subsite is dominated by infectious and inflammatory sources as previously discussed in the “Sinonasal Inflammatory Disease” section of this chapter. Malignant pathology at this site is often diagnosed after failed repeated treatment of suspected benign inflammatory sinona-sal pathology. Concerning preoperative imaging findings (uni-lateral disease; extensive disease; bony, orbital or intracranial invasion) and |
Surgery_Schwartz_4373 | Surgery_Schwartz | repeated treatment of suspected benign inflammatory sinona-sal pathology. Concerning preoperative imaging findings (uni-lateral disease; extensive disease; bony, orbital or intracranial invasion) and unusual clinical features may raise concerns about malignancy, and in these cases referral to a tertiary head and neck oncology center is preferred. A concerning history is one that involves a slow progression and worsening of symptoms, which may include nasal obstruction, facial pain, headache, epistaxis, and facial numbness. Most tumors at this site pres-ent with advanced stage given the inevitable delay in diagnosis. Numbness in the V2 distribution suggests invasion of pterygo-palatine fossa, and V3 distribution numbness can be an indi-cation of extension to the infratemporal fossa and skull base invasion to foramen ovale. Proptosis, epiphora, diploplia, and change in vision (typically starting with loss of color vision) are Brunicardi_Ch18_p0613-p0660.indd 64301/03/19 5:24 PM | Surgery_Schwartz. repeated treatment of suspected benign inflammatory sinona-sal pathology. Concerning preoperative imaging findings (uni-lateral disease; extensive disease; bony, orbital or intracranial invasion) and unusual clinical features may raise concerns about malignancy, and in these cases referral to a tertiary head and neck oncology center is preferred. A concerning history is one that involves a slow progression and worsening of symptoms, which may include nasal obstruction, facial pain, headache, epistaxis, and facial numbness. Most tumors at this site pres-ent with advanced stage given the inevitable delay in diagnosis. Numbness in the V2 distribution suggests invasion of pterygo-palatine fossa, and V3 distribution numbness can be an indi-cation of extension to the infratemporal fossa and skull base invasion to foramen ovale. Proptosis, epiphora, diploplia, and change in vision (typically starting with loss of color vision) are Brunicardi_Ch18_p0613-p0660.indd 64301/03/19 5:24 PM |
Surgery_Schwartz_4374 | Surgery_Schwartz | skull base invasion to foramen ovale. Proptosis, epiphora, diploplia, and change in vision (typically starting with loss of color vision) are Brunicardi_Ch18_p0613-p0660.indd 64301/03/19 5:24 PM 644SPECIFIC CONSIDERATIONSPART IIall signs of advanced orbital invasion. Maxillary sinus tumors, the most common site for cancers of this site, can be prognos-ticated simply using Ohgren’s line (Fig. 18-35), an imaginary line from medial canthus to the angle of the mandible, which divides maxillary sinus into anterior-inferior and posterior-superior parts. Tumors from the anterior-inferior are more prognostically favorable.Although the most common pathology at this site continues to be squamous cell carcinoma, a brief discussion of other histo-pathology is warranted given significant variety, prognostic, and treatment-related differences between these at this subsite. Benign pathology at this site includes inverted papilloma, hemangiomas, hemangiopericytomas, angiofibromas, minor salivary | Surgery_Schwartz. skull base invasion to foramen ovale. Proptosis, epiphora, diploplia, and change in vision (typically starting with loss of color vision) are Brunicardi_Ch18_p0613-p0660.indd 64301/03/19 5:24 PM 644SPECIFIC CONSIDERATIONSPART IIall signs of advanced orbital invasion. Maxillary sinus tumors, the most common site for cancers of this site, can be prognos-ticated simply using Ohgren’s line (Fig. 18-35), an imaginary line from medial canthus to the angle of the mandible, which divides maxillary sinus into anterior-inferior and posterior-superior parts. Tumors from the anterior-inferior are more prognostically favorable.Although the most common pathology at this site continues to be squamous cell carcinoma, a brief discussion of other histo-pathology is warranted given significant variety, prognostic, and treatment-related differences between these at this subsite. Benign pathology at this site includes inverted papilloma, hemangiomas, hemangiopericytomas, angiofibromas, minor salivary |
Surgery_Schwartz_4375 | Surgery_Schwartz | prognostic, and treatment-related differences between these at this subsite. Benign pathology at this site includes inverted papilloma, hemangiomas, hemangiopericytomas, angiofibromas, minor salivary tumors, and benign fibrous histiocytomas. Fibro-osseous and osseous lesions, such as fibrous dysplasias, ossifying fibromas, osteo-mas, and myxomas, can also arise in this region. Additionally, encephaloceles and meningo-encephaloceles with herniation of intracranial content into the nasal cavity can present as sinonasal lesions; therefore, imaging, typically with an MRI, is warranted before biopsy of any sinonasal mass to prevent an iatrogenic CSF leak. In the evaluation of sinonasal malignant pathology, both CT and MRI are required because they provide complimentary information. MRI provides improved skull base, intracranial, and orbital invasion assessment, while CT provides better assessment of bony anatomy and invasion.Beyond squamous cell carcinoma, the next two most com-mon | Surgery_Schwartz. prognostic, and treatment-related differences between these at this subsite. Benign pathology at this site includes inverted papilloma, hemangiomas, hemangiopericytomas, angiofibromas, minor salivary tumors, and benign fibrous histiocytomas. Fibro-osseous and osseous lesions, such as fibrous dysplasias, ossifying fibromas, osteo-mas, and myxomas, can also arise in this region. Additionally, encephaloceles and meningo-encephaloceles with herniation of intracranial content into the nasal cavity can present as sinonasal lesions; therefore, imaging, typically with an MRI, is warranted before biopsy of any sinonasal mass to prevent an iatrogenic CSF leak. In the evaluation of sinonasal malignant pathology, both CT and MRI are required because they provide complimentary information. MRI provides improved skull base, intracranial, and orbital invasion assessment, while CT provides better assessment of bony anatomy and invasion.Beyond squamous cell carcinoma, the next two most com-mon |
Surgery_Schwartz_4376 | Surgery_Schwartz | provides improved skull base, intracranial, and orbital invasion assessment, while CT provides better assessment of bony anatomy and invasion.Beyond squamous cell carcinoma, the next two most com-mon malignancies at this site include adenoid cystic carcinoma and adenocarcinoma. Other pathologies include sinonasal undif-ferentiated carcinoma (SNUC), mucosal melanoma, lymphoma, esthesioneuroblastoma (previously known as olfactory neuro-blastoma), rhabdomyosarcoma, and angiosarcoma. Unlike other head and neck cancers, metastases to the regional lymphatic basis are extremely rare, and rarely will patients require or receive pri-mary or adjuvant treatment to the neck unless there is clinical or radiographic evidence of neck disease (approximately 15%).165The standard treatment for malignant tumors of the para-nasal sinuses is driven by the primary pathology; however, for most pathology, including SCC, the standard of care includes surgical resection followed by adjuvant radiotherapy.166 | Surgery_Schwartz. provides improved skull base, intracranial, and orbital invasion assessment, while CT provides better assessment of bony anatomy and invasion.Beyond squamous cell carcinoma, the next two most com-mon malignancies at this site include adenoid cystic carcinoma and adenocarcinoma. Other pathologies include sinonasal undif-ferentiated carcinoma (SNUC), mucosal melanoma, lymphoma, esthesioneuroblastoma (previously known as olfactory neuro-blastoma), rhabdomyosarcoma, and angiosarcoma. Unlike other head and neck cancers, metastases to the regional lymphatic basis are extremely rare, and rarely will patients require or receive pri-mary or adjuvant treatment to the neck unless there is clinical or radiographic evidence of neck disease (approximately 15%).165The standard treatment for malignant tumors of the para-nasal sinuses is driven by the primary pathology; however, for most pathology, including SCC, the standard of care includes surgical resection followed by adjuvant radiotherapy.166 |
Surgery_Schwartz_4377 | Surgery_Schwartz | tumors of the para-nasal sinuses is driven by the primary pathology; however, for most pathology, including SCC, the standard of care includes surgical resection followed by adjuvant radiotherapy.166 Advances in EEAs has led to a shift in management of these tumors with minimally invasive approaches that are associated with significantly lower complication and morbidity rates with comparable oncologic outcomes.167,168 Open approaches are, however, indicated when there is tumor abutting the anterior wall of the frontal sinus, anterior extension into nasal bones, anterior maxillary wall invasion, facial skin or soft tissue inva-sion, dural involvement above the orbit or periorbital invasion, tumors with significant inratemporal fossa invasion, and exten-sion into the oral cavity, including the hard palate or the floor of the maxillary sinus. Many tumors can be treated with an endo-scopic approach such a medial maxillectomy when the tumor arises from the medial wall of the maxilla. | Surgery_Schwartz. tumors of the para-nasal sinuses is driven by the primary pathology; however, for most pathology, including SCC, the standard of care includes surgical resection followed by adjuvant radiotherapy.166 Advances in EEAs has led to a shift in management of these tumors with minimally invasive approaches that are associated with significantly lower complication and morbidity rates with comparable oncologic outcomes.167,168 Open approaches are, however, indicated when there is tumor abutting the anterior wall of the frontal sinus, anterior extension into nasal bones, anterior maxillary wall invasion, facial skin or soft tissue inva-sion, dural involvement above the orbit or periorbital invasion, tumors with significant inratemporal fossa invasion, and exten-sion into the oral cavity, including the hard palate or the floor of the maxillary sinus. Many tumors can be treated with an endo-scopic approach such a medial maxillectomy when the tumor arises from the medial wall of the maxilla. |
Surgery_Schwartz_4378 | Surgery_Schwartz | the hard palate or the floor of the maxillary sinus. Many tumors can be treated with an endo-scopic approach such a medial maxillectomy when the tumor arises from the medial wall of the maxilla. Multidisciplinary assessment and treatment should include a skull base tumor board discussion with a head and neck oncologist/surgeon, a neurosurgeon, opthalmologist including oculoplastic surgeons, prosthodontists, and reconstructive surgeons. Preoperative embolization within 24 hours of tumor excision can be useful for vascular tumors.Extent of surgery and prognosis is dependent on the tumor location and extension. For tumors limited to the hard palate and lower maxillary sinus, an infrastructure maxillectomy is sufficient. A total maxillectomy without removal of the orbital floor may be warranted for more extensive tumors limited to the maxillary sinus. When the orbital periosteum is not invaded but tumor abuts this region, removal of the orbital floor with appro-priate reconstruction is | Surgery_Schwartz. the hard palate or the floor of the maxillary sinus. Many tumors can be treated with an endo-scopic approach such a medial maxillectomy when the tumor arises from the medial wall of the maxilla. Multidisciplinary assessment and treatment should include a skull base tumor board discussion with a head and neck oncologist/surgeon, a neurosurgeon, opthalmologist including oculoplastic surgeons, prosthodontists, and reconstructive surgeons. Preoperative embolization within 24 hours of tumor excision can be useful for vascular tumors.Extent of surgery and prognosis is dependent on the tumor location and extension. For tumors limited to the hard palate and lower maxillary sinus, an infrastructure maxillectomy is sufficient. A total maxillectomy without removal of the orbital floor may be warranted for more extensive tumors limited to the maxillary sinus. When the orbital periosteum is not invaded but tumor abuts this region, removal of the orbital floor with appro-priate reconstruction is |
Surgery_Schwartz_4379 | Surgery_Schwartz | for more extensive tumors limited to the maxillary sinus. When the orbital periosteum is not invaded but tumor abuts this region, removal of the orbital floor with appro-priate reconstruction is warranted. When there is invasion of periorbita, an orbital exenteration is warranted for most pathol-ogy. Tumors originating in the ethmoid sinuses may require excision of the cribriform plate and repair of subsequent skull base defect if the tumor originates or invades through the bony skull base. This is performed through an anterior craniofacial resection, where a neurosurgeon performs a frontal craniotomy for exposure of the anterior cranial fossa floor, while the head and neck surgeon performs a transfacial or endoscopic resection of the inferior bony and soft tissue structures. This approach often requires resection of dura and a dural repair to achieve negative margins. A less extensive surgery including a sphe-noethmoidectomy or medial maxillectomy can be entertained for smaller | Surgery_Schwartz. for more extensive tumors limited to the maxillary sinus. When the orbital periosteum is not invaded but tumor abuts this region, removal of the orbital floor with appro-priate reconstruction is warranted. When there is invasion of periorbita, an orbital exenteration is warranted for most pathol-ogy. Tumors originating in the ethmoid sinuses may require excision of the cribriform plate and repair of subsequent skull base defect if the tumor originates or invades through the bony skull base. This is performed through an anterior craniofacial resection, where a neurosurgeon performs a frontal craniotomy for exposure of the anterior cranial fossa floor, while the head and neck surgeon performs a transfacial or endoscopic resection of the inferior bony and soft tissue structures. This approach often requires resection of dura and a dural repair to achieve negative margins. A less extensive surgery including a sphe-noethmoidectomy or medial maxillectomy can be entertained for smaller |
Surgery_Schwartz_4380 | Surgery_Schwartz | often requires resection of dura and a dural repair to achieve negative margins. A less extensive surgery including a sphe-noethmoidectomy or medial maxillectomy can be entertained for smaller tumors originating in the lateral nasal wall through endoscopic or open approaches.Tumors are deemed to be unresectable if both optic nerves are involved, if there is carotid artery invasion, or if there is extensive intracranial extension. Chemotherapy has a limited application in the management of tumors at this subsite with two exceptions: rhabdomyosarcoma, which is primarily treated with chemotherapy followed by radiation therapy with surgery reserved for the salvage setting, and SNUC, where triple modal-ity treatment is required given tumor aggressiveness. Chemo-therapy in this setting may help to reduce the tumor bulk and allow for orbital preservation.NasopharynxThe anatomic borders of the nasopharyx are superiorly the adenoid patch, superolaterally the fossa of Rosenmüller and the | Surgery_Schwartz. often requires resection of dura and a dural repair to achieve negative margins. A less extensive surgery including a sphe-noethmoidectomy or medial maxillectomy can be entertained for smaller tumors originating in the lateral nasal wall through endoscopic or open approaches.Tumors are deemed to be unresectable if both optic nerves are involved, if there is carotid artery invasion, or if there is extensive intracranial extension. Chemotherapy has a limited application in the management of tumors at this subsite with two exceptions: rhabdomyosarcoma, which is primarily treated with chemotherapy followed by radiation therapy with surgery reserved for the salvage setting, and SNUC, where triple modal-ity treatment is required given tumor aggressiveness. Chemo-therapy in this setting may help to reduce the tumor bulk and allow for orbital preservation.NasopharynxThe anatomic borders of the nasopharyx are superiorly the adenoid patch, superolaterally the fossa of Rosenmüller and the |
Surgery_Schwartz_4381 | Surgery_Schwartz | help to reduce the tumor bulk and allow for orbital preservation.NasopharynxThe anatomic borders of the nasopharyx are superiorly the adenoid patch, superolaterally the fossa of Rosenmüller and the Eustachian tube orifices (torus tubarius), inferiorly the plane of the hard palate from the choana, anteriorly the posterior nasal cavity, and posteriorly the posterior pharyngeal wall. Malignant Subtotal temporalbone resectionTotal temporalbone resectionLateraltemporalbone resectionFigure 18-35. Examples of resection specimens for lateral tem-poral bone resection, subtotal temporal bone resection, and total temporal bone resection.Brunicardi_Ch18_p0613-p0660.indd 64401/03/19 5:24 PM 645DISORDERS OF THE HEAD AND NECKCHAPTER 18tumors of the nasopharynx are typically well differentiated or lymphoepithelial SCC. However, other tumors can present in this region including lymphoma, chordoma, chondroma, nasopharyngeal cyst (Tornwaldt’s cyst), angiofibroma, minor salivary gland tumor, | Surgery_Schwartz. help to reduce the tumor bulk and allow for orbital preservation.NasopharynxThe anatomic borders of the nasopharyx are superiorly the adenoid patch, superolaterally the fossa of Rosenmüller and the Eustachian tube orifices (torus tubarius), inferiorly the plane of the hard palate from the choana, anteriorly the posterior nasal cavity, and posteriorly the posterior pharyngeal wall. Malignant Subtotal temporalbone resectionTotal temporalbone resectionLateraltemporalbone resectionFigure 18-35. Examples of resection specimens for lateral tem-poral bone resection, subtotal temporal bone resection, and total temporal bone resection.Brunicardi_Ch18_p0613-p0660.indd 64401/03/19 5:24 PM 645DISORDERS OF THE HEAD AND NECKCHAPTER 18tumors of the nasopharynx are typically well differentiated or lymphoepithelial SCC. However, other tumors can present in this region including lymphoma, chordoma, chondroma, nasopharyngeal cyst (Tornwaldt’s cyst), angiofibroma, minor salivary gland tumor, |
Surgery_Schwartz_4382 | Surgery_Schwartz | or lymphoepithelial SCC. However, other tumors can present in this region including lymphoma, chordoma, chondroma, nasopharyngeal cyst (Tornwaldt’s cyst), angiofibroma, minor salivary gland tumor, paraganglioma, rhabdomyosarcoma, extramedullary plasmacytoma, and, rarely, sarcoma.Unlike other head and neck cancers, the nasopharynx site has unique ethnic and geographic predilection, namely, a higher incidence in southern China, Africa, Alaska, and in Green-land Eskimos. EBV is also more commonly seen in patients with NPC, and EBV titers are helpful in following treatment response.As previously discussed, a posterior (level V) neck mass should be considered NPC until proven otherwise. Other signs and symptoms include nasal obstruction, epistaxis, unilateral serous otitis media in an adult, and otalgia. Advanced disease can present with cranial neuropathies, particularly of the cranial nerves, which run in the cavernous sinus (CN V1, V2, III, IV, VI). Bilateral regional disease spread is | Surgery_Schwartz. or lymphoepithelial SCC. However, other tumors can present in this region including lymphoma, chordoma, chondroma, nasopharyngeal cyst (Tornwaldt’s cyst), angiofibroma, minor salivary gland tumor, paraganglioma, rhabdomyosarcoma, extramedullary plasmacytoma, and, rarely, sarcoma.Unlike other head and neck cancers, the nasopharynx site has unique ethnic and geographic predilection, namely, a higher incidence in southern China, Africa, Alaska, and in Green-land Eskimos. EBV is also more commonly seen in patients with NPC, and EBV titers are helpful in following treatment response.As previously discussed, a posterior (level V) neck mass should be considered NPC until proven otherwise. Other signs and symptoms include nasal obstruction, epistaxis, unilateral serous otitis media in an adult, and otalgia. Advanced disease can present with cranial neuropathies, particularly of the cranial nerves, which run in the cavernous sinus (CN V1, V2, III, IV, VI). Bilateral regional disease spread is |
Surgery_Schwartz_4383 | Surgery_Schwartz | otalgia. Advanced disease can present with cranial neuropathies, particularly of the cranial nerves, which run in the cavernous sinus (CN V1, V2, III, IV, VI). Bilateral regional disease spread is common, and the lym-phatic level involved include the posterior neck (level V), as well as the upper (level II) cervical nodes and retropharyngeal nodes. Distant metastatic disease is present in 5% of patients at diagnosis, highlighting the importance of a thorough staging workup.Staging includes a thorough physical examination using either a flexible or rigid endoscope to assess the mucosal extent of the disease. CT and MRI are complimentary as in the assess-ment of nasal cavity and paranasal sinus tumors with CT provid-ing better assessment of bony invasion and the MRI providing better soft tissue delineation, skull base invasion, and perineural spread with cranial nerve enhancement. Multimodality therapy with chemoradiotherapy is superior to radiotherapy alone in the management of | Surgery_Schwartz. otalgia. Advanced disease can present with cranial neuropathies, particularly of the cranial nerves, which run in the cavernous sinus (CN V1, V2, III, IV, VI). Bilateral regional disease spread is common, and the lym-phatic level involved include the posterior neck (level V), as well as the upper (level II) cervical nodes and retropharyngeal nodes. Distant metastatic disease is present in 5% of patients at diagnosis, highlighting the importance of a thorough staging workup.Staging includes a thorough physical examination using either a flexible or rigid endoscope to assess the mucosal extent of the disease. CT and MRI are complimentary as in the assess-ment of nasal cavity and paranasal sinus tumors with CT provid-ing better assessment of bony invasion and the MRI providing better soft tissue delineation, skull base invasion, and perineural spread with cranial nerve enhancement. Multimodality therapy with chemoradiotherapy is superior to radiotherapy alone in the management of |
Surgery_Schwartz_4384 | Surgery_Schwartz | soft tissue delineation, skull base invasion, and perineural spread with cranial nerve enhancement. Multimodality therapy with chemoradiotherapy is superior to radiotherapy alone in the management of nasopharyngeal carcinoma.169 Recurrent tumors are treated typically with reirradiation; however, there has been recent success with surgical salvage procedures, particular in those patients in which a negative margin can be achieved.170When resection is contemplated for recurrent nasopharyn-geal carcinoma or for low grade tumors such as some minor salivary gland tumors, a number of surgical approaches can be utilized for resection. These include endoscopic, transpalatal, transfacial via a maxillary swing procedure, and transcervical. In many cases, a combination of these techniques is required to achieve a negative margin. The transcervical approach pro-vides the added benefit of early access and control of the carotid artery. For benign and low-grade tumors, advances in EEA have made use | Surgery_Schwartz. soft tissue delineation, skull base invasion, and perineural spread with cranial nerve enhancement. Multimodality therapy with chemoradiotherapy is superior to radiotherapy alone in the management of nasopharyngeal carcinoma.169 Recurrent tumors are treated typically with reirradiation; however, there has been recent success with surgical salvage procedures, particular in those patients in which a negative margin can be achieved.170When resection is contemplated for recurrent nasopharyn-geal carcinoma or for low grade tumors such as some minor salivary gland tumors, a number of surgical approaches can be utilized for resection. These include endoscopic, transpalatal, transfacial via a maxillary swing procedure, and transcervical. In many cases, a combination of these techniques is required to achieve a negative margin. The transcervical approach pro-vides the added benefit of early access and control of the carotid artery. For benign and low-grade tumors, advances in EEA have made use |
Surgery_Schwartz_4385 | Surgery_Schwartz | to achieve a negative margin. The transcervical approach pro-vides the added benefit of early access and control of the carotid artery. For benign and low-grade tumors, advances in EEA have made use of the open approaches less common.Ear and Temporal BoneTemporal bone and ear tumors are rare account for <0.5% of all head and neck cancers. Subsites in this head and neck site from lateral to medial include the pinna (external ear), external auditory canal, middle ear, mastoid, and petrous portion of the temporal bone. Although the typical pathology at this site is squamous cell carcinoma, minor salivary gland tumors such as adenocarcinoma and adenoid cystic carcinoma can also present here. Given that the ear is in the high-risk region for aggressive skin cancers due to its unique exposure to ultraviolet light, cuta-neous malignancies such as basal cell carcinoma and melanoma can also present here. In the pediatric population, soft tissue sar-comas, most commonly rhabdomyosarcoma, can | Surgery_Schwartz. to achieve a negative margin. The transcervical approach pro-vides the added benefit of early access and control of the carotid artery. For benign and low-grade tumors, advances in EEA have made use of the open approaches less common.Ear and Temporal BoneTemporal bone and ear tumors are rare account for <0.5% of all head and neck cancers. Subsites in this head and neck site from lateral to medial include the pinna (external ear), external auditory canal, middle ear, mastoid, and petrous portion of the temporal bone. Although the typical pathology at this site is squamous cell carcinoma, minor salivary gland tumors such as adenocarcinoma and adenoid cystic carcinoma can also present here. Given that the ear is in the high-risk region for aggressive skin cancers due to its unique exposure to ultraviolet light, cuta-neous malignancies such as basal cell carcinoma and melanoma can also present here. In the pediatric population, soft tissue sar-comas, most commonly rhabdomyosarcoma, can |
Surgery_Schwartz_4386 | Surgery_Schwartz | to ultraviolet light, cuta-neous malignancies such as basal cell carcinoma and melanoma can also present here. In the pediatric population, soft tissue sar-comas, most commonly rhabdomyosarcoma, can present at this site. These tumors typically present with an advanced stage,171 and resection with clear margins and functional preservation is challenging because of the close proximity of vital structures, namely the facial nerve and the external auditory canal.172 Tumors involving the petrous apex or intracranial structures may present with headache and palsies of CN V and VI as well.Patients can present with ulceration, granulation, or bleed-ings from the external ear and auditory canal. This is often mistaken for an infectious or inflammatory process given the rarity of malignancy at this subsite; however, persistent granu-lation tissue in the ear should be biopsied and imaged to rule out malignancy. Patients can then present with otorrhea, otal-gia, hearing loss, vertigo, and facial | Surgery_Schwartz. to ultraviolet light, cuta-neous malignancies such as basal cell carcinoma and melanoma can also present here. In the pediatric population, soft tissue sar-comas, most commonly rhabdomyosarcoma, can present at this site. These tumors typically present with an advanced stage,171 and resection with clear margins and functional preservation is challenging because of the close proximity of vital structures, namely the facial nerve and the external auditory canal.172 Tumors involving the petrous apex or intracranial structures may present with headache and palsies of CN V and VI as well.Patients can present with ulceration, granulation, or bleed-ings from the external ear and auditory canal. This is often mistaken for an infectious or inflammatory process given the rarity of malignancy at this subsite; however, persistent granu-lation tissue in the ear should be biopsied and imaged to rule out malignancy. Patients can then present with otorrhea, otal-gia, hearing loss, vertigo, and facial |
Surgery_Schwartz_4387 | Surgery_Schwartz | subsite; however, persistent granu-lation tissue in the ear should be biopsied and imaged to rule out malignancy. Patients can then present with otorrhea, otal-gia, hearing loss, vertigo, and facial nerve paralysis. Appropri-ate imaging with CT and MRI is often required to appropriately delineate the lesion and stage and assist with the appropriate management plan.Cutaneous malignancies of the pinna and tragus can usu-ally be locally excised. However, at this subsite, spread into the perichondrium and cartilage can lead to rapid spread long that tissue plane. The importance of negative margins cannot be overstated at this subsite. Mohs microsurgery has been advo-cated for select tumors at this subsite for this reason; however, some tumors are so extensive that a total auriculectomy provides the best oncologic and cosmetic result. When there is exten-sion of tumor to the bony cartilaginous EAC junction, spread to parotid, temporomandibular joint, and skull base is possible. Advanced | Surgery_Schwartz. subsite; however, persistent granu-lation tissue in the ear should be biopsied and imaged to rule out malignancy. Patients can then present with otorrhea, otal-gia, hearing loss, vertigo, and facial nerve paralysis. Appropri-ate imaging with CT and MRI is often required to appropriately delineate the lesion and stage and assist with the appropriate management plan.Cutaneous malignancies of the pinna and tragus can usu-ally be locally excised. However, at this subsite, spread into the perichondrium and cartilage can lead to rapid spread long that tissue plane. The importance of negative margins cannot be overstated at this subsite. Mohs microsurgery has been advo-cated for select tumors at this subsite for this reason; however, some tumors are so extensive that a total auriculectomy provides the best oncologic and cosmetic result. When there is exten-sion of tumor to the bony cartilaginous EAC junction, spread to parotid, temporomandibular joint, and skull base is possible. Advanced |
Surgery_Schwartz_4388 | Surgery_Schwartz | the best oncologic and cosmetic result. When there is exten-sion of tumor to the bony cartilaginous EAC junction, spread to parotid, temporomandibular joint, and skull base is possible. Advanced tumors anterior to a vertical line along the EAC from a sagittal view benefit from a parotidectomy as well as a suprao-mohyoid neck dissection (levels I–III), whereas those behind this line benefit from a posterolateral neck dissection (levels II–V). As with other cutaneous malignancies, adjuvant radio-therapy is indicated for positive margins, perineural spread, or multiple involved lymph nodes.Tumors involving the EAC and middle ear require differ-ent management, including a sleeve resection of the external auditory canal, a lateral temporal bone resection, or a subtotal temporal bone resection (Fig. 18-36). A sleeve resection of the EAC skin and cartilage is rarely enough to achieve negative margins with the exception of some basal cell carcinomas of the skin overlying the cartilaginous | Surgery_Schwartz. the best oncologic and cosmetic result. When there is exten-sion of tumor to the bony cartilaginous EAC junction, spread to parotid, temporomandibular joint, and skull base is possible. Advanced tumors anterior to a vertical line along the EAC from a sagittal view benefit from a parotidectomy as well as a suprao-mohyoid neck dissection (levels I–III), whereas those behind this line benefit from a posterolateral neck dissection (levels II–V). As with other cutaneous malignancies, adjuvant radio-therapy is indicated for positive margins, perineural spread, or multiple involved lymph nodes.Tumors involving the EAC and middle ear require differ-ent management, including a sleeve resection of the external auditory canal, a lateral temporal bone resection, or a subtotal temporal bone resection (Fig. 18-36). A sleeve resection of the EAC skin and cartilage is rarely enough to achieve negative margins with the exception of some basal cell carcinomas of the skin overlying the cartilaginous |
Surgery_Schwartz_4389 | Surgery_Schwartz | (Fig. 18-36). A sleeve resection of the EAC skin and cartilage is rarely enough to achieve negative margins with the exception of some basal cell carcinomas of the skin overlying the cartilaginous EAC. For more extensive IIIIIIVIIVVFigure 18-36. Levels of the neck denoting lymph node bearing regions.Brunicardi_Ch18_p0613-p0660.indd 64501/03/19 5:24 PM 646SPECIFIC CONSIDERATIONSPART IItumors and more aggressive pathology, a lateral temporal bone resection may be required removing the cartilaginous and bony external auditory canal as well as the middle ear en bloc.173 A subtotal temporal bone resection also removes the inner ear and facial nerve as part of the resection and is indicated when the tumor extends into the middle ear and a deeper resection margin is required. Both of these procedures are followed by postopera-tive radiotherapy, which provides improved locoregional con-trol.173 The neck is managed in a similar fashion to pinna and external auditory canal malignancies | Surgery_Schwartz. (Fig. 18-36). A sleeve resection of the EAC skin and cartilage is rarely enough to achieve negative margins with the exception of some basal cell carcinomas of the skin overlying the cartilaginous EAC. For more extensive IIIIIIVIIVVFigure 18-36. Levels of the neck denoting lymph node bearing regions.Brunicardi_Ch18_p0613-p0660.indd 64501/03/19 5:24 PM 646SPECIFIC CONSIDERATIONSPART IItumors and more aggressive pathology, a lateral temporal bone resection may be required removing the cartilaginous and bony external auditory canal as well as the middle ear en bloc.173 A subtotal temporal bone resection also removes the inner ear and facial nerve as part of the resection and is indicated when the tumor extends into the middle ear and a deeper resection margin is required. Both of these procedures are followed by postopera-tive radiotherapy, which provides improved locoregional con-trol.173 The neck is managed in a similar fashion to pinna and external auditory canal malignancies |
Surgery_Schwartz_4390 | Surgery_Schwartz | procedures are followed by postopera-tive radiotherapy, which provides improved locoregional con-trol.173 The neck is managed in a similar fashion to pinna and external auditory canal malignancies typically requiring a supra-omohyoid (levels I–III) neck dissection. Survival outcomes are poor with a 5-year overall survival of <40%.174 Important pre-dictors of disease free survival include margin status, perineu-ral invasion, and regional lymphatic spread; the most important of these on multivariate analysis being lymphatic spread of disease.171Lateral temporal bone resections often require reconstruc-tion to close the wound, provide bulk, and vascularize tissue. If dura is encountered and even resected, a watertight dural closure is required to prevent a CSF leak and meningitis. Vascularized tissue has the added benefit of preparing the surgical bed for postoperative radiotherapy. These defects can be reconstructed with regional pedicled flaps (e.g., submental flap) or free flaps. The | Surgery_Schwartz. procedures are followed by postopera-tive radiotherapy, which provides improved locoregional con-trol.173 The neck is managed in a similar fashion to pinna and external auditory canal malignancies typically requiring a supra-omohyoid (levels I–III) neck dissection. Survival outcomes are poor with a 5-year overall survival of <40%.174 Important pre-dictors of disease free survival include margin status, perineu-ral invasion, and regional lymphatic spread; the most important of these on multivariate analysis being lymphatic spread of disease.171Lateral temporal bone resections often require reconstruc-tion to close the wound, provide bulk, and vascularize tissue. If dura is encountered and even resected, a watertight dural closure is required to prevent a CSF leak and meningitis. Vascularized tissue has the added benefit of preparing the surgical bed for postoperative radiotherapy. These defects can be reconstructed with regional pedicled flaps (e.g., submental flap) or free flaps. The |
Surgery_Schwartz_4391 | Surgery_Schwartz | tissue has the added benefit of preparing the surgical bed for postoperative radiotherapy. These defects can be reconstructed with regional pedicled flaps (e.g., submental flap) or free flaps. The most common free flaps used are the anterolateral thigh, although depending on body habitus and the depth of the defect, the radial forearm, lateral arm, and rectus abdominus may also be used.175 The deformity resulting from a total auriculectomy is often not reconstructed primarily, but an auricular prosthesis can be designed for further rehabilitation. Facial nerve reconstruc-tion when sacrifice is required is typically performed with cable grafts from the proximal facial nerve to select distal facial nerve branches. Because of the long distance between the proximal and distal branches, facial movement is typically delayed 6 to 12 months. However, if the masseteric nerve is connected through a cable graft to select distal facial nerve branches (typically the zygomatic branch), a shorter | Surgery_Schwartz. tissue has the added benefit of preparing the surgical bed for postoperative radiotherapy. These defects can be reconstructed with regional pedicled flaps (e.g., submental flap) or free flaps. The most common free flaps used are the anterolateral thigh, although depending on body habitus and the depth of the defect, the radial forearm, lateral arm, and rectus abdominus may also be used.175 The deformity resulting from a total auriculectomy is often not reconstructed primarily, but an auricular prosthesis can be designed for further rehabilitation. Facial nerve reconstruc-tion when sacrifice is required is typically performed with cable grafts from the proximal facial nerve to select distal facial nerve branches. Because of the long distance between the proximal and distal branches, facial movement is typically delayed 6 to 12 months. However, if the masseteric nerve is connected through a cable graft to select distal facial nerve branches (typically the zygomatic branch), a shorter |
Surgery_Schwartz_4392 | Surgery_Schwartz | movement is typically delayed 6 to 12 months. However, if the masseteric nerve is connected through a cable graft to select distal facial nerve branches (typically the zygomatic branch), a shorter cable graft is required, and facial movement can be achieved earlier. A variety of other static and dynamic procedures can be provided secondarily. The most important of these procedures are related to preserving eye clo-sure to avoid corneal abrasions or desiccation, which can ulti-mately lead to blindness. In the immediate postoperative period, taping of the eyelids and generous application of eye lubrication is required to prevent exposure keratitis. Upper lid gold weight implants, lower lid shortening procedures, and tarsorrhaphy can be performed secondarily to assist with eye closure.NeckAn undiagnosed neck mass needs to be carefully evaluated and worked up so as to not interfere with the definitive management of the patient and future treatment options. The patient’s age, social | Surgery_Schwartz. movement is typically delayed 6 to 12 months. However, if the masseteric nerve is connected through a cable graft to select distal facial nerve branches (typically the zygomatic branch), a shorter cable graft is required, and facial movement can be achieved earlier. A variety of other static and dynamic procedures can be provided secondarily. The most important of these procedures are related to preserving eye clo-sure to avoid corneal abrasions or desiccation, which can ulti-mately lead to blindness. In the immediate postoperative period, taping of the eyelids and generous application of eye lubrication is required to prevent exposure keratitis. Upper lid gold weight implants, lower lid shortening procedures, and tarsorrhaphy can be performed secondarily to assist with eye closure.NeckAn undiagnosed neck mass needs to be carefully evaluated and worked up so as to not interfere with the definitive management of the patient and future treatment options. The patient’s age, social |
Surgery_Schwartz_4393 | Surgery_Schwartz | undiagnosed neck mass needs to be carefully evaluated and worked up so as to not interfere with the definitive management of the patient and future treatment options. The patient’s age, social history, including alcohol and smoking history, preced-ing illness history, and synchronous upper aerodigestive tract physical examination findings can significantly impact the dif-ferential diagnosis and the investigation to work up a neck mass. A thorough history and head and neck examination, including fiberoptic nasolaryngoscopy, are therefore paramount to com-plete evaluation. With regard to age, in children, a neck mass is far more likely to be congenital, inflammatory, or infectious, whereas in adults, neck masses >2 cm have a >80% probability of being malignant. Typically, the first investigation is an FNA biopsy, which can be performed with ultrasound or CT guid-ance when the mass is not easily palpable or largely cystic with a small solid component. Imaging is critical in | Surgery_Schwartz. undiagnosed neck mass needs to be carefully evaluated and worked up so as to not interfere with the definitive management of the patient and future treatment options. The patient’s age, social history, including alcohol and smoking history, preced-ing illness history, and synchronous upper aerodigestive tract physical examination findings can significantly impact the dif-ferential diagnosis and the investigation to work up a neck mass. A thorough history and head and neck examination, including fiberoptic nasolaryngoscopy, are therefore paramount to com-plete evaluation. With regard to age, in children, a neck mass is far more likely to be congenital, inflammatory, or infectious, whereas in adults, neck masses >2 cm have a >80% probability of being malignant. Typically, the first investigation is an FNA biopsy, which can be performed with ultrasound or CT guid-ance when the mass is not easily palpable or largely cystic with a small solid component. Imaging is critical in |
Surgery_Schwartz_4394 | Surgery_Schwartz | investigation is an FNA biopsy, which can be performed with ultrasound or CT guid-ance when the mass is not easily palpable or largely cystic with a small solid component. Imaging is critical in characterizing the neck mass, particularly assessing the borders, consistency, and location which then impacts the differential diagnosis. For instance, a cystic neck mass can be a branchial cleft cyst or a regional metastasis from an oropharynx cancer or metastatic papillary thyroid cancer. Therefore, the imaging findings also significantly impact the differential diagnosis.When the imaging and FNA does not provide adequate information for a diagnosis, a core biopsy can be considered, particularly if the diagnosis of lymphoma is suspected and an open biopsy wants to be avoided. For a suspected carcinoma, an open biopsy may be required; however, in that case, the incision needs to be planned such that the procedure can be converted to a neck dissection, and a frozen section can be sent. If the | Surgery_Schwartz. investigation is an FNA biopsy, which can be performed with ultrasound or CT guid-ance when the mass is not easily palpable or largely cystic with a small solid component. Imaging is critical in characterizing the neck mass, particularly assessing the borders, consistency, and location which then impacts the differential diagnosis. For instance, a cystic neck mass can be a branchial cleft cyst or a regional metastasis from an oropharynx cancer or metastatic papillary thyroid cancer. Therefore, the imaging findings also significantly impact the differential diagnosis.When the imaging and FNA does not provide adequate information for a diagnosis, a core biopsy can be considered, particularly if the diagnosis of lymphoma is suspected and an open biopsy wants to be avoided. For a suspected carcinoma, an open biopsy may be required; however, in that case, the incision needs to be planned such that the procedure can be converted to a neck dissection, and a frozen section can be sent. If the |
Surgery_Schwartz_4395 | Surgery_Schwartz | an open biopsy may be required; however, in that case, the incision needs to be planned such that the procedure can be converted to a neck dissection, and a frozen section can be sent. If the diagnosis of squamous cell carcinoma is confirmed on frozen section, then a neck dissection should be performed to further prognosticate the disease. In the case of lymphoma, biopsy does not need to remove the entire lymphoma, particularly if there is an added risk of injuring normal anatomical structures.Patterns of Lymph Node Metastasis. The lymphatic drain-age into the neck is divided into seven levels with standardized reporting within and across specialties, particularly as radiolo-gists, pathologists, surgeons, radiation oncologists, and radiolo-gists share the findings176,177 (Fig. 18-37). The levels include• Level I—the submental and submandibular nodes• Level Ia—the submental nodes; medial to the anterior belly of the digastric muscle bilaterally, symphysis of mandible superiorly, and | Surgery_Schwartz. an open biopsy may be required; however, in that case, the incision needs to be planned such that the procedure can be converted to a neck dissection, and a frozen section can be sent. If the diagnosis of squamous cell carcinoma is confirmed on frozen section, then a neck dissection should be performed to further prognosticate the disease. In the case of lymphoma, biopsy does not need to remove the entire lymphoma, particularly if there is an added risk of injuring normal anatomical structures.Patterns of Lymph Node Metastasis. The lymphatic drain-age into the neck is divided into seven levels with standardized reporting within and across specialties, particularly as radiolo-gists, pathologists, surgeons, radiation oncologists, and radiolo-gists share the findings176,177 (Fig. 18-37). The levels include• Level I—the submental and submandibular nodes• Level Ia—the submental nodes; medial to the anterior belly of the digastric muscle bilaterally, symphysis of mandible superiorly, and |
Surgery_Schwartz_4396 | Surgery_Schwartz | levels include• Level I—the submental and submandibular nodes• Level Ia—the submental nodes; medial to the anterior belly of the digastric muscle bilaterally, symphysis of mandible superiorly, and hyoid inferiorly; this level does not have any laterality as it includes both right and left sides• Level Ib—the submandibular nodes and gland; posterior to the anterior belly of digastric, anterior to the posterior belly of digastric, and inferior to the body of the mandibleFigure 18-37. Shaded region indicates the region included in a supraomohyoid neck dissection.Brunicardi_Ch18_p0613-p0660.indd 64601/03/19 5:24 PM 647DISORDERS OF THE HEAD AND NECKCHAPTER 18• Level IIa—upper jugular chain nodes; anterior to the poste-rior border of the sternocleidomastoid (SCM) muscle, poste-rior to the posterior aspect of the posterior belly of digastric, superior to the level of the hyoid, inferior to spinal accessory nerve (CN XI)• Level IIb—submuscular recess; superior to spinal accessory nerve | Surgery_Schwartz. levels include• Level I—the submental and submandibular nodes• Level Ia—the submental nodes; medial to the anterior belly of the digastric muscle bilaterally, symphysis of mandible superiorly, and hyoid inferiorly; this level does not have any laterality as it includes both right and left sides• Level Ib—the submandibular nodes and gland; posterior to the anterior belly of digastric, anterior to the posterior belly of digastric, and inferior to the body of the mandibleFigure 18-37. Shaded region indicates the region included in a supraomohyoid neck dissection.Brunicardi_Ch18_p0613-p0660.indd 64601/03/19 5:24 PM 647DISORDERS OF THE HEAD AND NECKCHAPTER 18• Level IIa—upper jugular chain nodes; anterior to the poste-rior border of the sternocleidomastoid (SCM) muscle, poste-rior to the posterior aspect of the posterior belly of digastric, superior to the level of the hyoid, inferior to spinal accessory nerve (CN XI)• Level IIb—submuscular recess; superior to spinal accessory nerve |
Surgery_Schwartz_4397 | Surgery_Schwartz | posterior aspect of the posterior belly of digastric, superior to the level of the hyoid, inferior to spinal accessory nerve (CN XI)• Level IIb—submuscular recess; superior to spinal accessory nerve to the level of the skull base• Level III—middle jugular chain nodes; inferior to the hyoid, superior to the level of the cricoid, deep to SCM muscle from posterior border of the muscle to the strap muscles medially• Level IV—lower jugular chain nodes; inferior to the level of the cricoid, superior to the clavicle, deep to SCM muscle from posterior border of the muscle to the strap muscles medially• Level V—posterior triangle nodes• Level Va—lateral to the posterior aspect of the SCM muscle, inferior and medial to splenius capitis and trapezius, superior to the spinal accessory nerve• Level Vb—lateral to the posterior aspect of SCM muscle, medial to trapezius, inferior to the spinal accessory nerve, superior to the clavicle• Level VI—anterior compartment nodes; inferior to the hyoid, | Surgery_Schwartz. posterior aspect of the posterior belly of digastric, superior to the level of the hyoid, inferior to spinal accessory nerve (CN XI)• Level IIb—submuscular recess; superior to spinal accessory nerve to the level of the skull base• Level III—middle jugular chain nodes; inferior to the hyoid, superior to the level of the cricoid, deep to SCM muscle from posterior border of the muscle to the strap muscles medially• Level IV—lower jugular chain nodes; inferior to the level of the cricoid, superior to the clavicle, deep to SCM muscle from posterior border of the muscle to the strap muscles medially• Level V—posterior triangle nodes• Level Va—lateral to the posterior aspect of the SCM muscle, inferior and medial to splenius capitis and trapezius, superior to the spinal accessory nerve• Level Vb—lateral to the posterior aspect of SCM muscle, medial to trapezius, inferior to the spinal accessory nerve, superior to the clavicle• Level VI—anterior compartment nodes; inferior to the hyoid, |
Surgery_Schwartz_4398 | Surgery_Schwartz | Vb—lateral to the posterior aspect of SCM muscle, medial to trapezius, inferior to the spinal accessory nerve, superior to the clavicle• Level VI—anterior compartment nodes; inferior to the hyoid, superior to suprasternal notch, medial to the lateral extent of the strap muscles bilaterally• Level VII—paratracheal nodes; inferior to the suprasternal notch in the upper mediastinumThere is a well-established pattern of regional spread from upper aerodigestive tract primary tumors.178 Lesions of the lip and oral cavity typically metastasize to levels I to III and skip metastases to the lower basin (levels III–IV) without involve-ment of the upper level (levels I–II). Oropharyngeal, laryngeal, and hypopharyngeal tumors most commonly spread to the lat-eral neck (levels II–IV). It is rare for any of these tumors to have isolated regional metastases to level V; however, naso-pharyngeal, thyroid, and head and neck malignant melanoma can metastasize to this level. Other sites for metastasis | Surgery_Schwartz. Vb—lateral to the posterior aspect of SCM muscle, medial to trapezius, inferior to the spinal accessory nerve, superior to the clavicle• Level VI—anterior compartment nodes; inferior to the hyoid, superior to suprasternal notch, medial to the lateral extent of the strap muscles bilaterally• Level VII—paratracheal nodes; inferior to the suprasternal notch in the upper mediastinumThere is a well-established pattern of regional spread from upper aerodigestive tract primary tumors.178 Lesions of the lip and oral cavity typically metastasize to levels I to III and skip metastases to the lower basin (levels III–IV) without involve-ment of the upper level (levels I–II). Oropharyngeal, laryngeal, and hypopharyngeal tumors most commonly spread to the lat-eral neck (levels II–IV). It is rare for any of these tumors to have isolated regional metastases to level V; however, naso-pharyngeal, thyroid, and head and neck malignant melanoma can metastasize to this level. Other sites for metastasis |
Surgery_Schwartz_4399 | Surgery_Schwartz | any of these tumors to have isolated regional metastases to level V; however, naso-pharyngeal, thyroid, and head and neck malignant melanoma can metastasize to this level. Other sites for metastasis include the retropharyngeal nodes (oropharyngeal, nasopharyngeal, and hypopharyngeal tumors), paratracheal and level VII nodes (thyroid, hypopharynx, and cervical esophageal tumors), and pretracheal (Delphian) nodes (thyroid and advanced glottic tumors with subglottic extension).Historically, a radical neck dissection (RND) was per-formed for all upper aerodigestive tract malignancies with sac-rifice of the SCM, internal jugular vein (IJV), and accessory nerve (CN XI) and removal of all lymphatic level (levels I–V). This was because cervical metastasis decreased the 5-year over-all survival rate by approximately 50%. However, growing evi-dence demonstrated that this was not necessary, and now a neck dissection is only recommended for upper aerodigestive tract malignancies when the risk of | Surgery_Schwartz. any of these tumors to have isolated regional metastases to level V; however, naso-pharyngeal, thyroid, and head and neck malignant melanoma can metastasize to this level. Other sites for metastasis include the retropharyngeal nodes (oropharyngeal, nasopharyngeal, and hypopharyngeal tumors), paratracheal and level VII nodes (thyroid, hypopharynx, and cervical esophageal tumors), and pretracheal (Delphian) nodes (thyroid and advanced glottic tumors with subglottic extension).Historically, a radical neck dissection (RND) was per-formed for all upper aerodigestive tract malignancies with sac-rifice of the SCM, internal jugular vein (IJV), and accessory nerve (CN XI) and removal of all lymphatic level (levels I–V). This was because cervical metastasis decreased the 5-year over-all survival rate by approximately 50%. However, growing evi-dence demonstrated that this was not necessary, and now a neck dissection is only recommended for upper aerodigestive tract malignancies when the risk of |
Surgery_Schwartz_4400 | Surgery_Schwartz | by approximately 50%. However, growing evi-dence demonstrated that this was not necessary, and now a neck dissection is only recommended for upper aerodigestive tract malignancies when the risk of occult disease is >20% in the clinically negative neck.179 When the neck is clinically positive, the level discussed in the previous paragraph for each site are excised with every attempt to preserve the SCM, IJV, and CN XI (selective neck dissection; SND). When there is direct exten-sion of the tumor or extralymphatic spread into these structures, sacrifice may be necessary in a modified radical neck dissection (MRND). The RND has been largely abandoned because the SND and MRND have been demonstrated to be equally effec-tive when it comes to oncologic outcomes with far improved functional outcomes.180,181SND has become the standard of care for most patients who are clinically node negative (cN0) and in those with limited cN1 disease. Patients with oral cavity cancer typically receive a | Surgery_Schwartz. by approximately 50%. However, growing evi-dence demonstrated that this was not necessary, and now a neck dissection is only recommended for upper aerodigestive tract malignancies when the risk of occult disease is >20% in the clinically negative neck.179 When the neck is clinically positive, the level discussed in the previous paragraph for each site are excised with every attempt to preserve the SCM, IJV, and CN XI (selective neck dissection; SND). When there is direct exten-sion of the tumor or extralymphatic spread into these structures, sacrifice may be necessary in a modified radical neck dissection (MRND). The RND has been largely abandoned because the SND and MRND have been demonstrated to be equally effec-tive when it comes to oncologic outcomes with far improved functional outcomes.180,181SND has become the standard of care for most patients who are clinically node negative (cN0) and in those with limited cN1 disease. Patients with oral cavity cancer typically receive a |
Surgery_Schwartz_4401 | Surgery_Schwartz | has become the standard of care for most patients who are clinically node negative (cN0) and in those with limited cN1 disease. Patients with oral cavity cancer typically receive a supraomohyoid (Fig. 18-38) neck dissection (levels I–III). Many surgeons will include a portion of level IV just below the omohyoid muscle given the rate of skip metastases previously discussed. Approximately 80% of patients with oral cavity can-cer present cN0; however, the rate of occult metastatic disease is approximately 30% and differs by subsite.182 This rate is further impacted by tumor thickness at the tongue subsite, with tumors 4 mm or thicker having a higher rate of occult disease.183 A recent prospective, randomized trial demonstrated the oncologic benefit of an elective neck dissection in cN0 oral cavity patients regardless of tumor thickness over an observation followed by therapeutic neck dissection in those with regional failures.184 An additional role of SND is as a staging tool to | Surgery_Schwartz. has become the standard of care for most patients who are clinically node negative (cN0) and in those with limited cN1 disease. Patients with oral cavity cancer typically receive a supraomohyoid (Fig. 18-38) neck dissection (levels I–III). Many surgeons will include a portion of level IV just below the omohyoid muscle given the rate of skip metastases previously discussed. Approximately 80% of patients with oral cavity can-cer present cN0; however, the rate of occult metastatic disease is approximately 30% and differs by subsite.182 This rate is further impacted by tumor thickness at the tongue subsite, with tumors 4 mm or thicker having a higher rate of occult disease.183 A recent prospective, randomized trial demonstrated the oncologic benefit of an elective neck dissection in cN0 oral cavity patients regardless of tumor thickness over an observation followed by therapeutic neck dissection in those with regional failures.184 An additional role of SND is as a staging tool to |
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