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Surgery_Schwartz_4402 | Surgery_Schwartz | oral cavity patients regardless of tumor thickness over an observation followed by therapeutic neck dissection in those with regional failures.184 An additional role of SND is as a staging tool to determine the need for postoperative radiation therapy. The lateral (Fig. 18-39) neck dissection (levels II–IV) is typically used in laryngeal and hypo-pharyngeal cancers. The posterolateral (Fig. 18-40 neck dissec-tion (levels II–V) is typically recommended in thyroid cancers, although recent evidence has demonstrated that a partial level V dissection may be all that is necessary for equivalent outcomes to a full level II to V neck dissection.176,185,186Despite advances in the surgical management of neck dis-ease, in clinically advanced nodal disease (with the exception of uncomplicated N1 disease), an MRND remains the treatment of choice. When the neck disease is advanced with extrano-dal extension (ENE), perineural invasion (PNI), lymphovas-cular invasion (LVI), and the presence of | Surgery_Schwartz. oral cavity patients regardless of tumor thickness over an observation followed by therapeutic neck dissection in those with regional failures.184 An additional role of SND is as a staging tool to determine the need for postoperative radiation therapy. The lateral (Fig. 18-39) neck dissection (levels II–IV) is typically used in laryngeal and hypo-pharyngeal cancers. The posterolateral (Fig. 18-40 neck dissec-tion (levels II–V) is typically recommended in thyroid cancers, although recent evidence has demonstrated that a partial level V dissection may be all that is necessary for equivalent outcomes to a full level II to V neck dissection.176,185,186Despite advances in the surgical management of neck dis-ease, in clinically advanced nodal disease (with the exception of uncomplicated N1 disease), an MRND remains the treatment of choice. When the neck disease is advanced with extrano-dal extension (ENE), perineural invasion (PNI), lymphovas-cular invasion (LVI), and the presence of |
Surgery_Schwartz_4403 | Surgery_Schwartz | disease), an MRND remains the treatment of choice. When the neck disease is advanced with extrano-dal extension (ENE), perineural invasion (PNI), lymphovas-cular invasion (LVI), and the presence of multiple involved nodes, postoperative radiotherapy improves locoregional con-trol.103 If there is a positive margin or ENE, then the addition of adjuvant chemotherapy to radiotherapy provides a survival benefit.113,187,188In patients receiving primary radiotherapy with advanced N stage disease (N2a or greater) or only a partial response to Figure 18-38. Shaded region indicates the region included in a lateral neck dissection.Brunicardi_Ch18_p0613-p0660.indd 64701/03/19 5:24 PM 648SPECIFIC CONSIDERATIONSPART IItreatment, a planned postradiotherapy neck dissection can be performed 6 to 8 weeks after completion of radiotherapy. This is to consolidate the treatment and provide prognostic information.Tumor factors that preclude surgery include prevertebral fascia invasion, skull base | Surgery_Schwartz. disease), an MRND remains the treatment of choice. When the neck disease is advanced with extrano-dal extension (ENE), perineural invasion (PNI), lymphovas-cular invasion (LVI), and the presence of multiple involved nodes, postoperative radiotherapy improves locoregional con-trol.103 If there is a positive margin or ENE, then the addition of adjuvant chemotherapy to radiotherapy provides a survival benefit.113,187,188In patients receiving primary radiotherapy with advanced N stage disease (N2a or greater) or only a partial response to Figure 18-38. Shaded region indicates the region included in a lateral neck dissection.Brunicardi_Ch18_p0613-p0660.indd 64701/03/19 5:24 PM 648SPECIFIC CONSIDERATIONSPART IItreatment, a planned postradiotherapy neck dissection can be performed 6 to 8 weeks after completion of radiotherapy. This is to consolidate the treatment and provide prognostic information.Tumor factors that preclude surgery include prevertebral fascia invasion, skull base |
Surgery_Schwartz_4404 | Surgery_Schwartz | 8 weeks after completion of radiotherapy. This is to consolidate the treatment and provide prognostic information.Tumor factors that preclude surgery include prevertebral fascia invasion, skull base invasion, and >270o circumferential encasement of the internal carotid artery. These factors are asso-ciated with very poor 5-year survival (<20%). In such cases, sac-rifice of the carotid is not indicated given the risk of stroke and death. Surgical debulking is also not associated with improved survival. However, there is a role for neoadjuvant chemother-apy, and in those that respond and if the disease becomes resect-able, survival benefit has been demonstrated.189 Recurrent neck metastasis after radiotherapy to the neck or a comprehensive neck dissection is associated with very poor survival.190Parapharyngeal Space Masses. The parapharyngeal space is a potential inverted pyramidal space bordered superiorly at the skull base along the sphenoid and inferiorly at the greater cornu of the | Surgery_Schwartz. 8 weeks after completion of radiotherapy. This is to consolidate the treatment and provide prognostic information.Tumor factors that preclude surgery include prevertebral fascia invasion, skull base invasion, and >270o circumferential encasement of the internal carotid artery. These factors are asso-ciated with very poor 5-year survival (<20%). In such cases, sac-rifice of the carotid is not indicated given the risk of stroke and death. Surgical debulking is also not associated with improved survival. However, there is a role for neoadjuvant chemother-apy, and in those that respond and if the disease becomes resect-able, survival benefit has been demonstrated.189 Recurrent neck metastasis after radiotherapy to the neck or a comprehensive neck dissection is associated with very poor survival.190Parapharyngeal Space Masses. The parapharyngeal space is a potential inverted pyramidal space bordered superiorly at the skull base along the sphenoid and inferiorly at the greater cornu of the |
Surgery_Schwartz_4405 | Surgery_Schwartz | Space Masses. The parapharyngeal space is a potential inverted pyramidal space bordered superiorly at the skull base along the sphenoid and inferiorly at the greater cornu of the hyoid. Medially it is bordered by the buccopha-ryngeal fascia covering the superior constrictor, anteriorly the pterygomandibular raphe, posteriorly the prevertebral fascia, and laterally by the deep surface of the parotid gland and ramus of the mandible. The differential diagnosis for parapharyngeal masses is very much dependent on the anatomy and contents of this space which is divided into the preand poststyloid spaces by the tensor-styloid fascia. This fascia attaches the tensor veli palatini muscle to the styloid. The contents of the prestyloid parapharyngeal space include fat, the deep lobe of the parotid, and lymph nodes, and branches of V3 (lingual, inferior alveo-lus, and auriculotemporal nerves), whereas the contents of the poststyloid space including cranial nerves IX to XII, the inter-nal jugular | Surgery_Schwartz. Space Masses. The parapharyngeal space is a potential inverted pyramidal space bordered superiorly at the skull base along the sphenoid and inferiorly at the greater cornu of the hyoid. Medially it is bordered by the buccopha-ryngeal fascia covering the superior constrictor, anteriorly the pterygomandibular raphe, posteriorly the prevertebral fascia, and laterally by the deep surface of the parotid gland and ramus of the mandible. The differential diagnosis for parapharyngeal masses is very much dependent on the anatomy and contents of this space which is divided into the preand poststyloid spaces by the tensor-styloid fascia. This fascia attaches the tensor veli palatini muscle to the styloid. The contents of the prestyloid parapharyngeal space include fat, the deep lobe of the parotid, and lymph nodes, and branches of V3 (lingual, inferior alveo-lus, and auriculotemporal nerves), whereas the contents of the poststyloid space including cranial nerves IX to XII, the inter-nal jugular |
Surgery_Schwartz_4406 | Surgery_Schwartz | and lymph nodes, and branches of V3 (lingual, inferior alveo-lus, and auriculotemporal nerves), whereas the contents of the poststyloid space including cranial nerves IX to XII, the inter-nal jugular vein, the internal carotid artery, and the sympathetic chain. Nearly half of all parapharyngeal masses are of parotid origin, while 20% to 25% are of neurogenic origin, such as paragangliomas (glomus vagale, carotid body tumor), schwan-nomas, and neurofibromas. Lymphatic origin masses such as lymphoma and lymph node metastases represent 15% of tumors at this subsite. Therefore, most prestyloid lesions are considered of salivary gland origin, whereas poststyloid lesions are typi-cally vascular or neurogenic.Tumors of the parapharyngeal space can displace the lat-eral pharyngeal wall medially into the oropharynx (Fig. 18-41) and can thus cause obstructive sleep apnea, voice change, and dysphagia in addition to cranial neuropathies, Horner’s syn-drome, or vascular compression. In addition to | Surgery_Schwartz. and lymph nodes, and branches of V3 (lingual, inferior alveo-lus, and auriculotemporal nerves), whereas the contents of the poststyloid space including cranial nerves IX to XII, the inter-nal jugular vein, the internal carotid artery, and the sympathetic chain. Nearly half of all parapharyngeal masses are of parotid origin, while 20% to 25% are of neurogenic origin, such as paragangliomas (glomus vagale, carotid body tumor), schwan-nomas, and neurofibromas. Lymphatic origin masses such as lymphoma and lymph node metastases represent 15% of tumors at this subsite. Therefore, most prestyloid lesions are considered of salivary gland origin, whereas poststyloid lesions are typi-cally vascular or neurogenic.Tumors of the parapharyngeal space can displace the lat-eral pharyngeal wall medially into the oropharynx (Fig. 18-41) and can thus cause obstructive sleep apnea, voice change, and dysphagia in addition to cranial neuropathies, Horner’s syn-drome, or vascular compression. In addition to |
Surgery_Schwartz_4407 | Surgery_Schwartz | the oropharynx (Fig. 18-41) and can thus cause obstructive sleep apnea, voice change, and dysphagia in addition to cranial neuropathies, Horner’s syn-drome, or vascular compression. In addition to CT and MRI, poststyloid lesions should be investigated with a 24-hour uri-nary catecholamine collection because some paragangliomas are functional and this should be managed preoperatively.Surgical access to these tumors can be performed using a purely transcervical approach with the excision of the subman-dibular gland for access. A transfacial or transparotid approach can be used as an adjunct for certain tumors by removing the parotid gland. This ensures identification of the facial nerve Figure 18-39. Shaded region indicates the region included in a posterolateral neck dissection.ParotidglandStylomandibularligamentFigure 18-40. Parapharyngeal mass—prestyloid with prominent oropharyngeal presentation typical of a dumbbell tumor.Brunicardi_Ch18_p0613-p0660.indd 64801/03/19 5:24 PM | Surgery_Schwartz. the oropharynx (Fig. 18-41) and can thus cause obstructive sleep apnea, voice change, and dysphagia in addition to cranial neuropathies, Horner’s syn-drome, or vascular compression. In addition to CT and MRI, poststyloid lesions should be investigated with a 24-hour uri-nary catecholamine collection because some paragangliomas are functional and this should be managed preoperatively.Surgical access to these tumors can be performed using a purely transcervical approach with the excision of the subman-dibular gland for access. A transfacial or transparotid approach can be used as an adjunct for certain tumors by removing the parotid gland. This ensures identification of the facial nerve Figure 18-39. Shaded region indicates the region included in a posterolateral neck dissection.ParotidglandStylomandibularligamentFigure 18-40. Parapharyngeal mass—prestyloid with prominent oropharyngeal presentation typical of a dumbbell tumor.Brunicardi_Ch18_p0613-p0660.indd 64801/03/19 5:24 PM |
Surgery_Schwartz_4408 | Surgery_Schwartz | 18-40. Parapharyngeal mass—prestyloid with prominent oropharyngeal presentation typical of a dumbbell tumor.Brunicardi_Ch18_p0613-p0660.indd 64801/03/19 5:24 PM 649DISORDERS OF THE HEAD AND NECKCHAPTER 18prior to removal of the mass, which is just deep to it. Rarely, a transmandibular approach is required by performing a midline or parasymphyseal mandibulotomy with a lateral swing. Tran-soral approaches have been described, but they are not recom-mended and are largely contraindicated due to poor exposure and control of the associated vasculature.Benign Neck Masses. Many benign neck masses require surgical intervention for diagnostic, cosmetic, and symptom-atic relief. This is particularly true for lesions that are prone to recurrent infections, especially in the pediatric population. Such masses include thyroglossal duct cyst, branchial cleft cyst, lymphangioma (cystic hygroma), hemangioma, and der-moid cyst. Lymphangioma and hemangioma were previously discussed and will not be | Surgery_Schwartz. 18-40. Parapharyngeal mass—prestyloid with prominent oropharyngeal presentation typical of a dumbbell tumor.Brunicardi_Ch18_p0613-p0660.indd 64801/03/19 5:24 PM 649DISORDERS OF THE HEAD AND NECKCHAPTER 18prior to removal of the mass, which is just deep to it. Rarely, a transmandibular approach is required by performing a midline or parasymphyseal mandibulotomy with a lateral swing. Tran-soral approaches have been described, but they are not recom-mended and are largely contraindicated due to poor exposure and control of the associated vasculature.Benign Neck Masses. Many benign neck masses require surgical intervention for diagnostic, cosmetic, and symptom-atic relief. This is particularly true for lesions that are prone to recurrent infections, especially in the pediatric population. Such masses include thyroglossal duct cyst, branchial cleft cyst, lymphangioma (cystic hygroma), hemangioma, and der-moid cyst. Lymphangioma and hemangioma were previously discussed and will not be |
Surgery_Schwartz_4409 | Surgery_Schwartz | Such masses include thyroglossal duct cyst, branchial cleft cyst, lymphangioma (cystic hygroma), hemangioma, and der-moid cyst. Lymphangioma and hemangioma were previously discussed and will not be discussed in this section.During fetal growth, the thyroid gland descends along a tract from the foramen cecum at the base of tongue into the ante-rior low neck. A vestigial remainder of this tract is called a thy-roglossal duct cyst, which typically presents as a subcutaneous swelling near the hyoid in the midline or slightly paramedian. Patients may complain of recurrent infections of this mass after an upper respiratory tract infection. Investigations include thy-roid function tests and a neck and thyroid ultrasound to confirm that the patient has thyroid tissue in the lower neck . Treatment involves removal of the cyst, the tract, and the central portion of the hyoid (Sistrunk procedure), often with a small portion of the base of tongue if the tract extends above the hyoid.During fetal | Surgery_Schwartz. Such masses include thyroglossal duct cyst, branchial cleft cyst, lymphangioma (cystic hygroma), hemangioma, and der-moid cyst. Lymphangioma and hemangioma were previously discussed and will not be discussed in this section.During fetal growth, the thyroid gland descends along a tract from the foramen cecum at the base of tongue into the ante-rior low neck. A vestigial remainder of this tract is called a thy-roglossal duct cyst, which typically presents as a subcutaneous swelling near the hyoid in the midline or slightly paramedian. Patients may complain of recurrent infections of this mass after an upper respiratory tract infection. Investigations include thy-roid function tests and a neck and thyroid ultrasound to confirm that the patient has thyroid tissue in the lower neck . Treatment involves removal of the cyst, the tract, and the central portion of the hyoid (Sistrunk procedure), often with a small portion of the base of tongue if the tract extends above the hyoid.During fetal |
Surgery_Schwartz_4410 | Surgery_Schwartz | involves removal of the cyst, the tract, and the central portion of the hyoid (Sistrunk procedure), often with a small portion of the base of tongue if the tract extends above the hyoid.During fetal growth, the branchial cleft apparatus may persist, forming a branchial cleft remnant (cyst, sinus, or tract), numbered to their corresponding embryologic branchial cleft. First branchial cleft anomalies parallel the EAC (Work Type I; preauricular) or go through the parotid gland ending at the bony-cartilaginous EAC junction (Work Type II; angle of the mandible). Second branchial anomalies (Fig. 18-42), the most common type, start at the anterior border of the SCM and head toward the tonsillar fossa traveling deep to second arch struc-tures (CN VII and external carotid artery) and superficial to third arch structures (stylopharyngeus, IX, and internal carotid artery). Third and fourth branchial anomalies are difficult to dis-tinguish clinically and frequently open into the pyriform sinus | Surgery_Schwartz. involves removal of the cyst, the tract, and the central portion of the hyoid (Sistrunk procedure), often with a small portion of the base of tongue if the tract extends above the hyoid.During fetal growth, the branchial cleft apparatus may persist, forming a branchial cleft remnant (cyst, sinus, or tract), numbered to their corresponding embryologic branchial cleft. First branchial cleft anomalies parallel the EAC (Work Type I; preauricular) or go through the parotid gland ending at the bony-cartilaginous EAC junction (Work Type II; angle of the mandible). Second branchial anomalies (Fig. 18-42), the most common type, start at the anterior border of the SCM and head toward the tonsillar fossa traveling deep to second arch struc-tures (CN VII and external carotid artery) and superficial to third arch structures (stylopharyngeus, IX, and internal carotid artery). Third and fourth branchial anomalies are difficult to dis-tinguish clinically and frequently open into the pyriform sinus |
Surgery_Schwartz_4411 | Surgery_Schwartz | to third arch structures (stylopharyngeus, IX, and internal carotid artery). Third and fourth branchial anomalies are difficult to dis-tinguish clinically and frequently open into the pyriform sinus often presenting with recurrent thyroid infections.191 These anomalies ascend posterior the internal carotid artery and deep to CN IX but superficial to CN XI and XII. Dermoid cysts tend to present as midline masses and represent trapped epithelium originating from the embryonic closure of the midline. These can be reliably diagnosed and distinguished from thyroglossal duct cysts using an ultrasound predictive model.192Cervical Fascial Planes. The fascial planes often predict the pathway and extent of infectious spread in the neck and are there-fore clinically important. The deep fascial layers of the neck Figure 18-41. Computed tomography scan demonstrating a branchial cleft cyst with operative specimen.Facial n.Anterior facial v.Retromandibular v.Temporal branchFrontal branchPosterior | Surgery_Schwartz. to third arch structures (stylopharyngeus, IX, and internal carotid artery). Third and fourth branchial anomalies are difficult to dis-tinguish clinically and frequently open into the pyriform sinus often presenting with recurrent thyroid infections.191 These anomalies ascend posterior the internal carotid artery and deep to CN IX but superficial to CN XI and XII. Dermoid cysts tend to present as midline masses and represent trapped epithelium originating from the embryonic closure of the midline. These can be reliably diagnosed and distinguished from thyroglossal duct cysts using an ultrasound predictive model.192Cervical Fascial Planes. The fascial planes often predict the pathway and extent of infectious spread in the neck and are there-fore clinically important. The deep fascial layers of the neck Figure 18-41. Computed tomography scan demonstrating a branchial cleft cyst with operative specimen.Facial n.Anterior facial v.Retromandibular v.Temporal branchFrontal branchPosterior |
Surgery_Schwartz_4412 | Surgery_Schwartz | of the neck Figure 18-41. Computed tomography scan demonstrating a branchial cleft cyst with operative specimen.Facial n.Anterior facial v.Retromandibular v.Temporal branchFrontal branchPosterior bellyof digastric m.StylomastoidforamenCervicalbranchMasseter m.Zygomatic branchParotid ductBuccalbranchMandibularbranchFigure 18-42. Example of a tumor in the parotid with the pattern of the facial nerve and associated anatomy. m. = muscle; n. = nerve; v. = vein.Brunicardi_Ch18_p0613-p0660.indd 64901/03/19 5:24 PM 650SPECIFIC CONSIDERATIONSPART IIinclude three separate layers: the superficial deep (investing) layer, the pretracheal (visceral) layer, and the prevertebral layer. The investing layer forms a cone around the neck and surrounds the SCM muscle and the anterior and posterior neck. It spans from the mandible to the clavicle and manubrium. The visceral layer surrounds the trachea, thyroid, and esophagus and blends laterally with the carotid sheath extending inferiorly to the | Surgery_Schwartz. of the neck Figure 18-41. Computed tomography scan demonstrating a branchial cleft cyst with operative specimen.Facial n.Anterior facial v.Retromandibular v.Temporal branchFrontal branchPosterior bellyof digastric m.StylomastoidforamenCervicalbranchMasseter m.Zygomatic branchParotid ductBuccalbranchMandibularbranchFigure 18-42. Example of a tumor in the parotid with the pattern of the facial nerve and associated anatomy. m. = muscle; n. = nerve; v. = vein.Brunicardi_Ch18_p0613-p0660.indd 64901/03/19 5:24 PM 650SPECIFIC CONSIDERATIONSPART IIinclude three separate layers: the superficial deep (investing) layer, the pretracheal (visceral) layer, and the prevertebral layer. The investing layer forms a cone around the neck and surrounds the SCM muscle and the anterior and posterior neck. It spans from the mandible to the clavicle and manubrium. The visceral layer surrounds the trachea, thyroid, and esophagus and blends laterally with the carotid sheath extending inferiorly to the |
Surgery_Schwartz_4413 | Surgery_Schwartz | It spans from the mandible to the clavicle and manubrium. The visceral layer surrounds the trachea, thyroid, and esophagus and blends laterally with the carotid sheath extending inferiorly to the upper mediastinum. Between this layer and the prevertebral fascia is the retropharyngeal space. The prevertebral fascia covers the pre-vertebral musculature and space and extends down to the tho-racic vertebra and diaphragm. Infections of the prevertebral space between this fascia and the prevertebral musculature are considered to be in the prevertebral space and can extend all the way down to the sacrum. Therefore, neck infections can extend to the mediasti-num or beyond and need to be treated aggressively.Salivary Gland TumorsPrimary malignant tumors of the salivary glands are relatively rare and account for <2% of all head and neck malignancies. As previously mentioned, minor salivary gland malignancies can present anywhere in the upper aerodigestive tract, particularly on the palate; | Surgery_Schwartz. It spans from the mandible to the clavicle and manubrium. The visceral layer surrounds the trachea, thyroid, and esophagus and blends laterally with the carotid sheath extending inferiorly to the upper mediastinum. Between this layer and the prevertebral fascia is the retropharyngeal space. The prevertebral fascia covers the pre-vertebral musculature and space and extends down to the tho-racic vertebra and diaphragm. Infections of the prevertebral space between this fascia and the prevertebral musculature are considered to be in the prevertebral space and can extend all the way down to the sacrum. Therefore, neck infections can extend to the mediasti-num or beyond and need to be treated aggressively.Salivary Gland TumorsPrimary malignant tumors of the salivary glands are relatively rare and account for <2% of all head and neck malignancies. As previously mentioned, minor salivary gland malignancies can present anywhere in the upper aerodigestive tract, particularly on the palate; |
Surgery_Schwartz_4414 | Surgery_Schwartz | and account for <2% of all head and neck malignancies. As previously mentioned, minor salivary gland malignancies can present anywhere in the upper aerodigestive tract, particularly on the palate; however, the major salivary glands are the parotid, submandibular, and sublingual glands. The majority of tumors (80%) arise in the parotid gland (Fig. 18-44); however, 80% of these are benign, most commonly, pleomorphic adenomas (benign mixed tumors). As the salivary gland gets smaller, the proportion of tumors that are malignant increases; 50% of sub-mandibular/sublingual tumors and 80% of minor salivary gland tumors are malignant.Patients typically present with a mass because these tumors are well circumscribed and slow growing. However, certain signs and symptoms, such as pain, paresthesia, facial nerve weakness, or rapid growth, raise the concern for malig-nancy. If there is facial nerve weakness (10%–15% of cases), this usually represents tumor invading the facial nerve. Sub-mandibular | Surgery_Schwartz. and account for <2% of all head and neck malignancies. As previously mentioned, minor salivary gland malignancies can present anywhere in the upper aerodigestive tract, particularly on the palate; however, the major salivary glands are the parotid, submandibular, and sublingual glands. The majority of tumors (80%) arise in the parotid gland (Fig. 18-44); however, 80% of these are benign, most commonly, pleomorphic adenomas (benign mixed tumors). As the salivary gland gets smaller, the proportion of tumors that are malignant increases; 50% of sub-mandibular/sublingual tumors and 80% of minor salivary gland tumors are malignant.Patients typically present with a mass because these tumors are well circumscribed and slow growing. However, certain signs and symptoms, such as pain, paresthesia, facial nerve weakness, or rapid growth, raise the concern for malig-nancy. If there is facial nerve weakness (10%–15% of cases), this usually represents tumor invading the facial nerve. Sub-mandibular |
Surgery_Schwartz_4415 | Surgery_Schwartz | nerve weakness, or rapid growth, raise the concern for malig-nancy. If there is facial nerve weakness (10%–15% of cases), this usually represents tumor invading the facial nerve. Sub-mandibular and sublingual tumors present with a mass or swell-ing in the neck or floor of the mouth, respectively. Tumors in this region can invade the lingual nerve leading to tongue par-esthesia or the hypoglossal nerve invasion leading to paralysis. The close proximity to the mandible and tongue necessitates a thorough bimanual palpation to assess for fixation to these structures.The decision to dissect the neck in parotid cancers is fraught with uncertainty. However, parotid malignancies, par-ticularly carcinomas, have a propensity for regional lymphatic spread, first to the intraand periglandular nodes followed by the upper cervical chain (levels I–III). Occult nodal metastases are present in 30% of cases and are predicted by intraor peri-glandular nodes, high-risk histology (high histological | Surgery_Schwartz. nerve weakness, or rapid growth, raise the concern for malig-nancy. If there is facial nerve weakness (10%–15% of cases), this usually represents tumor invading the facial nerve. Sub-mandibular and sublingual tumors present with a mass or swell-ing in the neck or floor of the mouth, respectively. Tumors in this region can invade the lingual nerve leading to tongue par-esthesia or the hypoglossal nerve invasion leading to paralysis. The close proximity to the mandible and tongue necessitates a thorough bimanual palpation to assess for fixation to these structures.The decision to dissect the neck in parotid cancers is fraught with uncertainty. However, parotid malignancies, par-ticularly carcinomas, have a propensity for regional lymphatic spread, first to the intraand periglandular nodes followed by the upper cervical chain (levels I–III). Occult nodal metastases are present in 30% of cases and are predicted by intraor peri-glandular nodes, high-risk histology (high histological |
Surgery_Schwartz_4416 | Surgery_Schwartz | followed by the upper cervical chain (levels I–III). Occult nodal metastases are present in 30% of cases and are predicted by intraor peri-glandular nodes, high-risk histology (high histological grade), and extraparotid extension.193 Patients with advanced tumor stage (T3/T4a), perineural invasion, high risk histology, or clin-ically involved adenopathy should have their neck dissected. Submandibular gland cancers metastasize to the submental (Ia) and submandibular triangle lymph nodes followed by the upper cervical chain (levels II–III). Extraglandular extension and regional metastases are poor prognostic factors.Following a thorough history and physical examination, an FNA biopsy should be performed to provide an accurate preoperative diagnosis in 70% to 80% of cases when reviewed by an experienced cytopathologist. If the biopsy is nondiag-nostic, a repeat biopsy should be performed under image-guidance, typically with an ultrasound. An open or incisional biopsy should be avoided | Surgery_Schwartz. followed by the upper cervical chain (levels I–III). Occult nodal metastases are present in 30% of cases and are predicted by intraor peri-glandular nodes, high-risk histology (high histological grade), and extraparotid extension.193 Patients with advanced tumor stage (T3/T4a), perineural invasion, high risk histology, or clin-ically involved adenopathy should have their neck dissected. Submandibular gland cancers metastasize to the submental (Ia) and submandibular triangle lymph nodes followed by the upper cervical chain (levels II–III). Extraglandular extension and regional metastases are poor prognostic factors.Following a thorough history and physical examination, an FNA biopsy should be performed to provide an accurate preoperative diagnosis in 70% to 80% of cases when reviewed by an experienced cytopathologist. If the biopsy is nondiag-nostic, a repeat biopsy should be performed under image-guidance, typically with an ultrasound. An open or incisional biopsy should be avoided |
Surgery_Schwartz_4417 | Surgery_Schwartz | an experienced cytopathologist. If the biopsy is nondiag-nostic, a repeat biopsy should be performed under image-guidance, typically with an ultrasound. An open or incisional biopsy should be avoided because of the risk of tumor spill-age and cutaneous spread. Also, this approach is fraught with risk to the facial nerve. Salivary gland tumors are worked up with appropriate imaging, typically with an MRI because of the increased soft tissue definition. FNA and imaging results are critical in guiding the surgeon to the extent of surgery. The minimal extent of surgery for salivary gland tumors is a superficial parotidectomy, removing all of the salivary gland tissue superficial to CN VII, which is meticulously dissected during this procedure.The final histopathologic diagnosis in salivary gland tumors can be challenging. Nonetheless, there is a well-outlined histological classification used by pathologists.194 Benign and malignant tumors of the salivary glands are divided into | Surgery_Schwartz. an experienced cytopathologist. If the biopsy is nondiag-nostic, a repeat biopsy should be performed under image-guidance, typically with an ultrasound. An open or incisional biopsy should be avoided because of the risk of tumor spill-age and cutaneous spread. Also, this approach is fraught with risk to the facial nerve. Salivary gland tumors are worked up with appropriate imaging, typically with an MRI because of the increased soft tissue definition. FNA and imaging results are critical in guiding the surgeon to the extent of surgery. The minimal extent of surgery for salivary gland tumors is a superficial parotidectomy, removing all of the salivary gland tissue superficial to CN VII, which is meticulously dissected during this procedure.The final histopathologic diagnosis in salivary gland tumors can be challenging. Nonetheless, there is a well-outlined histological classification used by pathologists.194 Benign and malignant tumors of the salivary glands are divided into |
Surgery_Schwartz_4418 | Surgery_Schwartz | gland tumors can be challenging. Nonetheless, there is a well-outlined histological classification used by pathologists.194 Benign and malignant tumors of the salivary glands are divided into epi-thelial, nonepithelial, and metastatic neoplasms. Benign epithe-lial tumors are most commonly pleomorphic adenoma (85%), monomorphic adenoma, Warthin’s tumor (papillary cystad-enoma lymphomatosum), oncocytoma, or sebaceous neoplasm. Nonepithelial benign lesions include lipoma and hemangioma. Treatment of benign neoplasms is surgical excision for diag-nostic and therapeutic purposes. The parotid superficial lobe is usually dissected off of the facial nerve, which is preserved. For pleomorphic adenoma, an extracapsular dissection is favored over enucleation due to tumor pseudopods, incomplete excision, and a higher risk of tumor spillage, all of which are associated with higher recurrence rates.195 Recurrence is associated with a high degree of morbidity.Malignant epithelial tumors range in | Surgery_Schwartz. gland tumors can be challenging. Nonetheless, there is a well-outlined histological classification used by pathologists.194 Benign and malignant tumors of the salivary glands are divided into epi-thelial, nonepithelial, and metastatic neoplasms. Benign epithe-lial tumors are most commonly pleomorphic adenoma (85%), monomorphic adenoma, Warthin’s tumor (papillary cystad-enoma lymphomatosum), oncocytoma, or sebaceous neoplasm. Nonepithelial benign lesions include lipoma and hemangioma. Treatment of benign neoplasms is surgical excision for diag-nostic and therapeutic purposes. The parotid superficial lobe is usually dissected off of the facial nerve, which is preserved. For pleomorphic adenoma, an extracapsular dissection is favored over enucleation due to tumor pseudopods, incomplete excision, and a higher risk of tumor spillage, all of which are associated with higher recurrence rates.195 Recurrence is associated with a high degree of morbidity.Malignant epithelial tumors range in |
Surgery_Schwartz_4419 | Surgery_Schwartz | and a higher risk of tumor spillage, all of which are associated with higher recurrence rates.195 Recurrence is associated with a high degree of morbidity.Malignant epithelial tumors range in aggressiveness based on tumor histology, grade, perineural invasion, and regional metastases. Mucoepidermoid carcinoma is the most common primary malignancy of the salivary glands and can be high grade (more epidermoid) or low grade (more mucinous). High grade mucoepidermoid carcinoma can be hard to differentiated from squamous cell carcinoma, particularly on FNA. Adenoid cystic is the second most common primary salivary gland malignancy and has three histological subtypes: tubular, cribriform, and solid. Higher grade/risk tumors have a higher degree of solid differentiation.194 Adenoid cystic cancers are known for peri-neural invasion and late recurrences and distant metastases. Car-cinoma ex pleomorphic adenoma is an aggressive malignancy that arises from a preexisting benign mixed tumor | Surgery_Schwartz. and a higher risk of tumor spillage, all of which are associated with higher recurrence rates.195 Recurrence is associated with a high degree of morbidity.Malignant epithelial tumors range in aggressiveness based on tumor histology, grade, perineural invasion, and regional metastases. Mucoepidermoid carcinoma is the most common primary malignancy of the salivary glands and can be high grade (more epidermoid) or low grade (more mucinous). High grade mucoepidermoid carcinoma can be hard to differentiated from squamous cell carcinoma, particularly on FNA. Adenoid cystic is the second most common primary salivary gland malignancy and has three histological subtypes: tubular, cribriform, and solid. Higher grade/risk tumors have a higher degree of solid differentiation.194 Adenoid cystic cancers are known for peri-neural invasion and late recurrences and distant metastases. Car-cinoma ex pleomorphic adenoma is an aggressive malignancy that arises from a preexisting benign mixed tumor |
Surgery_Schwartz_4420 | Surgery_Schwartz | cancers are known for peri-neural invasion and late recurrences and distant metastases. Car-cinoma ex pleomorphic adenoma is an aggressive malignancy that arises from a preexisting benign mixed tumor highlighting the importance of removing these benign masses before malig-nant transformation.Surgical excision remains the standard of care, typi-cally with facial nerve preservation unless the nerve is directly invaded by tumor. For tumors that extend beyond the superficial lobe, nerve branches can be splayed, and a total parotid can be performed by removing parotid tissue deep to the nerve while preserving the integrity and function of the nerve. Whenever possible, the nerve is preserved even if microscopic disease is left on the nerve, so long as gross tumor is not left behind (i.e., the nerve is not encased). If this is not possible or if the nerve is not working preoperatively, nerve sacrifice is usually recommended.Elective neck dissection is warranted in high-grade muco-epidermoid | Surgery_Schwartz. cancers are known for peri-neural invasion and late recurrences and distant metastases. Car-cinoma ex pleomorphic adenoma is an aggressive malignancy that arises from a preexisting benign mixed tumor highlighting the importance of removing these benign masses before malig-nant transformation.Surgical excision remains the standard of care, typi-cally with facial nerve preservation unless the nerve is directly invaded by tumor. For tumors that extend beyond the superficial lobe, nerve branches can be splayed, and a total parotid can be performed by removing parotid tissue deep to the nerve while preserving the integrity and function of the nerve. Whenever possible, the nerve is preserved even if microscopic disease is left on the nerve, so long as gross tumor is not left behind (i.e., the nerve is not encased). If this is not possible or if the nerve is not working preoperatively, nerve sacrifice is usually recommended.Elective neck dissection is warranted in high-grade muco-epidermoid |
Surgery_Schwartz_4421 | Surgery_Schwartz | is not encased). If this is not possible or if the nerve is not working preoperatively, nerve sacrifice is usually recommended.Elective neck dissection is warranted in high-grade muco-epidermoid carcinomas and other high-risk pathology and grade where the risk of occult disease is greater than 15% to 20%. Therapeutic neck dissection is recommended in patients with clinically or radiographically evident disease. Postoperative radiotherapy is indicated in patients with perineural invasion, advanced local disease (T4a), extraglandular disease including regional metastases, and high-grade histology.Brunicardi_Ch18_p0613-p0660.indd 65001/03/19 5:24 PM 651DISORDERS OF THE HEAD AND NECKCHAPTER 18RECONSTRUCTIONLocal Flaps and Skin GraftsLocal flaps are commonly used for cutaneous reconstruction in the head and neck. Local flaps are most commonly utilized for reconstruction after Mohs micrographic surgery for cutaneous malignancy, or for reconstruction of melanoma defects. Skin grafts are | Surgery_Schwartz. is not encased). If this is not possible or if the nerve is not working preoperatively, nerve sacrifice is usually recommended.Elective neck dissection is warranted in high-grade muco-epidermoid carcinomas and other high-risk pathology and grade where the risk of occult disease is greater than 15% to 20%. Therapeutic neck dissection is recommended in patients with clinically or radiographically evident disease. Postoperative radiotherapy is indicated in patients with perineural invasion, advanced local disease (T4a), extraglandular disease including regional metastases, and high-grade histology.Brunicardi_Ch18_p0613-p0660.indd 65001/03/19 5:24 PM 651DISORDERS OF THE HEAD AND NECKCHAPTER 18RECONSTRUCTIONLocal Flaps and Skin GraftsLocal flaps are commonly used for cutaneous reconstruction in the head and neck. Local flaps are most commonly utilized for reconstruction after Mohs micrographic surgery for cutaneous malignancy, or for reconstruction of melanoma defects. Skin grafts are |
Surgery_Schwartz_4422 | Surgery_Schwartz | in the head and neck. Local flaps are most commonly utilized for reconstruction after Mohs micrographic surgery for cutaneous malignancy, or for reconstruction of melanoma defects. Skin grafts are also commonly used for reconstruction of scalp defects after surgical resection of cutaneous malignancies. Skin grafts may also be utilized in the oral cavity for resurfacing of super-ficial defects of the tongue, floor of mouth, and buccal mucosa.Regional FlapsThree regional flaps deserve mention as potential flaps for head and neck reconstruction. The first is the pectoralis major myo-cutaneous flap, based upon the thoracoacromial artery.196 This flap may be used as a primary option for hypopharyngeal recon-struction after total laryngectomy. This flap may also be utilized to protect the great vessels from becoming exposed, or as a sal-vage reconstructive procedure should the great vessels become exposed. Another commonly utilized regional flap is the sub-mental flap, based upon the | Surgery_Schwartz. in the head and neck. Local flaps are most commonly utilized for reconstruction after Mohs micrographic surgery for cutaneous malignancy, or for reconstruction of melanoma defects. Skin grafts are also commonly used for reconstruction of scalp defects after surgical resection of cutaneous malignancies. Skin grafts may also be utilized in the oral cavity for resurfacing of super-ficial defects of the tongue, floor of mouth, and buccal mucosa.Regional FlapsThree regional flaps deserve mention as potential flaps for head and neck reconstruction. The first is the pectoralis major myo-cutaneous flap, based upon the thoracoacromial artery.196 This flap may be used as a primary option for hypopharyngeal recon-struction after total laryngectomy. This flap may also be utilized to protect the great vessels from becoming exposed, or as a sal-vage reconstructive procedure should the great vessels become exposed. Another commonly utilized regional flap is the sub-mental flap, based upon the |
Surgery_Schwartz_4423 | Surgery_Schwartz | great vessels from becoming exposed, or as a sal-vage reconstructive procedure should the great vessels become exposed. Another commonly utilized regional flap is the sub-mental flap, based upon the submental vessel branches of the facial artery. This flap may be utilized for intraoral reconstruc-tion and/or parotid and temporal bone reconstruction.197 Care must be taken during the neck dissection in order to preserve the submental vessels that supply this flap. Finally, the supraclavic-ular flap is based upon the supraclavicular artery, arising from the transverse cervical artery.198 This is a thin, fasciocutaneous flap that is commonly used for external neck and facial recon-struction in which thin tissue is desired.Free Tissue TransferThe majority of major defects of the head and neck require free tissue transfer for optimal reconstruction.199 A full discussion of head and neck reconstructive microsurgery is beyond the scope of this chapter; however, a brief overview of free tissue | Surgery_Schwartz. great vessels from becoming exposed, or as a sal-vage reconstructive procedure should the great vessels become exposed. Another commonly utilized regional flap is the sub-mental flap, based upon the submental vessel branches of the facial artery. This flap may be utilized for intraoral reconstruc-tion and/or parotid and temporal bone reconstruction.197 Care must be taken during the neck dissection in order to preserve the submental vessels that supply this flap. Finally, the supraclavic-ular flap is based upon the supraclavicular artery, arising from the transverse cervical artery.198 This is a thin, fasciocutaneous flap that is commonly used for external neck and facial recon-struction in which thin tissue is desired.Free Tissue TransferThe majority of major defects of the head and neck require free tissue transfer for optimal reconstruction.199 A full discussion of head and neck reconstructive microsurgery is beyond the scope of this chapter; however, a brief overview of free tissue |
Surgery_Schwartz_4424 | Surgery_Schwartz | free tissue transfer for optimal reconstruction.199 A full discussion of head and neck reconstructive microsurgery is beyond the scope of this chapter; however, a brief overview of free tissue transfer is provided in this section. Free tissue transfer allows the sur-geon to transplant tissue from a wide array of donor sites, each of which have distinct advantages.200 For example, for floor of mouth reconstruction, where thin tissue is desired, the surgeon may select the radial forearm as the donor site. On the other hand, when presented with a total glossectomy defect, where thick tissue is desired for adequate volume reconstruction, the rectus may be the optimal donor site. Considering osseous defects, for reconstruction of a segmental mandible defect with minimal soft tissue deficit, the fibula osseocutaneous free tis-sue transfer may be the optimal choice.201 On the other hand, reconstruction of an osseous mandible defect with a large muco-sal and external soft tissue deficit may | Surgery_Schwartz. free tissue transfer for optimal reconstruction.199 A full discussion of head and neck reconstructive microsurgery is beyond the scope of this chapter; however, a brief overview of free tissue transfer is provided in this section. Free tissue transfer allows the sur-geon to transplant tissue from a wide array of donor sites, each of which have distinct advantages.200 For example, for floor of mouth reconstruction, where thin tissue is desired, the surgeon may select the radial forearm as the donor site. On the other hand, when presented with a total glossectomy defect, where thick tissue is desired for adequate volume reconstruction, the rectus may be the optimal donor site. Considering osseous defects, for reconstruction of a segmental mandible defect with minimal soft tissue deficit, the fibula osseocutaneous free tis-sue transfer may be the optimal choice.201 On the other hand, reconstruction of an osseous mandible defect with a large muco-sal and external soft tissue deficit may |
Surgery_Schwartz_4425 | Surgery_Schwartz | fibula osseocutaneous free tis-sue transfer may be the optimal choice.201 On the other hand, reconstruction of an osseous mandible defect with a large muco-sal and external soft tissue deficit may be best served by the scapula donor site, where vascularized bone can be combined with a large skin paddle, and an additional latissimus dorsi myocutaneous free tissue transfer, if needed.202 The ability to harvest tissue from multiple donor sites is critical to obtain-ing the optimal reconstructive result. Table 18-6 lists the com-monly utilized donor sites and their reconstructive advantages and disadvantages.Table 18-6Free tissue transfer donor sites for head and neck reconstructionFLAPBLOOD SUPPLYCHARACTERISTICSCOMMON DEFECTSRadial forearmRadial arteryThin, pliable, long pediclePartial and hemiglossectomy, floor of mouth, buccal defectsAnterolateral thighDescending branch of lateral femoral circumflex arteryThicker adipose than radial forearm, can have myocutaneous (most common) or | Surgery_Schwartz. fibula osseocutaneous free tis-sue transfer may be the optimal choice.201 On the other hand, reconstruction of an osseous mandible defect with a large muco-sal and external soft tissue deficit may be best served by the scapula donor site, where vascularized bone can be combined with a large skin paddle, and an additional latissimus dorsi myocutaneous free tissue transfer, if needed.202 The ability to harvest tissue from multiple donor sites is critical to obtain-ing the optimal reconstructive result. Table 18-6 lists the com-monly utilized donor sites and their reconstructive advantages and disadvantages.Table 18-6Free tissue transfer donor sites for head and neck reconstructionFLAPBLOOD SUPPLYCHARACTERISTICSCOMMON DEFECTSRadial forearmRadial arteryThin, pliable, long pediclePartial and hemiglossectomy, floor of mouth, buccal defectsAnterolateral thighDescending branch of lateral femoral circumflex arteryThicker adipose than radial forearm, can have myocutaneous (most common) or |
Surgery_Schwartz_4426 | Surgery_Schwartz | hemiglossectomy, floor of mouth, buccal defectsAnterolateral thighDescending branch of lateral femoral circumflex arteryThicker adipose than radial forearm, can have myocutaneous (most common) or septocutaneous perforatorsHypopharynx, external neck/facial skin, extended hemiglossectomy/total glossectomyLateral armPosterior radial collateral arteryOutstanding color match for facial skin, resists ptosis, diminutive pedicleParotid, temporal bone, external face and neck skinRectusDeep inferior epigastric arteryThick adipose tissue for large volume defects, long pedicle, poor external skin color matchTotal glossectomy, skull baseLatissimus dorsiThoracodorsal arteryLarge surface area of muscle, requires semi-lateral position, can be difficult for two-team harvestExtensive scalp and skull base defectsFibula osseocutaneousPeroneal arteryExcellent bone stock and length, long pedicle, thin skin paddleSegmental mandible and maxillaScapula osseocutaneousCircumflex scapular arteryLess bone | Surgery_Schwartz. hemiglossectomy, floor of mouth, buccal defectsAnterolateral thighDescending branch of lateral femoral circumflex arteryThicker adipose than radial forearm, can have myocutaneous (most common) or septocutaneous perforatorsHypopharynx, external neck/facial skin, extended hemiglossectomy/total glossectomyLateral armPosterior radial collateral arteryOutstanding color match for facial skin, resists ptosis, diminutive pedicleParotid, temporal bone, external face and neck skinRectusDeep inferior epigastric arteryThick adipose tissue for large volume defects, long pedicle, poor external skin color matchTotal glossectomy, skull baseLatissimus dorsiThoracodorsal arteryLarge surface area of muscle, requires semi-lateral position, can be difficult for two-team harvestExtensive scalp and skull base defectsFibula osseocutaneousPeroneal arteryExcellent bone stock and length, long pedicle, thin skin paddleSegmental mandible and maxillaScapula osseocutaneousCircumflex scapular arteryLess bone |
Surgery_Schwartz_4427 | Surgery_Schwartz | base defectsFibula osseocutaneousPeroneal arteryExcellent bone stock and length, long pedicle, thin skin paddleSegmental mandible and maxillaScapula osseocutaneousCircumflex scapular arteryLess bone length compared to fibula, large scapular or parascapular skin paddles ideal for large composite defectsSegmental mandible and maxilla defects with extensive soft tissue componentsRadial forearm osseocutaneousRadial arteryLong pedicle, diminutive bone stockPartial mandible defects, orbitIliac crestDeep circumflex iliac arteryUp to 16 cm of bone available, limited soft tissue, significant donor site morbiditySegmental mandible defects with small intraoral component and large external skin componentBrunicardi_Ch18_p0613-p0660.indd 65101/03/19 5:24 PM 652SPECIFIC CONSIDERATIONSPART IIFigure 18-43 shows a prototypical hemiglossectomy defect from a T2 N0 oral tongue cancer that was reconstructed with a rectangle template radial forearm free tissue transfer.203 The radial forearm free tissue | Surgery_Schwartz. base defectsFibula osseocutaneousPeroneal arteryExcellent bone stock and length, long pedicle, thin skin paddleSegmental mandible and maxillaScapula osseocutaneousCircumflex scapular arteryLess bone length compared to fibula, large scapular or parascapular skin paddles ideal for large composite defectsSegmental mandible and maxilla defects with extensive soft tissue componentsRadial forearm osseocutaneousRadial arteryLong pedicle, diminutive bone stockPartial mandible defects, orbitIliac crestDeep circumflex iliac arteryUp to 16 cm of bone available, limited soft tissue, significant donor site morbiditySegmental mandible defects with small intraoral component and large external skin componentBrunicardi_Ch18_p0613-p0660.indd 65101/03/19 5:24 PM 652SPECIFIC CONSIDERATIONSPART IIFigure 18-43 shows a prototypical hemiglossectomy defect from a T2 N0 oral tongue cancer that was reconstructed with a rectangle template radial forearm free tissue transfer.203 The radial forearm free tissue |
Surgery_Schwartz_4428 | Surgery_Schwartz | shows a prototypical hemiglossectomy defect from a T2 N0 oral tongue cancer that was reconstructed with a rectangle template radial forearm free tissue transfer.203 The radial forearm free tissue transfer provides thin, pliable tis-sue, with a long pedicle, and is a staple for hemiglossectomy and partial glossectomy reconstruction.Figure 18-44 shows a composite mandible defect from a T4a N0 mandibular alveolus cancer, after segmental mandibu-lectomy, reconstructed with a fibula osseocutaneous free tissue transfer.204 The 2.5-mm titanium reconstruction plate was bent to a mandible model. A template of the osseous defect is made and transferred to the fibula, and wedge ostectomies are made in the bone so that it can be snug fit into the bone defect.Figure 18-45 shows a palate defect after an infrastructure maxillectomy for a T2 N0 maxillary alveolus cancer. The defect resulted in direct communication with the buccal space, nasal cavity, and maxillary sinus. A radial forearm free tissue | Surgery_Schwartz. shows a prototypical hemiglossectomy defect from a T2 N0 oral tongue cancer that was reconstructed with a rectangle template radial forearm free tissue transfer.203 The radial forearm free tissue transfer provides thin, pliable tis-sue, with a long pedicle, and is a staple for hemiglossectomy and partial glossectomy reconstruction.Figure 18-44 shows a composite mandible defect from a T4a N0 mandibular alveolus cancer, after segmental mandibu-lectomy, reconstructed with a fibula osseocutaneous free tissue transfer.204 The 2.5-mm titanium reconstruction plate was bent to a mandible model. A template of the osseous defect is made and transferred to the fibula, and wedge ostectomies are made in the bone so that it can be snug fit into the bone defect.Figure 18-45 shows a palate defect after an infrastructure maxillectomy for a T2 N0 maxillary alveolus cancer. The defect resulted in direct communication with the buccal space, nasal cavity, and maxillary sinus. A radial forearm free tissue |
Surgery_Schwartz_4429 | Surgery_Schwartz | infrastructure maxillectomy for a T2 N0 maxillary alveolus cancer. The defect resulted in direct communication with the buccal space, nasal cavity, and maxillary sinus. A radial forearm free tissue transfer was utilized to achieve oronasal separation.TRACHEOTOMYIndications and TimingThe most common cause for tracheotomy is prolonged intuba-tion typically in critically ill intensive care unit patients. Pro-longed intubation increases the risk of laryngeal and subglottic injury, which may lead to stenosis. In the critically ill patient, it has been hypothesized that early tracheotomy may improve inpatient survival and decreased intensive care unit length of stay while increasing patient comfort. However, a large ran-domized clinical trial demonstrated no benefit from early tra-cheotomy on shortor long-term survival and other important secondary outcomes.205 Furthermore, clinicians are poor pre-dictors of which patients require extended ventilatory support. Another study demonstrated no | Surgery_Schwartz. infrastructure maxillectomy for a T2 N0 maxillary alveolus cancer. The defect resulted in direct communication with the buccal space, nasal cavity, and maxillary sinus. A radial forearm free tissue transfer was utilized to achieve oronasal separation.TRACHEOTOMYIndications and TimingThe most common cause for tracheotomy is prolonged intuba-tion typically in critically ill intensive care unit patients. Pro-longed intubation increases the risk of laryngeal and subglottic injury, which may lead to stenosis. In the critically ill patient, it has been hypothesized that early tracheotomy may improve inpatient survival and decreased intensive care unit length of stay while increasing patient comfort. However, a large ran-domized clinical trial demonstrated no benefit from early tra-cheotomy on shortor long-term survival and other important secondary outcomes.205 Furthermore, clinicians are poor pre-dictors of which patients require extended ventilatory support. Another study demonstrated no |
Surgery_Schwartz_4430 | Surgery_Schwartz | long-term survival and other important secondary outcomes.205 Furthermore, clinicians are poor pre-dictors of which patients require extended ventilatory support. Another study demonstrated no evidence that early tracheos-tomy reduced mortality, duration of mechanical ventilation, intensive care unit stay, or ventilatory associated pneumonia.206 It did, however, provide a shorter duration of sedation. Beyond prolonged intubation, tracheotomy is also indicated in patients who require frequent pulmonary toilet, in patients with neu-rologic deficits that impair protective airway reflexes, and in head and neck upper aerodigestive tract surgery as a temporary airway in the perioperative period to bypass airway obstruction.Technique and ComplicationsThe procedure can be performed using an open or a percuta-neous technique. Complications of tracheostomy include pneu-mothorax, tracheal stenosis, wound infection/stomatitis with large-vessel erosion, and failure to close after decannulation. A | Surgery_Schwartz. long-term survival and other important secondary outcomes.205 Furthermore, clinicians are poor pre-dictors of which patients require extended ventilatory support. Another study demonstrated no evidence that early tracheos-tomy reduced mortality, duration of mechanical ventilation, intensive care unit stay, or ventilatory associated pneumonia.206 It did, however, provide a shorter duration of sedation. Beyond prolonged intubation, tracheotomy is also indicated in patients who require frequent pulmonary toilet, in patients with neu-rologic deficits that impair protective airway reflexes, and in head and neck upper aerodigestive tract surgery as a temporary airway in the perioperative period to bypass airway obstruction.Technique and ComplicationsThe procedure can be performed using an open or a percuta-neous technique. Complications of tracheostomy include pneu-mothorax, tracheal stenosis, wound infection/stomatitis with large-vessel erosion, and failure to close after decannulation. A |
Surgery_Schwartz_4431 | Surgery_Schwartz | or a percuta-neous technique. Complications of tracheostomy include pneu-mothorax, tracheal stenosis, wound infection/stomatitis with large-vessel erosion, and failure to close after decannulation. A meta-analysis of 15 randomized studies assessing nearly 1000 patients demonstrated no difference between the open and percutaneous techniques, although there was a trend toward fewer complications in the percutaneous approach.207 The per-cutaneous approach was also found to be cheaper and had the added benefit of being performed at the bedside outside of the operating room. A Cochrane review on the topic lower wound infection/stomatitis and unfavorable scarring rates with the per-cutaneous approach.208 Mortality and serious adverse events did not differ between the two techniques.The use of cricothyroidotomy, typically in the emergency setting, is inferior to a tracheotomy due to higher incidence of vocal cord dysfunction and subglottic stenosis. There-fore, soon after a cricothyroidotomy | Surgery_Schwartz. or a percuta-neous technique. Complications of tracheostomy include pneu-mothorax, tracheal stenosis, wound infection/stomatitis with large-vessel erosion, and failure to close after decannulation. A meta-analysis of 15 randomized studies assessing nearly 1000 patients demonstrated no difference between the open and percutaneous techniques, although there was a trend toward fewer complications in the percutaneous approach.207 The per-cutaneous approach was also found to be cheaper and had the added benefit of being performed at the bedside outside of the operating room. A Cochrane review on the topic lower wound infection/stomatitis and unfavorable scarring rates with the per-cutaneous approach.208 Mortality and serious adverse events did not differ between the two techniques.The use of cricothyroidotomy, typically in the emergency setting, is inferior to a tracheotomy due to higher incidence of vocal cord dysfunction and subglottic stenosis. There-fore, soon after a cricothyroidotomy |
Surgery_Schwartz_4432 | Surgery_Schwartz | typically in the emergency setting, is inferior to a tracheotomy due to higher incidence of vocal cord dysfunction and subglottic stenosis. There-fore, soon after a cricothyroidotomy is performed, a formal Figure 18-43. A. Defect after left hemiglossectomy for T2 N0 oral tongue squamous cell carcinoma. B. Radial forearm free tissue transfer harvested for reconstruction. C. Inset of the radial forearm free tissue transfer.ABCBrunicardi_Ch18_p0613-p0660.indd 65201/03/19 5:25 PM 653DISORDERS OF THE HEAD AND NECKCHAPTER 18Figure 18-45. A. Palate defect after infrastructure maxillectomy for T2 N0 squamous cell carcinoma of the maxillary alveolus. B. Inset of radial forearm free tissue transfer. C. Six month postop-erative result, with complete oronasal separation and return to full, preoperative levels of speech and swallowing.tracheotomy should be used with decannulation of the crico-thyroidotomy site. Most tracheostomies are not permanent and can be reversed simply by removing the | Surgery_Schwartz. typically in the emergency setting, is inferior to a tracheotomy due to higher incidence of vocal cord dysfunction and subglottic stenosis. There-fore, soon after a cricothyroidotomy is performed, a formal Figure 18-43. A. Defect after left hemiglossectomy for T2 N0 oral tongue squamous cell carcinoma. B. Radial forearm free tissue transfer harvested for reconstruction. C. Inset of the radial forearm free tissue transfer.ABCBrunicardi_Ch18_p0613-p0660.indd 65201/03/19 5:25 PM 653DISORDERS OF THE HEAD AND NECKCHAPTER 18Figure 18-45. A. Palate defect after infrastructure maxillectomy for T2 N0 squamous cell carcinoma of the maxillary alveolus. B. Inset of radial forearm free tissue transfer. C. Six month postop-erative result, with complete oronasal separation and return to full, preoperative levels of speech and swallowing.tracheotomy should be used with decannulation of the crico-thyroidotomy site. Most tracheostomies are not permanent and can be reversed simply by removing the |
Surgery_Schwartz_4433 | Surgery_Schwartz | levels of speech and swallowing.tracheotomy should be used with decannulation of the crico-thyroidotomy site. Most tracheostomies are not permanent and can be reversed simply by removing the tube and applying a pressure dressing. The stoma usually spontaneously heals within 2 to 3 weeks.Speech with Tracheotomy and DecannulationWhen a large cuffed tracheostomy is initially placed, speech is not possible, particularly when the cuff is up. However, when the tube is downsized to a cuffless tracheostomy tube, ABCFigure 18-44. A. Segmental mandible defect after composite resec-tion for T4a N0 squamous cell carcinoma of the mandibular alveolus. B. Fibula free tissue transfer harvested for reconstruction and template for wedge ostectomy. C. Inset of fibula free tissue transfer.ABCBrunicardi_Ch18_p0613-p0660.indd 65301/03/19 5:25 PM 654SPECIFIC CONSIDERATIONSPART IIintermittent finger occlusion or placement of Passy-Muir valve can allow the patient to voice while still bypassing the upper | Surgery_Schwartz. levels of speech and swallowing.tracheotomy should be used with decannulation of the crico-thyroidotomy site. Most tracheostomies are not permanent and can be reversed simply by removing the tube and applying a pressure dressing. The stoma usually spontaneously heals within 2 to 3 weeks.Speech with Tracheotomy and DecannulationWhen a large cuffed tracheostomy is initially placed, speech is not possible, particularly when the cuff is up. However, when the tube is downsized to a cuffless tracheostomy tube, ABCFigure 18-44. A. Segmental mandible defect after composite resec-tion for T4a N0 squamous cell carcinoma of the mandibular alveolus. B. Fibula free tissue transfer harvested for reconstruction and template for wedge ostectomy. C. Inset of fibula free tissue transfer.ABCBrunicardi_Ch18_p0613-p0660.indd 65301/03/19 5:25 PM 654SPECIFIC CONSIDERATIONSPART IIintermittent finger occlusion or placement of Passy-Muir valve can allow the patient to voice while still bypassing the upper |
Surgery_Schwartz_4434 | Surgery_Schwartz | 65301/03/19 5:25 PM 654SPECIFIC CONSIDERATIONSPART IIintermittent finger occlusion or placement of Passy-Muir valve can allow the patient to voice while still bypassing the upper airway obstruction in inspiration. Prior to decannulation, the patient has to tolerate capping for 24 to 48 hours, but this period can be extended in patients with concerns for pulmonary toilet and an inability to clear secretions.LONG TERM MANAGEMENT AND REHABILITATIONPalliative CareFor patients with unresectable disease (greater than 180o of encasement around the carotid artery, prevertebral fascia inva-sion, and skull base invasion) or distant metastases, palliative care options exist. The NCCN guidelines recommend clinical trials for patients in this category because there is not a single accepted regimen for patients with incurable disease but the goal of treatment is to control symptoms and maintain quality of life while minimizing the side effects of treatment.106 This may include a combination of | Surgery_Schwartz. 65301/03/19 5:25 PM 654SPECIFIC CONSIDERATIONSPART IIintermittent finger occlusion or placement of Passy-Muir valve can allow the patient to voice while still bypassing the upper airway obstruction in inspiration. Prior to decannulation, the patient has to tolerate capping for 24 to 48 hours, but this period can be extended in patients with concerns for pulmonary toilet and an inability to clear secretions.LONG TERM MANAGEMENT AND REHABILITATIONPalliative CareFor patients with unresectable disease (greater than 180o of encasement around the carotid artery, prevertebral fascia inva-sion, and skull base invasion) or distant metastases, palliative care options exist. The NCCN guidelines recommend clinical trials for patients in this category because there is not a single accepted regimen for patients with incurable disease but the goal of treatment is to control symptoms and maintain quality of life while minimizing the side effects of treatment.106 This may include a combination of |
Surgery_Schwartz_4435 | Surgery_Schwartz | for patients with incurable disease but the goal of treatment is to control symptoms and maintain quality of life while minimizing the side effects of treatment.106 This may include a combination of radiotherapy, usually in a hypofrac-tionated pattern with high dose per fraction regimen, chemother-apy, or simply pain management. A recent trial demonstrated the utility of immunotherapy, specifically, Nivolumab, in the management of recurrent unresectable head and neck cancer, showing a higher response rate (13.3%) compared to standard therapy (5.8%) with lower treatment-related adverse events (13.1% vs. 35.1%, respectively).209 From a surgical perspective, some patients require tracheostomy or gastrostomy tube place-ment to manage airway compromise and dysphagia, respec-tively. Palliative care facilities and hospice care allow patients to retain dignity when they have a limited short-term outlook.Follow-Up CarePatients diagnosed and treated for a head and neck tumor require follow-up | Surgery_Schwartz. for patients with incurable disease but the goal of treatment is to control symptoms and maintain quality of life while minimizing the side effects of treatment.106 This may include a combination of radiotherapy, usually in a hypofrac-tionated pattern with high dose per fraction regimen, chemother-apy, or simply pain management. A recent trial demonstrated the utility of immunotherapy, specifically, Nivolumab, in the management of recurrent unresectable head and neck cancer, showing a higher response rate (13.3%) compared to standard therapy (5.8%) with lower treatment-related adverse events (13.1% vs. 35.1%, respectively).209 From a surgical perspective, some patients require tracheostomy or gastrostomy tube place-ment to manage airway compromise and dysphagia, respec-tively. Palliative care facilities and hospice care allow patients to retain dignity when they have a limited short-term outlook.Follow-Up CarePatients diagnosed and treated for a head and neck tumor require follow-up |
Surgery_Schwartz_4436 | Surgery_Schwartz | care facilities and hospice care allow patients to retain dignity when they have a limited short-term outlook.Follow-Up CarePatients diagnosed and treated for a head and neck tumor require follow-up care aimed at monitoring for recurrence and the side effects of therapy. The NCCN guidelines recommend follow-up assessment every 3 months for the first year after treatment, every 4 months during the following year, and then every 6 months until year 4, with an annual follow-up at 5 years post treatment and thereafter.106 This regimen is not well followed in North America, and further investigation is required to assess why this might be and to improve adherence rates.210 Follow-up should consist of a thorough history to assess for any emerg-ing symptoms such as pain, otalgia, or dysphagia as these are often the first sign of a recurrence. Assessment by speech lan-guage pathology and a dietician is often beneficial to ascertain swallowing function and nutritional intake, respectively. | Surgery_Schwartz. care facilities and hospice care allow patients to retain dignity when they have a limited short-term outlook.Follow-Up CarePatients diagnosed and treated for a head and neck tumor require follow-up care aimed at monitoring for recurrence and the side effects of therapy. The NCCN guidelines recommend follow-up assessment every 3 months for the first year after treatment, every 4 months during the following year, and then every 6 months until year 4, with an annual follow-up at 5 years post treatment and thereafter.106 This regimen is not well followed in North America, and further investigation is required to assess why this might be and to improve adherence rates.210 Follow-up should consist of a thorough history to assess for any emerg-ing symptoms such as pain, otalgia, or dysphagia as these are often the first sign of a recurrence. Assessment by speech lan-guage pathology and a dietician is often beneficial to ascertain swallowing function and nutritional intake, respectively. |
Surgery_Schwartz_4437 | Surgery_Schwartz | as these are often the first sign of a recurrence. Assessment by speech lan-guage pathology and a dietician is often beneficial to ascertain swallowing function and nutritional intake, respectively. Some patients require dilation or reinsertion of a gastrostomy tube if they develop pharyngeal strictures and are unable to maintain their weight. The history should be followed with a thorough head and neck examination, including fiberoptic nasolaryg-noscopy, because of the significant risk of developing a sec-ond primary in the upper aerodigestive tract.93 Patients should have their thyroid stimulating hormone (TSH) checked once a year, especially in those that have radiation as they may develop hypothyroidism at an earlier age than the general population. Shoulder dysfunction after neck dissection with extensive accessory nerve dissection or in patients who have had a scapu-lar system free flap should be managed with physiotherapy to minimize the long-term effects and improve function. | Surgery_Schwartz. as these are often the first sign of a recurrence. Assessment by speech lan-guage pathology and a dietician is often beneficial to ascertain swallowing function and nutritional intake, respectively. Some patients require dilation or reinsertion of a gastrostomy tube if they develop pharyngeal strictures and are unable to maintain their weight. The history should be followed with a thorough head and neck examination, including fiberoptic nasolaryg-noscopy, because of the significant risk of developing a sec-ond primary in the upper aerodigestive tract.93 Patients should have their thyroid stimulating hormone (TSH) checked once a year, especially in those that have radiation as they may develop hypothyroidism at an earlier age than the general population. Shoulder dysfunction after neck dissection with extensive accessory nerve dissection or in patients who have had a scapu-lar system free flap should be managed with physiotherapy to minimize the long-term effects and improve function. |
Surgery_Schwartz_4438 | Surgery_Schwartz | with extensive accessory nerve dissection or in patients who have had a scapu-lar system free flap should be managed with physiotherapy to minimize the long-term effects and improve function. Chronic pain can occur in head and neck cancer patients, and this is often assessed and managed by a pain specialist. Ongoing dental evaluation is needed in some patients to treat caries and prevent osteoradionecrosis.REFERENCESEntries highlighted in bright blue are key references. 1. Hajioff D, MacKeith S. Otitis externa. BMJ Clin Evid. 2015;2015:0510. 2. Sylvester MJ, Sanghvi S, Patel VM, Eloy JA, Ying YM. Malignant otitis externa hospitalizations: analysis of patient characteristics. Laryngoscope. 2017;127(10):2328-2336. 3. Carfrae MJ, Kesser BW. Malignant otitis externa. Otolaryngol Clin North Am. 2008;41(3):537-549, viii-ix. 4. Venekamp RP, Damoiseaux RA, Schilder AG. Acute otitis media in children. Am Fam Physician. 2017;95(2):109-110. 5. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical | Surgery_Schwartz. with extensive accessory nerve dissection or in patients who have had a scapu-lar system free flap should be managed with physiotherapy to minimize the long-term effects and improve function. Chronic pain can occur in head and neck cancer patients, and this is often assessed and managed by a pain specialist. Ongoing dental evaluation is needed in some patients to treat caries and prevent osteoradionecrosis.REFERENCESEntries highlighted in bright blue are key references. 1. Hajioff D, MacKeith S. Otitis externa. BMJ Clin Evid. 2015;2015:0510. 2. Sylvester MJ, Sanghvi S, Patel VM, Eloy JA, Ying YM. Malignant otitis externa hospitalizations: analysis of patient characteristics. Laryngoscope. 2017;127(10):2328-2336. 3. Carfrae MJ, Kesser BW. Malignant otitis externa. Otolaryngol Clin North Am. 2008;41(3):537-549, viii-ix. 4. Venekamp RP, Damoiseaux RA, Schilder AG. Acute otitis media in children. Am Fam Physician. 2017;95(2):109-110. 5. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical |
Surgery_Schwartz_4439 | Surgery_Schwartz | 2008;41(3):537-549, viii-ix. 4. Venekamp RP, Damoiseaux RA, Schilder AG. Acute otitis media in children. Am Fam Physician. 2017;95(2):109-110. 5. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical practice guideline: otitis media with effusion execu-tive summary (update). Otolaryngol Head Neck Surg. 2016;154(2):201-214. 6. American Academy of Pediatrics Subcommittee on Manage-ment of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113(5):1451-1465. 7. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diag-nosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-e999. 8. Principi N, Marchisio P, Rosazza C, Sciarrabba CS, Esposito S. Acute otitis media with spontaneous tympanic membrane perforation. Eur J Clin Microbiol Infect Dis. 2017;36(1): 11-18. 9. Kuo CL, Shiao AS, Yung M, et al. Updates and knowl-edge gaps in cholesteatoma research. Biomed Res Int. 2015;2015:854024. 10. Cunningham M, Guardiani E, Kim HJ, Brook I. Otitis | Surgery_Schwartz. 2008;41(3):537-549, viii-ix. 4. Venekamp RP, Damoiseaux RA, Schilder AG. Acute otitis media in children. Am Fam Physician. 2017;95(2):109-110. 5. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Clinical practice guideline: otitis media with effusion execu-tive summary (update). Otolaryngol Head Neck Surg. 2016;154(2):201-214. 6. American Academy of Pediatrics Subcommittee on Manage-ment of Acute Otitis Media. Diagnosis and management of acute otitis media. Pediatrics. 2004;113(5):1451-1465. 7. Lieberthal AS, Carroll AE, Chonmaitree T, et al. The diag-nosis and management of acute otitis media. Pediatrics. 2013;131(3):e964-e999. 8. Principi N, Marchisio P, Rosazza C, Sciarrabba CS, Esposito S. Acute otitis media with spontaneous tympanic membrane perforation. Eur J Clin Microbiol Infect Dis. 2017;36(1): 11-18. 9. Kuo CL, Shiao AS, Yung M, et al. Updates and knowl-edge gaps in cholesteatoma research. Biomed Res Int. 2015;2015:854024. 10. Cunningham M, Guardiani E, Kim HJ, Brook I. Otitis |
Surgery_Schwartz_4440 | Surgery_Schwartz | 2017;36(1): 11-18. 9. Kuo CL, Shiao AS, Yung M, et al. Updates and knowl-edge gaps in cholesteatoma research. Biomed Res Int. 2015;2015:854024. 10. Cunningham M, Guardiani E, Kim HJ, Brook I. Otitis media. Future Microbiol. 2012;7(6):733-753. 11. Choi JW, Park YH. Facial nerve paralysis in patients with chronic ear infections: surgical outcomes and radiologic anal-ysis. Clin Exp Otorhinolaryngol. 2015;8(3):218-223. 12. Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guide-line: Bell’s palsy. Otolaryngol Head Neck Surg. 2013;149 (3 suppl):S1-S27. 13. Gantz BJ, Rubinstein JT, Gidley P, Woodworth GG. Surgical management of Bell’s palsy. Laryngoscope. 1999;109(8):1177-1188. 14. Danner CJ. Facial nerve paralysis. Otolaryngol Clin North Am. 2008;41(3):619-632. 15. Jackler RK, Pfister MHF. Acoustic neuroma (vestibular schwanomma). In: Jackler RK, Brackmann DE, eds. Neurotol-ogy. 2nd ed. Philadelphia: Elsevier Mosby; 2005:727-782. 16. Carlson ML, Habermann EB, Wagie AE, et al. The | Surgery_Schwartz. 2017;36(1): 11-18. 9. Kuo CL, Shiao AS, Yung M, et al. Updates and knowl-edge gaps in cholesteatoma research. Biomed Res Int. 2015;2015:854024. 10. Cunningham M, Guardiani E, Kim HJ, Brook I. Otitis media. Future Microbiol. 2012;7(6):733-753. 11. Choi JW, Park YH. Facial nerve paralysis in patients with chronic ear infections: surgical outcomes and radiologic anal-ysis. Clin Exp Otorhinolaryngol. 2015;8(3):218-223. 12. Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guide-line: Bell’s palsy. Otolaryngol Head Neck Surg. 2013;149 (3 suppl):S1-S27. 13. Gantz BJ, Rubinstein JT, Gidley P, Woodworth GG. Surgical management of Bell’s palsy. Laryngoscope. 1999;109(8):1177-1188. 14. Danner CJ. Facial nerve paralysis. Otolaryngol Clin North Am. 2008;41(3):619-632. 15. Jackler RK, Pfister MHF. Acoustic neuroma (vestibular schwanomma). In: Jackler RK, Brackmann DE, eds. Neurotol-ogy. 2nd ed. Philadelphia: Elsevier Mosby; 2005:727-782. 16. Carlson ML, Habermann EB, Wagie AE, et al. The |
Surgery_Schwartz_4441 | Surgery_Schwartz | MHF. Acoustic neuroma (vestibular schwanomma). In: Jackler RK, Brackmann DE, eds. Neurotol-ogy. 2nd ed. Philadelphia: Elsevier Mosby; 2005:727-782. 16. Carlson ML, Habermann EB, Wagie AE, et al. The chang-ing landscape of vestibular schwannoma management in the United States—a shift toward conservatism. Otolaryngol Head Neck Surg. 2015;153(3):440-446. 17. Blackwell DL, Lucas JW, Clarke TC. Summary health statis-tics for U.S. adults: national health interview survey, 2012. Vital Health Stat 10. 2014;(260):1-161. 18. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinus-itis executive summary. Otolaryngol Head Neck Surg. 2015;152(4):598-609. 19. Fokkens WJ, Lund VJ, Mullol J, et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A sum-mary for otorhinolaryngologists. Rhinology. 2012;50(1):1-12. 20. Brook I. Microbiology of sinusitis. Proc Am Thorac Soc. 2011;8(1):90-100. 21. Miracle AC, Mukherji SK. Conebeam | Surgery_Schwartz. MHF. Acoustic neuroma (vestibular schwanomma). In: Jackler RK, Brackmann DE, eds. Neurotol-ogy. 2nd ed. Philadelphia: Elsevier Mosby; 2005:727-782. 16. Carlson ML, Habermann EB, Wagie AE, et al. The chang-ing landscape of vestibular schwannoma management in the United States—a shift toward conservatism. Otolaryngol Head Neck Surg. 2015;153(3):440-446. 17. Blackwell DL, Lucas JW, Clarke TC. Summary health statis-tics for U.S. adults: national health interview survey, 2012. Vital Health Stat 10. 2014;(260):1-161. 18. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinus-itis executive summary. Otolaryngol Head Neck Surg. 2015;152(4):598-609. 19. Fokkens WJ, Lund VJ, Mullol J, et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A sum-mary for otorhinolaryngologists. Rhinology. 2012;50(1):1-12. 20. Brook I. Microbiology of sinusitis. Proc Am Thorac Soc. 2011;8(1):90-100. 21. Miracle AC, Mukherji SK. Conebeam |
Surgery_Schwartz_4442 | Surgery_Schwartz | polyps 2012. A sum-mary for otorhinolaryngologists. Rhinology. 2012;50(1):1-12. 20. Brook I. Microbiology of sinusitis. Proc Am Thorac Soc. 2011;8(1):90-100. 21. Miracle AC, Mukherji SK. Conebeam CT of the head and neck, part 2: clinical applications. AJNR Am J Neuroradiol. 2009;30(7):1285-1292.Brunicardi_Ch18_p0613-p0660.indd 65401/03/19 5:25 PM 655DISORDERS OF THE HEAD AND NECKCHAPTER 18 22. de Lara D, Ditzel Filho LF, Prevedello DM, et al. Endonasal endoscopic approaches to the paramedian skull base. World Neurosurg. 2014;82(6 suppl):S121-S129. 23. Baugh RF, Archer SM, Mitchell RB, et al. Clinical prac-tice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;144(1 suppl):S1-S30. 24. Cohen JF, Bertille N, Cohen R, Chalumeau M. Rapid antigen detection test for group A streptococcus in children with phar-yngitis. Cochrane Database Syst Rev. 2016;7:CD010502. 25. Gates GA, Avery CA, Cooper JC Jr, Prihoda TJ. Chronic secretory otitis media: effects of surgical | Surgery_Schwartz. polyps 2012. A sum-mary for otorhinolaryngologists. Rhinology. 2012;50(1):1-12. 20. Brook I. Microbiology of sinusitis. Proc Am Thorac Soc. 2011;8(1):90-100. 21. Miracle AC, Mukherji SK. Conebeam CT of the head and neck, part 2: clinical applications. AJNR Am J Neuroradiol. 2009;30(7):1285-1292.Brunicardi_Ch18_p0613-p0660.indd 65401/03/19 5:25 PM 655DISORDERS OF THE HEAD AND NECKCHAPTER 18 22. de Lara D, Ditzel Filho LF, Prevedello DM, et al. Endonasal endoscopic approaches to the paramedian skull base. World Neurosurg. 2014;82(6 suppl):S121-S129. 23. Baugh RF, Archer SM, Mitchell RB, et al. Clinical prac-tice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;144(1 suppl):S1-S30. 24. Cohen JF, Bertille N, Cohen R, Chalumeau M. Rapid antigen detection test for group A streptococcus in children with phar-yngitis. Cochrane Database Syst Rev. 2016;7:CD010502. 25. Gates GA, Avery CA, Cooper JC Jr, Prihoda TJ. Chronic secretory otitis media: effects of surgical |
Surgery_Schwartz_4443 | Surgery_Schwartz | group A streptococcus in children with phar-yngitis. Cochrane Database Syst Rev. 2016;7:CD010502. 25. Gates GA, Avery CA, Cooper JC Jr, Prihoda TJ. Chronic secretory otitis media: effects of surgical management. Ann Otol Rhinol Laryngol Suppl. 1989;138:2-32. 26. Caterson EJ, Tsai DM, Cauley R, Dowdall JR, Tracy LE. Transillumination of the occult submucous cleft palate. J Cra-niofac Surg. 2014;25(6):2160-2163. 27. Ozkiris M, Karacavus S, Kapusuz Z, Saydam L. Compari-son of two different adenoidectomy techniques with special emphasis on postoperative nasal mucociliary clearance rates: coblation technique vs. cold curettage. Int J Pediatr Otorhi-nolaryngol. 2013;77(3):389-393. 28. Sapthavee A, Bhushan B, Penn E, Billings KR. A comparison of revision adenoidectomy rates based on techniques. Otolar-yngol Head Neck Surg. 2013;148(5):841-846. 29. Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decis Making. | Surgery_Schwartz. group A streptococcus in children with phar-yngitis. Cochrane Database Syst Rev. 2016;7:CD010502. 25. Gates GA, Avery CA, Cooper JC Jr, Prihoda TJ. Chronic secretory otitis media: effects of surgical management. Ann Otol Rhinol Laryngol Suppl. 1989;138:2-32. 26. Caterson EJ, Tsai DM, Cauley R, Dowdall JR, Tracy LE. Transillumination of the occult submucous cleft palate. J Cra-niofac Surg. 2014;25(6):2160-2163. 27. Ozkiris M, Karacavus S, Kapusuz Z, Saydam L. Compari-son of two different adenoidectomy techniques with special emphasis on postoperative nasal mucociliary clearance rates: coblation technique vs. cold curettage. Int J Pediatr Otorhi-nolaryngol. 2013;77(3):389-393. 28. Sapthavee A, Bhushan B, Penn E, Billings KR. A comparison of revision adenoidectomy rates based on techniques. Otolar-yngol Head Neck Surg. 2013;148(5):841-846. 29. Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decis Making. |
Surgery_Schwartz_4444 | Surgery_Schwartz | Otolar-yngol Head Neck Surg. 2013;148(5):841-846. 29. Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decis Making. 1981;1(3):239-246. 30. Little P, Stuart B, Hobbs FD, et al. Predictors of suppurative complications for acute sore throat in primary care: prospec-tive clinical cohort study. BMJ. 2013;347:f6867. 31. Fine AM, Nizet V, Mandl KD. Large-scale validation of the centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012;172(11):847-852. 32. Brodsky L. Modern assessment of tonsils and adenoids. Pedi-atr Clin North Am. 1989;36(6):1551-1569. 33. Roland PS, Rosenfeld RM, Brooks LJ, et al. Clinical practice guideline: polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;145(1 suppl):S1-S15. 34. Statham MM, Myer CM 3rd. Complications of adeno-tonsillectomy. Curr Opin Otolaryngol Head Neck Surg. | Surgery_Schwartz. Otolar-yngol Head Neck Surg. 2013;148(5):841-846. 29. Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decis Making. 1981;1(3):239-246. 30. Little P, Stuart B, Hobbs FD, et al. Predictors of suppurative complications for acute sore throat in primary care: prospec-tive clinical cohort study. BMJ. 2013;347:f6867. 31. Fine AM, Nizet V, Mandl KD. Large-scale validation of the centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012;172(11):847-852. 32. Brodsky L. Modern assessment of tonsils and adenoids. Pedi-atr Clin North Am. 1989;36(6):1551-1569. 33. Roland PS, Rosenfeld RM, Brooks LJ, et al. Clinical practice guideline: polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;145(1 suppl):S1-S15. 34. Statham MM, Myer CM 3rd. Complications of adeno-tonsillectomy. Curr Opin Otolaryngol Head Neck Surg. |
Surgery_Schwartz_4445 | Surgery_Schwartz | prior to tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;145(1 suppl):S1-S15. 34. Statham MM, Myer CM 3rd. Complications of adeno-tonsillectomy. Curr Opin Otolaryngol Head Neck Surg. 2010;18(6):539-543. 35. Friedman M, Hamilton C, Samuelson CG, et al. Transoral robotic glossectomy for the treatment of obstructive sleep apnea-hypopnea syndrome. Otolaryngol Head Neck Surg. 2012;146(5):854-862. 36. Chaturvedi AK, Anderson WF, Lortet-Tieulent J, et al. World-wide trends in incidence rates for oral cavity and oropharyn-geal cancers. J Clin Oncol. 2013;31(36):4550-4559. 37. Knabel MJ, Bock JM. Globus sensation and laryngopha-ryngeal reflux. Ear Nose Throat J. 2015;94(10-11):445-447. 38. Story BH, Titze IR. Voice simulation with a body-cover model of the vocal folds. J Acoust Soc Am. 1995;97(2): 1249-1260. 39. Rosen CA, Gartner-Schmidt J, Hathaway B, et al. A nomen-clature paradigm for benign midmembranous vocal fold lesions. Laryngoscope. 2012;122(6):1335-1341. 40. Martins RH, | Surgery_Schwartz. prior to tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;145(1 suppl):S1-S15. 34. Statham MM, Myer CM 3rd. Complications of adeno-tonsillectomy. Curr Opin Otolaryngol Head Neck Surg. 2010;18(6):539-543. 35. Friedman M, Hamilton C, Samuelson CG, et al. Transoral robotic glossectomy for the treatment of obstructive sleep apnea-hypopnea syndrome. Otolaryngol Head Neck Surg. 2012;146(5):854-862. 36. Chaturvedi AK, Anderson WF, Lortet-Tieulent J, et al. World-wide trends in incidence rates for oral cavity and oropharyn-geal cancers. J Clin Oncol. 2013;31(36):4550-4559. 37. Knabel MJ, Bock JM. Globus sensation and laryngopha-ryngeal reflux. Ear Nose Throat J. 2015;94(10-11):445-447. 38. Story BH, Titze IR. Voice simulation with a body-cover model of the vocal folds. J Acoust Soc Am. 1995;97(2): 1249-1260. 39. Rosen CA, Gartner-Schmidt J, Hathaway B, et al. A nomen-clature paradigm for benign midmembranous vocal fold lesions. Laryngoscope. 2012;122(6):1335-1341. 40. Martins RH, |
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Surgery_Schwartz_4479 | Surgery_Schwartz | phase III randomized intergroup study 0099. J Clin Oncol. 1998;16(4):1310-1317. 170. Vlantis AC, Tsang RK, Yu BK, et al. Nasopharyngectomy and surgical margin status: a survival analysis. Arch Otolaryngol Head Neck Surg. 2007;133(12):1296-1301. 171. Sinha S, Dedmon MM, Naunheim MR, Fuller JC, Gray ST, Lin DT. Update on surgical outcomes of lateral temporal bone resection for ear and temporal bone malignancies. J Neurol Surg B Skull Base. 2017;78(1):37-42. 172. Beyea JA, Moberly AC. Squamous cell carcinoma of the temporal bone. Otolaryngol Clin North Am. 2015;48(2): 281-292. 173. Mazzoni A, Zanoletti E, Marioni G, Martini A. En bloc temporal bone resections in squamous cell carcinoma of the ear. technique, principles, and limits. Acta Otolaryngol. 2016;136(5):425-432. 174. Gurgel RK, Karnell LH, Hansen MR. Middle ear cancer: a population-based study. Laryngoscope. 2009;119(10): 1913-1917. 175. Rosenthal EL, King T, McGrew BM, Carroll W, Magnuson JS, Wax MK. Evolution of a paradigm for | Surgery_Schwartz. phase III randomized intergroup study 0099. J Clin Oncol. 1998;16(4):1310-1317. 170. Vlantis AC, Tsang RK, Yu BK, et al. Nasopharyngectomy and surgical margin status: a survival analysis. Arch Otolaryngol Head Neck Surg. 2007;133(12):1296-1301. 171. Sinha S, Dedmon MM, Naunheim MR, Fuller JC, Gray ST, Lin DT. Update on surgical outcomes of lateral temporal bone resection for ear and temporal bone malignancies. J Neurol Surg B Skull Base. 2017;78(1):37-42. 172. Beyea JA, Moberly AC. Squamous cell carcinoma of the temporal bone. Otolaryngol Clin North Am. 2015;48(2): 281-292. 173. Mazzoni A, Zanoletti E, Marioni G, Martini A. En bloc temporal bone resections in squamous cell carcinoma of the ear. technique, principles, and limits. Acta Otolaryngol. 2016;136(5):425-432. 174. Gurgel RK, Karnell LH, Hansen MR. Middle ear cancer: a population-based study. Laryngoscope. 2009;119(10): 1913-1917. 175. Rosenthal EL, King T, McGrew BM, Carroll W, Magnuson JS, Wax MK. Evolution of a paradigm for |
Surgery_Schwartz_4480 | Surgery_Schwartz | LH, Hansen MR. Middle ear cancer: a population-based study. Laryngoscope. 2009;119(10): 1913-1917. 175. Rosenthal EL, King T, McGrew BM, Carroll W, Magnuson JS, Wax MK. Evolution of a paradigm for free tissue transfer reconstruction of lateral temporal bone defects. Head Neck. 2008;30(5):589-594. 176. Ferris R, Goldenberg D, Haymart MR, et al. American Thyroid Association consensus review of the anatomy, ter-minology and rationale for lateral neck dissection in dif-ferentiated thyroid cancer. Thyroid. 2012;22(5):501-508. 177. Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification update:revisions proposed by the American Head and Neck Society and the American Academy of Otolar-yngology—Head and Neck Surgery. Arch Otolaryngol Head Neck Surg. 2002;128(7):751-758. 178. Wang Y, Ow TJ, Myers JN. Pathways for cervical metasta-sis in malignant neoplasms of the head and neck region. Clin Anat. 2012;25(1):54-71. 179. Weiss MH, Harrison LB, Isaacs RS. Use of decision analy-sis | Surgery_Schwartz. LH, Hansen MR. Middle ear cancer: a population-based study. Laryngoscope. 2009;119(10): 1913-1917. 175. Rosenthal EL, King T, McGrew BM, Carroll W, Magnuson JS, Wax MK. Evolution of a paradigm for free tissue transfer reconstruction of lateral temporal bone defects. Head Neck. 2008;30(5):589-594. 176. Ferris R, Goldenberg D, Haymart MR, et al. American Thyroid Association consensus review of the anatomy, ter-minology and rationale for lateral neck dissection in dif-ferentiated thyroid cancer. Thyroid. 2012;22(5):501-508. 177. Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification update:revisions proposed by the American Head and Neck Society and the American Academy of Otolar-yngology—Head and Neck Surgery. Arch Otolaryngol Head Neck Surg. 2002;128(7):751-758. 178. Wang Y, Ow TJ, Myers JN. Pathways for cervical metasta-sis in malignant neoplasms of the head and neck region. Clin Anat. 2012;25(1):54-71. 179. Weiss MH, Harrison LB, Isaacs RS. Use of decision analy-sis |
Surgery_Schwartz_4481 | Surgery_Schwartz | Y, Ow TJ, Myers JN. Pathways for cervical metasta-sis in malignant neoplasms of the head and neck region. Clin Anat. 2012;25(1):54-71. 179. Weiss MH, Harrison LB, Isaacs RS. Use of decision analy-sis in planning a management strategy for the stage N0 neck. Arch Otolaryngol Head Neck Surg. 1994;120(7):699-702. 180. Bocca E, Pignataro O, Oldini C, Cappa C. Functional neck dissection: an evaluation and review of 843 cases. Laryngo-scope. 1984;94(7):942-945. 181. Medina JE, Byers RM. Supraomohyoid neck dissection: rationale, indications, and surgical technique. Head Neck. 1989;11(2):111-122. 182. Shah JP. Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. Am J Surg. 1990;160(4):405-409. 183. Huang SH, Hwang D, Lockwood G, Goldstein DP, O’Sullivan B. Predictive value of tumor thickness for cervi-cal lymph-node involvement in squamous cell carcinoma of the oral cavity: a meta-analysis of reported studies. Cancer. | Surgery_Schwartz. Y, Ow TJ, Myers JN. Pathways for cervical metasta-sis in malignant neoplasms of the head and neck region. Clin Anat. 2012;25(1):54-71. 179. Weiss MH, Harrison LB, Isaacs RS. Use of decision analy-sis in planning a management strategy for the stage N0 neck. Arch Otolaryngol Head Neck Surg. 1994;120(7):699-702. 180. Bocca E, Pignataro O, Oldini C, Cappa C. Functional neck dissection: an evaluation and review of 843 cases. Laryngo-scope. 1984;94(7):942-945. 181. Medina JE, Byers RM. Supraomohyoid neck dissection: rationale, indications, and surgical technique. Head Neck. 1989;11(2):111-122. 182. Shah JP. Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. Am J Surg. 1990;160(4):405-409. 183. Huang SH, Hwang D, Lockwood G, Goldstein DP, O’Sullivan B. Predictive value of tumor thickness for cervi-cal lymph-node involvement in squamous cell carcinoma of the oral cavity: a meta-analysis of reported studies. Cancer. |
Surgery_Schwartz_4482 | Surgery_Schwartz | G, Goldstein DP, O’Sullivan B. Predictive value of tumor thickness for cervi-cal lymph-node involvement in squamous cell carcinoma of the oral cavity: a meta-analysis of reported studies. Cancer. 2009;115(7):1489-1497. 184. D’Cruz AK, Vaish R, Kapre N, et al. Elective versus thera-peutic neck dissection in node-negative oral cancer. N Engl J Med. 2015;373(6):521-529. 185. Farrag T, Lin F, Brownlee N, Kim M, Sheth S, Tufano RP. Is routine dissection of level II-B and V-A necessary in patients with papillary thyroid cancer undergoing lateral neck dissec-tion for FNA-confirmed metastases in other levels. World J Surg. 2009;33(8):1680-1683. 186. Eskander A, Merdad M, Freeman JL, Witterick IJ. Pattern of spread to the lateral neck in metastatic well-differenti-ated thyroid cancer: a systematic review and meta-analy-sis. Thyroid. 2013;23(5):583-592. 187. Cooper JS, Zhang Q, Pajak TF, et al. Long-term follow-up of the RTOG 9501/intergroup phase III trial: postoperative concurrent radiation | Surgery_Schwartz. G, Goldstein DP, O’Sullivan B. Predictive value of tumor thickness for cervi-cal lymph-node involvement in squamous cell carcinoma of the oral cavity: a meta-analysis of reported studies. Cancer. 2009;115(7):1489-1497. 184. D’Cruz AK, Vaish R, Kapre N, et al. Elective versus thera-peutic neck dissection in node-negative oral cancer. N Engl J Med. 2015;373(6):521-529. 185. Farrag T, Lin F, Brownlee N, Kim M, Sheth S, Tufano RP. Is routine dissection of level II-B and V-A necessary in patients with papillary thyroid cancer undergoing lateral neck dissec-tion for FNA-confirmed metastases in other levels. World J Surg. 2009;33(8):1680-1683. 186. Eskander A, Merdad M, Freeman JL, Witterick IJ. Pattern of spread to the lateral neck in metastatic well-differenti-ated thyroid cancer: a systematic review and meta-analy-sis. Thyroid. 2013;23(5):583-592. 187. Cooper JS, Zhang Q, Pajak TF, et al. Long-term follow-up of the RTOG 9501/intergroup phase III trial: postoperative concurrent radiation |
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Surgery_Schwartz_4484 | Surgery_Schwartz | M. Surgical salvage of recurrent cancer of the head and neck. Curr Oncol Rep. 2014;16(5):386-014-0386-0. 191. James A, Stewart C, Warrick P, Tzifa C, Forte V. Branchial sinus of the piriform fossa: reappraisal of third and fourth bran-chial anomalies. Laryngoscope. 2007;117(11):1920-1924. 192. Oyewumi M, Inarejos E, Greer ML, et al. Ultrasound to differ-entiate thyroglossal duct cysts and dermoid cysts in children. Laryngoscope. 2015;125(4):998-1003. 193. Stodulski D, Mikaszewski B, Majewska H, Wisniewski P, Stankiewicz C. Probability and pattern of occult cervical lymph node metastases in primary parotid carcinoma. Eur Arch Otorhinolaryngol. 2017;274(3):1659-1664. 194. Seethala RR. An update on grading of salivary gland carcino-mas. Head Neck Pathol. 2009;3(1):69-77. 195. Colella G, Cannavale R, Chiodini P. Meta-analysis of sur-gical approaches to the treatment of parotid pleomorphic adenomas and recurrence rates. J Craniomaxillofac Surg. 2015;43(6):738-745. 196. Ariyan S. The | Surgery_Schwartz. M. Surgical salvage of recurrent cancer of the head and neck. Curr Oncol Rep. 2014;16(5):386-014-0386-0. 191. James A, Stewart C, Warrick P, Tzifa C, Forte V. Branchial sinus of the piriform fossa: reappraisal of third and fourth bran-chial anomalies. Laryngoscope. 2007;117(11):1920-1924. 192. Oyewumi M, Inarejos E, Greer ML, et al. Ultrasound to differ-entiate thyroglossal duct cysts and dermoid cysts in children. Laryngoscope. 2015;125(4):998-1003. 193. Stodulski D, Mikaszewski B, Majewska H, Wisniewski P, Stankiewicz C. Probability and pattern of occult cervical lymph node metastases in primary parotid carcinoma. Eur Arch Otorhinolaryngol. 2017;274(3):1659-1664. 194. Seethala RR. An update on grading of salivary gland carcino-mas. Head Neck Pathol. 2009;3(1):69-77. 195. Colella G, Cannavale R, Chiodini P. Meta-analysis of sur-gical approaches to the treatment of parotid pleomorphic adenomas and recurrence rates. J Craniomaxillofac Surg. 2015;43(6):738-745. 196. Ariyan S. The |
Surgery_Schwartz_4485 | Surgery_Schwartz | Cannavale R, Chiodini P. Meta-analysis of sur-gical approaches to the treatment of parotid pleomorphic adenomas and recurrence rates. J Craniomaxillofac Surg. 2015;43(6):738-745. 196. Ariyan S. The functional pectoralis major musculocutaneous island flap for head and neck reconstruction. Plast Reconstr Surg. 1990;86(4):807-808. 197. Howard BE, Nagel TH, Barrs DM, Donald CB, Hayden RE. Reconstruction of lateral skull base defects: a comparison of the submental flap to free and regional flaps. Otolaryngol Head Neck Surg. 2016;154(6):1014-1018. 198. Herr MW, Emerick KS, Deschler DG. The supraclavicular artery flap for head and neck reconstruction. JAMA Facial Plast Surg. 2014;16(2):127-132. 199. Chepeha DB, Annich G, Pynnonen MA, et al. Pectoralis major myocutaneous flap vs revascularized free tissue trans-fer: complications, gastrostomy tube dependence, and hospi-talization. Arch Otolaryngol Head Neck Surg. 2004;130(2): 181-186. 200. Kang SY, Old MO, Teknos TN. Lateral arm free tissue | Surgery_Schwartz. Cannavale R, Chiodini P. Meta-analysis of sur-gical approaches to the treatment of parotid pleomorphic adenomas and recurrence rates. J Craniomaxillofac Surg. 2015;43(6):738-745. 196. Ariyan S. The functional pectoralis major musculocutaneous island flap for head and neck reconstruction. Plast Reconstr Surg. 1990;86(4):807-808. 197. Howard BE, Nagel TH, Barrs DM, Donald CB, Hayden RE. Reconstruction of lateral skull base defects: a comparison of the submental flap to free and regional flaps. Otolaryngol Head Neck Surg. 2016;154(6):1014-1018. 198. Herr MW, Emerick KS, Deschler DG. The supraclavicular artery flap for head and neck reconstruction. JAMA Facial Plast Surg. 2014;16(2):127-132. 199. Chepeha DB, Annich G, Pynnonen MA, et al. Pectoralis major myocutaneous flap vs revascularized free tissue trans-fer: complications, gastrostomy tube dependence, and hospi-talization. Arch Otolaryngol Head Neck Surg. 2004;130(2): 181-186. 200. Kang SY, Old MO, Teknos TN. Lateral arm free tissue |
Surgery_Schwartz_4486 | Surgery_Schwartz | tissue trans-fer: complications, gastrostomy tube dependence, and hospi-talization. Arch Otolaryngol Head Neck Surg. 2004;130(2): 181-186. 200. Kang SY, Old MO, Teknos TN. Lateral arm free tissue transfer for parotid reconstruction: a pictorial essay. Head Neck. 2017. 201. Chepeha DB, Teknos TN, Fung K, et al. Lateral oroman-dibular defect: when is it appropriate to use a bridging reconstruction plate combined with a soft tissue revascu-larized flap? Head Neck. 2008;30(6):709-717. 202. Chepeha DB, Khariwala SS, Chanowski EJ, et al. Thoracodor-sal artery scapular tip autogenous transplant: vascularized bone with a long pedicle and flexible soft tissue. Arch Otolaryngol Head Neck Surg. 2010;136(10):958-964. 203. Chepeha DB, Teknos TN, Shargorodsky J, et al. Rectangle tongue template for reconstruction of the hemiglossectomy defect. Arch Otolaryngol Head Neck Surg. 2008;134(9):993-998. 204. Kang SY, Old MO, Teknos TN. Contour and osteotomy of free fibula transplant using a ruler | Surgery_Schwartz. tissue trans-fer: complications, gastrostomy tube dependence, and hospi-talization. Arch Otolaryngol Head Neck Surg. 2004;130(2): 181-186. 200. Kang SY, Old MO, Teknos TN. Lateral arm free tissue transfer for parotid reconstruction: a pictorial essay. Head Neck. 2017. 201. Chepeha DB, Teknos TN, Fung K, et al. Lateral oroman-dibular defect: when is it appropriate to use a bridging reconstruction plate combined with a soft tissue revascu-larized flap? Head Neck. 2008;30(6):709-717. 202. Chepeha DB, Khariwala SS, Chanowski EJ, et al. Thoracodor-sal artery scapular tip autogenous transplant: vascularized bone with a long pedicle and flexible soft tissue. Arch Otolaryngol Head Neck Surg. 2010;136(10):958-964. 203. Chepeha DB, Teknos TN, Shargorodsky J, et al. Rectangle tongue template for reconstruction of the hemiglossectomy defect. Arch Otolaryngol Head Neck Surg. 2008;134(9):993-998. 204. Kang SY, Old MO, Teknos TN. Contour and osteotomy of free fibula transplant using a ruler |
Surgery_Schwartz_4487 | Surgery_Schwartz | for reconstruction of the hemiglossectomy defect. Arch Otolaryngol Head Neck Surg. 2008;134(9):993-998. 204. Kang SY, Old MO, Teknos TN. Contour and osteotomy of free fibula transplant using a ruler template. Laryngoscope. 2016;126(10):2288-2290. 205. Young D, Harrison DA, Cuthbertson BH, Rowan K, Trac-Man Collaborators. Effect of early vs late tracheostomy placement on survival in patients receiving mechani-cal ventilation: the TracMan randomized trial. JAMA. 2013;309(20):2121-2129. 206. Szakmany T, Russell P, Wilkes AR, Hall JE. Effect of early tracheostomy on resource utilization and clinical outcomes in Brunicardi_Ch18_p0613-p0660.indd 65901/03/19 5:25 PM 660SPECIFIC CONSIDERATIONSPART IIcritically ill patients: meta-analysis of randomized controlled trials. Br J Anaesth. 2015;114(3):396-405. 207. Higgins KM, Punthakee X. Meta-analysis comparison of open versus percutaneous tracheostomy. Laryngoscope. 2007;117(3):447-454. 208. Brass P, Hellmich M, Ladra A, Ladra J, Wrzosek A. | Surgery_Schwartz. for reconstruction of the hemiglossectomy defect. Arch Otolaryngol Head Neck Surg. 2008;134(9):993-998. 204. Kang SY, Old MO, Teknos TN. Contour and osteotomy of free fibula transplant using a ruler template. Laryngoscope. 2016;126(10):2288-2290. 205. Young D, Harrison DA, Cuthbertson BH, Rowan K, Trac-Man Collaborators. Effect of early vs late tracheostomy placement on survival in patients receiving mechani-cal ventilation: the TracMan randomized trial. JAMA. 2013;309(20):2121-2129. 206. Szakmany T, Russell P, Wilkes AR, Hall JE. Effect of early tracheostomy on resource utilization and clinical outcomes in Brunicardi_Ch18_p0613-p0660.indd 65901/03/19 5:25 PM 660SPECIFIC CONSIDERATIONSPART IIcritically ill patients: meta-analysis of randomized controlled trials. Br J Anaesth. 2015;114(3):396-405. 207. Higgins KM, Punthakee X. Meta-analysis comparison of open versus percutaneous tracheostomy. Laryngoscope. 2007;117(3):447-454. 208. Brass P, Hellmich M, Ladra A, Ladra J, Wrzosek A. |
Surgery_Schwartz_4488 | Surgery_Schwartz | KM, Punthakee X. Meta-analysis comparison of open versus percutaneous tracheostomy. Laryngoscope. 2007;117(3):447-454. 208. Brass P, Hellmich M, Ladra A, Ladra J, Wrzosek A. Percuta-neous techniques versus surgical techniques for tracheostomy. Cochrane Database Syst Rev. 2016;7:CD008045. 209. Ferris RL, Blumenschein G, Jr, Fayette J, et al. Nivolumab for recurrent squamous-cell carcinoma of the head and neck. N Engl J Med. 2016. 210. Eskander A, Monteiro E, Irish J, et al. Adherence to guideline-recommended process measures for squamous cell carcinoma of the head and neck in ontario: impact of surgeon and hospi-tal volume. Head Neck. 2016;38 Suppl 1:E1987-E1992.Brunicardi_Ch18_p0613-p0660.indd 66001/03/19 5:25 PM | Surgery_Schwartz. KM, Punthakee X. Meta-analysis comparison of open versus percutaneous tracheostomy. Laryngoscope. 2007;117(3):447-454. 208. Brass P, Hellmich M, Ladra A, Ladra J, Wrzosek A. Percuta-neous techniques versus surgical techniques for tracheostomy. Cochrane Database Syst Rev. 2016;7:CD008045. 209. Ferris RL, Blumenschein G, Jr, Fayette J, et al. Nivolumab for recurrent squamous-cell carcinoma of the head and neck. N Engl J Med. 2016. 210. Eskander A, Monteiro E, Irish J, et al. Adherence to guideline-recommended process measures for squamous cell carcinoma of the head and neck in ontario: impact of surgeon and hospi-tal volume. Head Neck. 2016;38 Suppl 1:E1987-E1992.Brunicardi_Ch18_p0613-p0660.indd 66001/03/19 5:25 PM |
Surgery_Schwartz_4489 | Surgery_Schwartz | Chest Wall, Lung, Mediastinum, and PleuraKatie S. Nason, Rose B. Ganim, and James D. Luketich 19chapterTRACHEAAnatomyThe trachea is composed of cartilaginous and membranous por-tions, beginning with the cricoid cartilage, the first complete cartilaginous ring of the airway. The cricoid cartilage consists of an anterior arch and a posterior broad-based plate. Articulat-ing with the posterior cricoid plate are the arytenoid cartilages. The vocal cords originate from the arytenoid cartilages and then attach to the thyroid cartilage. The subglottic space, the nar-rowest part of the trachea with an internal diameter of approxi-mately 2 cm, begins at the inferior surface of the vocal cords and extends to the first tracheal ring. The remainder of the distal trachea is 10.0 to 13.0 cm long, consists of 18 to 22 rings, and has an internal diameter of 2.3 cm (Fig. 19-1).1Bronchoscopically, the tracheal rings are visible as C-shaped hyaline cartilaginous structures that provide rigid-ity to the | Surgery_Schwartz. Chest Wall, Lung, Mediastinum, and PleuraKatie S. Nason, Rose B. Ganim, and James D. Luketich 19chapterTRACHEAAnatomyThe trachea is composed of cartilaginous and membranous por-tions, beginning with the cricoid cartilage, the first complete cartilaginous ring of the airway. The cricoid cartilage consists of an anterior arch and a posterior broad-based plate. Articulat-ing with the posterior cricoid plate are the arytenoid cartilages. The vocal cords originate from the arytenoid cartilages and then attach to the thyroid cartilage. The subglottic space, the nar-rowest part of the trachea with an internal diameter of approxi-mately 2 cm, begins at the inferior surface of the vocal cords and extends to the first tracheal ring. The remainder of the distal trachea is 10.0 to 13.0 cm long, consists of 18 to 22 rings, and has an internal diameter of 2.3 cm (Fig. 19-1).1Bronchoscopically, the tracheal rings are visible as C-shaped hyaline cartilaginous structures that provide rigid-ity to the |
Surgery_Schwartz_4490 | Surgery_Schwartz | of 18 to 22 rings, and has an internal diameter of 2.3 cm (Fig. 19-1).1Bronchoscopically, the tracheal rings are visible as C-shaped hyaline cartilaginous structures that provide rigid-ity to the anterior and lateral tracheal walls. The open ends of the C-rings are connected by the trachealis smooth muscle and encased in a dense band of connective tissue called perichon-drium. The first tracheal ring is attached directly to the cricoid cartilage; there are approximately two rings for every 1 cm of tracheal length.The tracheal blood supply, which includes the inferior thy-roid, subclavian, supreme intercostal, internal thoracic, innomi-nate, and superior and middle bronchial arteries, enters the airway near the junction of the membranous and cartilaginous portions (Fig. 19-2). Each arterial branch supplies a segment of 1.0 to 2.0 cm, thereby limiting circumferential mobilization to that same distance. The vessels are interconnected along the lat-eral surface of the trachea by an | Surgery_Schwartz. of 18 to 22 rings, and has an internal diameter of 2.3 cm (Fig. 19-1).1Bronchoscopically, the tracheal rings are visible as C-shaped hyaline cartilaginous structures that provide rigid-ity to the anterior and lateral tracheal walls. The open ends of the C-rings are connected by the trachealis smooth muscle and encased in a dense band of connective tissue called perichon-drium. The first tracheal ring is attached directly to the cricoid cartilage; there are approximately two rings for every 1 cm of tracheal length.The tracheal blood supply, which includes the inferior thy-roid, subclavian, supreme intercostal, internal thoracic, innomi-nate, and superior and middle bronchial arteries, enters the airway near the junction of the membranous and cartilaginous portions (Fig. 19-2). Each arterial branch supplies a segment of 1.0 to 2.0 cm, thereby limiting circumferential mobilization to that same distance. The vessels are interconnected along the lat-eral surface of the trachea by an |
Surgery_Schwartz_4491 | Surgery_Schwartz | branch supplies a segment of 1.0 to 2.0 cm, thereby limiting circumferential mobilization to that same distance. The vessels are interconnected along the lat-eral surface of the trachea by an important longitudinal vascular anastomosis that feeds transverse segmental vessels to the soft tissues between the cartilages.Tracheal InjuryTracheal injury can result from a variety of causes, includ-ing inhalation of smoke or toxic fumes, aspiration of liquids or solid objects, endotracheal intubation, blunt and penetrating trauma, and iatrogenic injury during operative procedures. Early diagnosis is critical to avoid subsequent complications, includ-ing respiratory infection and tracheal stenosis. Management of smoke or toxic fume inhalation and liquid aspiration is com-monly supportive; use of antibiotics, respiratory support, and airway clearance with flexible bronchoscopy is dictated by the patient’s condition. In rare circumstances, extracorporeal mem-brane oxygenation is required if | Surgery_Schwartz. branch supplies a segment of 1.0 to 2.0 cm, thereby limiting circumferential mobilization to that same distance. The vessels are interconnected along the lat-eral surface of the trachea by an important longitudinal vascular anastomosis that feeds transverse segmental vessels to the soft tissues between the cartilages.Tracheal InjuryTracheal injury can result from a variety of causes, includ-ing inhalation of smoke or toxic fumes, aspiration of liquids or solid objects, endotracheal intubation, blunt and penetrating trauma, and iatrogenic injury during operative procedures. Early diagnosis is critical to avoid subsequent complications, includ-ing respiratory infection and tracheal stenosis. Management of smoke or toxic fume inhalation and liquid aspiration is com-monly supportive; use of antibiotics, respiratory support, and airway clearance with flexible bronchoscopy is dictated by the patient’s condition. In rare circumstances, extracorporeal mem-brane oxygenation is required if |
Surgery_Schwartz_4492 | Surgery_Schwartz | of antibiotics, respiratory support, and airway clearance with flexible bronchoscopy is dictated by the patient’s condition. In rare circumstances, extracorporeal mem-brane oxygenation is required if there is associated injury to the more distal airways and lung parenchyma.Despite ubiquitous use of high-volume–low-pressure cuffs, overinflation of the endotracheal cuff is the most common cause of injury secondary to endotracheal intubation. High cuff pressures can cause ischemia of the contiguous airway wall in as short as 4 hours. Prolonged overinflation can lead to scarring Trachea661Anatomy / 661Tracheal Injury / 661Tracheal Fistulas / 664Tracheal Neoplasms / 665Lung667Anatomy / 667Normal Lung Histology / 668Preinvasive Lesions / 669Invasive or Malignant Lesions / 670Lung Cancer Epidemiology / 673Screening for Lung Cancer in High-Risk Populations / 675Solitary Pulmonary Nodule / 677Metastatic Lesions to the Lung / 678Primary Lung Cancer-Associated Signs and Symptoms / 680Lung | Surgery_Schwartz. of antibiotics, respiratory support, and airway clearance with flexible bronchoscopy is dictated by the patient’s condition. In rare circumstances, extracorporeal mem-brane oxygenation is required if there is associated injury to the more distal airways and lung parenchyma.Despite ubiquitous use of high-volume–low-pressure cuffs, overinflation of the endotracheal cuff is the most common cause of injury secondary to endotracheal intubation. High cuff pressures can cause ischemia of the contiguous airway wall in as short as 4 hours. Prolonged overinflation can lead to scarring Trachea661Anatomy / 661Tracheal Injury / 661Tracheal Fistulas / 664Tracheal Neoplasms / 665Lung667Anatomy / 667Normal Lung Histology / 668Preinvasive Lesions / 669Invasive or Malignant Lesions / 670Lung Cancer Epidemiology / 673Screening for Lung Cancer in High-Risk Populations / 675Solitary Pulmonary Nodule / 677Metastatic Lesions to the Lung / 678Primary Lung Cancer-Associated Signs and Symptoms / 680Lung |
Surgery_Schwartz_4493 | Surgery_Schwartz | / 673Screening for Lung Cancer in High-Risk Populations / 675Solitary Pulmonary Nodule / 677Metastatic Lesions to the Lung / 678Primary Lung Cancer-Associated Signs and Symptoms / 680Lung Cancer Management / 683Lung Cancer Treatment / 693Options for Thoracic Surgical Approaches / 701Postoperative Care / 703Postoperative Complications / 705Spontaneous Pneumothorax / 705Pulmonary Infections / 706Massive Hemoptysis / 717End-Stage Lung Disease / 719Chest Wall720Chest Wall Mass / 720Benign Chest Wall Neoplasms / 722Primary Malignant Chest Wall Tumors / 723Other Tumors of the Chest Wall / 725Chest Wall Reconstruction / 726Mediastinum726Anatomy and Pathologic Entities / 726History and Physical Examination / 727Imaging and Serum Markers / 727Diagnostic Nonsurgical Biopsies of the Mediastinum / 729Surgical Biopsies and Resection of Mediastinal Masses / 730Mediastinal Neoplasms / 730Mediastinal Cysts / 735Mediastinitis / 735Pleura and Pleural Space736Anatomy / 736Pleural Effusion / | Surgery_Schwartz. / 673Screening for Lung Cancer in High-Risk Populations / 675Solitary Pulmonary Nodule / 677Metastatic Lesions to the Lung / 678Primary Lung Cancer-Associated Signs and Symptoms / 680Lung Cancer Management / 683Lung Cancer Treatment / 693Options for Thoracic Surgical Approaches / 701Postoperative Care / 703Postoperative Complications / 705Spontaneous Pneumothorax / 705Pulmonary Infections / 706Massive Hemoptysis / 717End-Stage Lung Disease / 719Chest Wall720Chest Wall Mass / 720Benign Chest Wall Neoplasms / 722Primary Malignant Chest Wall Tumors / 723Other Tumors of the Chest Wall / 725Chest Wall Reconstruction / 726Mediastinum726Anatomy and Pathologic Entities / 726History and Physical Examination / 727Imaging and Serum Markers / 727Diagnostic Nonsurgical Biopsies of the Mediastinum / 729Surgical Biopsies and Resection of Mediastinal Masses / 730Mediastinal Neoplasms / 730Mediastinal Cysts / 735Mediastinitis / 735Pleura and Pleural Space736Anatomy / 736Pleural Effusion / |
Surgery_Schwartz_4494 | Surgery_Schwartz | / 729Surgical Biopsies and Resection of Mediastinal Masses / 730Mediastinal Neoplasms / 730Mediastinal Cysts / 735Mediastinitis / 735Pleura and Pleural Space736Anatomy / 736Pleural Effusion / 736Access and Drainage of Pleural Fluid Collections / 736Malignant Pleural Effusion / 739Empyema / 740Chylothorax / 741Tumors of the Pleura / 743Brunicardi_Ch19_p0661-p0750.indd 66101/03/19 7:00 PM 662Key Points1 Lung cancer continues to be a highly lethal and extremely common cancer, with 57% of patients presenting with dis-tant metastasis and 5-year survival of 18%. Lung cancer incidence is second only to the incidence of prostate cancer in men and breast cancer in women, with 222,500 esti-mated new cases in 2017. Squamous cell carcinoma and adenocarcinoma of the lung are the most common sub-types and are rarely found in the absence of a smoking history. Nonsmokers who live with smokers have a 24% increased risk of lung cancer compared to nonsmokers who do not live with smokers.2 A | Surgery_Schwartz. / 729Surgical Biopsies and Resection of Mediastinal Masses / 730Mediastinal Neoplasms / 730Mediastinal Cysts / 735Mediastinitis / 735Pleura and Pleural Space736Anatomy / 736Pleural Effusion / 736Access and Drainage of Pleural Fluid Collections / 736Malignant Pleural Effusion / 739Empyema / 740Chylothorax / 741Tumors of the Pleura / 743Brunicardi_Ch19_p0661-p0750.indd 66101/03/19 7:00 PM 662Key Points1 Lung cancer continues to be a highly lethal and extremely common cancer, with 57% of patients presenting with dis-tant metastasis and 5-year survival of 18%. Lung cancer incidence is second only to the incidence of prostate cancer in men and breast cancer in women, with 222,500 esti-mated new cases in 2017. Squamous cell carcinoma and adenocarcinoma of the lung are the most common sub-types and are rarely found in the absence of a smoking history. Nonsmokers who live with smokers have a 24% increased risk of lung cancer compared to nonsmokers who do not live with smokers.2 A |
Surgery_Schwartz_4495 | Surgery_Schwartz | sub-types and are rarely found in the absence of a smoking history. Nonsmokers who live with smokers have a 24% increased risk of lung cancer compared to nonsmokers who do not live with smokers.2 A multidisciplinary approach to evaluation of NSCLC, with standardized criteria and terminology for diagnosis in cytologic and small biopsy specimens, and routine molec-ular testing for known mutations, such as EGFR mutations and EML4-ALK fusion oncogenes is now recommended for the evaluation and management of lung nodules due to major advances in targeted therapy. Adequate tissue acquisition at the time of diagnostic workup is critical and facilitates patient care while minimizing the number of procedures to which the patient is subjected.3 The terms bronchioloalveolar carcinoma and mixed subtype adenocarcinoma have been eliminated from the classification of lung adenocarcinoma as a result of increased understanding of important clinical, radiologic, pathologic, and genetic differences | Surgery_Schwartz. sub-types and are rarely found in the absence of a smoking history. Nonsmokers who live with smokers have a 24% increased risk of lung cancer compared to nonsmokers who do not live with smokers.2 A multidisciplinary approach to evaluation of NSCLC, with standardized criteria and terminology for diagnosis in cytologic and small biopsy specimens, and routine molec-ular testing for known mutations, such as EGFR mutations and EML4-ALK fusion oncogenes is now recommended for the evaluation and management of lung nodules due to major advances in targeted therapy. Adequate tissue acquisition at the time of diagnostic workup is critical and facilitates patient care while minimizing the number of procedures to which the patient is subjected.3 The terms bronchioloalveolar carcinoma and mixed subtype adenocarcinoma have been eliminated from the classification of lung adenocarcinoma as a result of increased understanding of important clinical, radiologic, pathologic, and genetic differences |
Surgery_Schwartz_4496 | Surgery_Schwartz | adenocarcinoma have been eliminated from the classification of lung adenocarcinoma as a result of increased understanding of important clinical, radiologic, pathologic, and genetic differences between mucinous and nonmucinous adenocarcinomas. The classification system delineates a stepwise pathologic progression, from AAH to invasive adenocarcinoma based on the predominant histo-logic growth patterns.4 The U.S. Preventive Services Task Force now recommends annual screening for lung cancer with low-dose computed tomography screening in high risk patients. Annual screen-ing averted 14% of lung cancer deaths when applied to a population of asymptomatic adults age 55 to 80 years who have a 30 pack-year smoking history and are either currently smoking or have quit within the past 15 years. Patients should be healthy enough to tolerate curative treat-ment, specifically surgery per guidelines, and screening should be discontinued once the patient has not smoked for 15 years or develops a | Surgery_Schwartz. adenocarcinoma have been eliminated from the classification of lung adenocarcinoma as a result of increased understanding of important clinical, radiologic, pathologic, and genetic differences between mucinous and nonmucinous adenocarcinomas. The classification system delineates a stepwise pathologic progression, from AAH to invasive adenocarcinoma based on the predominant histo-logic growth patterns.4 The U.S. Preventive Services Task Force now recommends annual screening for lung cancer with low-dose computed tomography screening in high risk patients. Annual screen-ing averted 14% of lung cancer deaths when applied to a population of asymptomatic adults age 55 to 80 years who have a 30 pack-year smoking history and are either currently smoking or have quit within the past 15 years. Patients should be healthy enough to tolerate curative treat-ment, specifically surgery per guidelines, and screening should be discontinued once the patient has not smoked for 15 years or develops a |
Surgery_Schwartz_4497 | Surgery_Schwartz | Patients should be healthy enough to tolerate curative treat-ment, specifically surgery per guidelines, and screening should be discontinued once the patient has not smoked for 15 years or develops a life-limiting health condition, becomes unable to tolerate lung surgery, or is unwilling to undergo curative lung resection. With this approach, it is expected that 50% of diagnosed cancers will be early stage. Screening of patients age 50 years or older with a 20 pack-year or greater history and additional risk factors (as determined by the Tammemagi lung cancer risk calculator or other validated risk scores) that increase the risk of lung cancer to 1.3% or greater should also be considered as part of lung cancer screening programs. In all cases, patient–physician shared decision-making should be undertaken, with a discussion of the risks and benefits of screening.5 Assessment of patient risk before thoracic resection is based on clinical judgment and systematic assessment of | Surgery_Schwartz. Patients should be healthy enough to tolerate curative treat-ment, specifically surgery per guidelines, and screening should be discontinued once the patient has not smoked for 15 years or develops a life-limiting health condition, becomes unable to tolerate lung surgery, or is unwilling to undergo curative lung resection. With this approach, it is expected that 50% of diagnosed cancers will be early stage. Screening of patients age 50 years or older with a 20 pack-year or greater history and additional risk factors (as determined by the Tammemagi lung cancer risk calculator or other validated risk scores) that increase the risk of lung cancer to 1.3% or greater should also be considered as part of lung cancer screening programs. In all cases, patient–physician shared decision-making should be undertaken, with a discussion of the risks and benefits of screening.5 Assessment of patient risk before thoracic resection is based on clinical judgment and systematic assessment of |
Surgery_Schwartz_4498 | Surgery_Schwartz | should be undertaken, with a discussion of the risks and benefits of screening.5 Assessment of patient risk before thoracic resection is based on clinical judgment and systematic assessment of cardiopulmonary status using established algorithms.6 Maximum oxygen consumption (v. o2max) values provide important additional information in those patients with severely impaired Dlco and forced expiratory volume in 1 second. Values of <10 mL/kg per minute generally pro-hibit any major pulmonary resection because the mortality in patients with these levels is 26% compared with only 8.3% in patients whose v. o2max is ≥10 mL/kg per minute; values of >15 mL/kg per minute generally indicate the patient’s ability to tolerate pneumonectomy.7 Tumor ablative strategies are viable alternatives to surgical resection for early stage lung cancer in inoperable patients. While premature, ablative techniques may ultimately be shown to have efficacy equivalent to lobectomy for the pri-mary treatment of very | Surgery_Schwartz. should be undertaken, with a discussion of the risks and benefits of screening.5 Assessment of patient risk before thoracic resection is based on clinical judgment and systematic assessment of cardiopulmonary status using established algorithms.6 Maximum oxygen consumption (v. o2max) values provide important additional information in those patients with severely impaired Dlco and forced expiratory volume in 1 second. Values of <10 mL/kg per minute generally pro-hibit any major pulmonary resection because the mortality in patients with these levels is 26% compared with only 8.3% in patients whose v. o2max is ≥10 mL/kg per minute; values of >15 mL/kg per minute generally indicate the patient’s ability to tolerate pneumonectomy.7 Tumor ablative strategies are viable alternatives to surgical resection for early stage lung cancer in inoperable patients. While premature, ablative techniques may ultimately be shown to have efficacy equivalent to lobectomy for the pri-mary treatment of very |
Surgery_Schwartz_4499 | Surgery_Schwartz | resection for early stage lung cancer in inoperable patients. While premature, ablative techniques may ultimately be shown to have efficacy equivalent to lobectomy for the pri-mary treatment of very small peripheral early-stage lung cancers and become primary therapy, even in operable patients, although limited resection with wedge (at least 2 cm margin and at least 1:1 tumor/margin ratio) and seg-mentectomy provide better margins of treatment and nodal sampling ensures occult nodal metastasis are identified. Multidisciplinary collaboration among thoracic surgery, interventional radiology/pulmonology, and radiation oncol-ogy is required to ensure that development of these ablative techniques occurs through properly designed and well-con-trolled prospective studies and will ensure that patients receive the best available therapy, regardless of whether it is surgical resection or ablative therapy.8 The term non–small cell lung carcinoma (NSCLC) includes many tumor cell types, including | Surgery_Schwartz. resection for early stage lung cancer in inoperable patients. While premature, ablative techniques may ultimately be shown to have efficacy equivalent to lobectomy for the pri-mary treatment of very small peripheral early-stage lung cancers and become primary therapy, even in operable patients, although limited resection with wedge (at least 2 cm margin and at least 1:1 tumor/margin ratio) and seg-mentectomy provide better margins of treatment and nodal sampling ensures occult nodal metastasis are identified. Multidisciplinary collaboration among thoracic surgery, interventional radiology/pulmonology, and radiation oncol-ogy is required to ensure that development of these ablative techniques occurs through properly designed and well-con-trolled prospective studies and will ensure that patients receive the best available therapy, regardless of whether it is surgical resection or ablative therapy.8 The term non–small cell lung carcinoma (NSCLC) includes many tumor cell types, including |
Surgery_Schwartz_4500 | Surgery_Schwartz | receive the best available therapy, regardless of whether it is surgical resection or ablative therapy.8 The term non–small cell lung carcinoma (NSCLC) includes many tumor cell types, including large cell, squa-mous cell, and adenocarcinoma. The approach to diagno-sis and management and the terminology used in describing these tumors are evolving rapidly. In particular, the evaluation and management of adenocarcinoma of the lung has shifted dramatically and firm establishment of NSCLC cell type prior to chemotherapy for advanced stage lung cancer is essential.9 Increasing evidence suggests a significant role for gastro-esophageal reflux disease in the pathogenesis of chronic lung diseases such as bronchiectasis and idiopathic pulmo-nary fibrosis, and it may also contribute to bronchiolitis obliterans syndrome in lung transplant patients.10 Treatment of pulmonary aspergillosis/aspergilloma is indi-vidualized. Following colonization of a lung cavity or area of bronchiectasis, fungal | Surgery_Schwartz. receive the best available therapy, regardless of whether it is surgical resection or ablative therapy.8 The term non–small cell lung carcinoma (NSCLC) includes many tumor cell types, including large cell, squa-mous cell, and adenocarcinoma. The approach to diagno-sis and management and the terminology used in describing these tumors are evolving rapidly. In particular, the evaluation and management of adenocarcinoma of the lung has shifted dramatically and firm establishment of NSCLC cell type prior to chemotherapy for advanced stage lung cancer is essential.9 Increasing evidence suggests a significant role for gastro-esophageal reflux disease in the pathogenesis of chronic lung diseases such as bronchiectasis and idiopathic pulmo-nary fibrosis, and it may also contribute to bronchiolitis obliterans syndrome in lung transplant patients.10 Treatment of pulmonary aspergillosis/aspergilloma is indi-vidualized. Following colonization of a lung cavity or area of bronchiectasis, fungal |
Surgery_Schwartz_4501 | Surgery_Schwartz | obliterans syndrome in lung transplant patients.10 Treatment of pulmonary aspergillosis/aspergilloma is indi-vidualized. Following colonization of a lung cavity or area of bronchiectasis, fungal growth within the cavity appears as an irregular cavitary lining, progressing over time as a late finding in chronic pulmonary aspergillosis to a fungal ball called an aspergilloma. Asymptomatic patients can be observed without any additional therapy. Similarly, mild hemoptysis, which is not life-threatening, can be managed with medical therapy, including antifungals and cough suppressants. Oral triazole therapy is now considered the standard of care for chronic, cavitary pulmonary aspergil-losis. Massive hemoptysis had traditionally been an indi-cation for urgent or emergent operative intervention. However, with the advancement of endovascular tech-niques, bronchial artery embolization in select centers with experience in these techniques has been effective.11 In patients with malignant | Surgery_Schwartz. obliterans syndrome in lung transplant patients.10 Treatment of pulmonary aspergillosis/aspergilloma is indi-vidualized. Following colonization of a lung cavity or area of bronchiectasis, fungal growth within the cavity appears as an irregular cavitary lining, progressing over time as a late finding in chronic pulmonary aspergillosis to a fungal ball called an aspergilloma. Asymptomatic patients can be observed without any additional therapy. Similarly, mild hemoptysis, which is not life-threatening, can be managed with medical therapy, including antifungals and cough suppressants. Oral triazole therapy is now considered the standard of care for chronic, cavitary pulmonary aspergil-losis. Massive hemoptysis had traditionally been an indi-cation for urgent or emergent operative intervention. However, with the advancement of endovascular tech-niques, bronchial artery embolization in select centers with experience in these techniques has been effective.11 In patients with malignant |
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