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Master Techniques in OtolaryngologyHead and Neck Surgery

VOLUME

SERIES EDITOR

EUGENE

N. MYERS

EDITOR

ROBERT L. FERRIS

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MASTER TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Head and Neck Surgery THYROID, PARATHYROID, SALIVARY GLANDS, PARANASAL SINUSES AND NASOPHARYNX

Series Editor EUGENE N. MYERS, MD, FACS, FRCS EDIN (HON)

Volume Editors Master Techniques in Otolaryngology-Head and Neck Surgery Head and Neck Surgery: Larynx, Hypopharynx, Oropharynx, Oral Cavity and Neck Volume1 Robert L. Ferris, MD, PhD, FACS Masl&r Techniques in Otolaryngology-Head and Neck Surgery Head and Neck Surgery: Thyroid, Parathyroid, Salivary Glands, Paranasal Sinuses and Nasopharynx Volume2 Robert L. Ferris, MD, PhD, FACS Master Techniques in Otolaryngology-Head and Neck Surgery: Reconstructive Surgery Eric Genden, MD Master Techniques in Otolaryngology-Head and Neck Surgery: Skull Base Surgery Cari H. Snyderman, MD Paul Gardner, MD Master Techniques in Otolaryngology-Head and Neck Surgery: Rhinology David Kennedy, MD Master Techniques in Otolaryngology-Head and Neck Surgery: Facial Plastic Surgery Wayne Larrabee Jr, MD and James Ridgeway, MD Master Techniques in Otolaryngology-Head and Neck Surgery: Otology and Lateral Skull Base Surgery J. Thomas Roland, MD

MASTER TECHNIQUES IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY

Head and Neck Surgery THYROID, PARATHYROID, SALIVARY GLANDS, PARANASAL SINUSES AND NASOPHARYNX VOLUME2 Setles EdltDr

Eugene N. Myers, MD, FACS, FRCS Edin (Hon) Distinguished Professor and Emeritus Chair Department of 0tolaJY11gology lkliversity of Pii!Sburgh School of Medicine Professor, Oepartmem at Oral Maxillofacial Surgery UniVersity of Pittsburgh School of Dental Medicine Pittsburgh, Pennsylvania

Editor

Robert L. Ferris, MD, PhD, FACS UPMC Endowed Professor and Chief, Division of Head and Neck Surgery Vice Chair for Clinical Affairs, Departmem of OIDiaryngology Associate Director for Translational Res earth Co-leader, Canal!' Immunology Program University of Pittsburgh cancer lnslilute Plttslllrgh, Pennsylvania

I

•Wolters Kluwer Lippincott Williams & Wilkins Health Phitadelpllill• Baltimore • New Ycnt • London euenos Alru • Hong Kong • Sydney • Tokyo

Acquisitions Editor: Ryan Shaw Print Production Manager: Marian Bellus Product Developmental Editor: Dave Murphy Design Manager: Doug Smock Manufacturing Manager: Beth Welsh Marketing Manager: Daniel Dressler Production Services: SPi Global Copyright © 2014 Wolters Kluwer Health I lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at TWo Commerce Square, 2001 Market St., Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services).

9 8 7 6 5 4 3 2 1 Printed in China

Library of Congress Cataloging-in-Publication Data CIP data available from the publisher upon request. ISBN 978-1-4511-4367-6 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the author, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The author, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice. LWW.com

This series of books is dedicated to Barbara, my wife and best pal. Our daughter, Marjorie Fulbrigh~ her husband cary and their sons, Alexander F. Fulbright and Charles J. Fulbright. Our son, Jeffrey N. Myers, MO, PhD, his wife Usa and their sons Keith N. Myers, Brett A. Myers, and Blake D. Myers. All of whom /love and cherish. Eugene N. Myers

The conception, development and realization of a large new effort such as this requires much devotion and support from staff and loved ones. In particular, I would like to dedicate this book to my phenomenally supportive and successful wife, Laura, without whom I could not have

accomplished very many things in my career./ also appreciate the close mentoring relationship and guidance I have enjoyed over many years from Dr. Eugene N. Myers (Series Editor), who continues to provide opportunities for my career growth and contributions to the field of head and neck surgery. Robert L Ferris

Contributors

Ricardo L. camu, MD, FilCS

Pavel Dulguerov, MD

Professor Department of Otolaryngology-Head and Nec:k Sw:gety Director of the Comprehensive Skull Base Surgery Program The Ohio State University Medical Center Columbus, Ohio

Chief of Head and Neck Surge.ry Depamnent of Otorhinolaryngology-Head and Nec:k Surgery Gcmc:va University Hospital Geneva, Switzerland

rtlnclsco J. Cln.ntal, MD, FACS Associate Professor Department of Otolaryngology University of Miami Health System Miami, Florida

Clludlo R. Cemea, MD Professor Department of Head and Neck Surgery University of Silo Paulo Medical School Department of Head and Neck Surgery Federal University of Sio Paulo Silo Paulo, Brazil

Jimmy Yu-wll et.J, MD, MS, FRCS Chief, Division of Head & Neck S'lqery, Division of Plaslic & Rca:m.siJ:uctiv Surgery Department of Surgery Queen Muy Hospital The University of Hong Kong Hong Kong, Republic of China

MLI·KIIIn Chill, MD, MS, PhD Professor ChWlg Shan Medical University

Chief Medical Director Changhua Christian Hospital Pn':sident Taiwan Head and Neck Society Tai.chung City, Taiwan. Republic of China Woang Youn Cllung, MD Chief, Division of Endocrine Swgecy Department of Surgery Yonsei University College of Medicine Seoul, S4 mm. tumor size >2 em, aruuomic location, microinvasion, and perineural infiltraSion. However, none of dl.ese IqlfCSent a fool proof means of defining the population at risk. When an early, invasive primary cancer of the oral cavity is identified and no clinically or radiologically involved cervical lymph nodes (LNs) are present, we must still consider managcmtmt of Che LNs. The 20% to 30% risk of oo:ult metastases must be weighed against Che morbidity of dissecting nec:b that do not contain metastatic cancer. Sentinel node biopsy iB appropriate for situations where the expected risk: of metastases falls in the 5% to 15% range, which might be too high to feel romfortable with watchful waiting but too low to justify Che potential morbidity of a selective neck dissection. In order to validate this tedmique for cancer of dl.e oral cavity, a trial funded by the National Cancer Institute was completed in North America under the auspices of the American College ofSurgeons Oncology Group (ACOSOG). The results of theACOSOG lrial. revealed, after centtalstep sectioning and immunohistochemistry fur cytok:eratins, a negative pnxti.ctive value (NPV) of 96% and false-negative :nue of 9.8%. Interestingly, for Tl cancers in both groups of SUJECOns, in the setting of a 25% true-positive rate, the fal.sc-ncga1ive rate was 0% and NPV was 100%. Similarly, for dl.e group of experienced surgeons, false-negative .rate was 0% and NPV was 100%.

HISTORY The typical patient who is a candidate for sentinel node biopsy presen.IS with a visible and accessible cancer in dl.e oral cavity. The patient will typically have seen or felt a lesion in the oral cavity, perhaps with the tongue, or at the time of brushing the teeth. The lesion is typically mildly lm.OOlllt'ortable. There may be a history of bleeding. The lesion may have been identified by the patient's dentist or physician as biopsy-proven squamous ceO carcinoma.

PHYSICAL EXAMINATION On physical c:umination, dl.ere iB a lesion, which is ideally 2 em) to prevent skin flap necrosis. The neck portion of the incision rarely needs to go beyond the level of the anterior border of the sternocleidomastoid (SCM) muscle. The exposure is adequate in most cases, the scar is small and well hi.clden, and the direction of the incision can be modified, should a neck dissection or extended base of skull resection become necessary. R.cocntly, the usc of a :rhytidectomy incision with the same vertical preauricular limb and a horizontd retroauricular limb near the neck hair line (Fig. 25.6) has been promoted as being more cosmetic. Whetber this incision is worth the extra time and gives a better cosmetic result remains to be demonstramd in randomized trials with blinded evaluation of the results. Furthennore, the :rhytidectomy approach is less versatile with difficulties to extend the incision for neck: dissection and limited exposure for an.k:riorly located lesions. Obviously, modifiauions of these incisiom are required. when skin has to be resected because of invasion by a tumor. malignant or benign. In these cases, the tumor is usually large enough to serve as a na.tunll tissue expander, and rarely are any difficulties encountered with the closure. During reoperation, especially for recurrent pleomorphic adenoma, the scar and any suspicious subcutaneous tissue must be excised at the beginning of the procedure. Although early parotidectomy techniques did not .raise the superficial facial skin flap before beginning dissection of the gland, it is now standard. The dissection of the skin flap is facilitated by prior infiltration. The flap can be raised in the subcutaneous adipose tissue, avoiding injury to the hair follicles. This plane of dissection is superficial to the SMAS and to the superficial cervical fascia. Dissection in this plane is advised if the tumor is very superficial, and this plane of dissection is the safest anteriorly where the distal branches of the

fi&LN2U

Rhytidectomy incision for parotidectomy.

211

CHAPTER 25 Superficial Parotidectomy facial nerve become more superficial. U8U8lly, diaaection in the supra-SMAS adipose tissue is easier, is mare expediti.oua, and reeul1! in ku bleeding. The dissection can al.&o be made in a plam: deep to the SMAS and is described as providing mare esthetic results and u a technique to prevent Frey syndrome. An advantage of s~SMAS diasection is the better vascularization of the akin flap. In s~SMAS dissection, progression beyoJld the an=ior ~on of the parotid gland should be cautious becmae hen: hcial ncm: bnmcbes rapidly become superficial. I use elementa of both; the akin is elevated superficial to the SMAS for a few centimeter& after which we search for the level of the parotid lobules and elevate the SMAS!paroti.d fascia layer to expose the entire gland. Unless some form of "minimalistic" resection is planned, the cutin: gland must be cxpoeed to allow for better visualization of the J.ateral aspect of the tumor. The di.saection can be carried out either with a scalpel or with scissors probably with similar results. When using scills,ms. emphasis has been p'W:cd on doing the dissection parallel to facial nerve fibenl and placing the sciasms shafts at right BDgles to the underlying parotid gland. Most of this dissedion is "blind," since the skin Haps are put under tension in a posterior direction. The edge of the instrument can be seen as its tip elevates the skin. After elevation of the skin Oap, stay sutures can be placed on the 8ap and the ear lobule to help the retraction. The next step is to free the posterior aspect of the parotid gland. The gland is easily sepa11dl:d from the SCM muscle, a step n:quiring sectioning of the superficial layer of the deep cervical fasci.a. At this point, it often becomes obvious that the anterior branch of the greater auricular nerve has to be transected. Some believe that the nerve should be tied. to prevent the OOCUJl:ellCe of a postoperative neuroma. The posterior and "lobular" branch of the greater auricular ncm: can usually be preserved, although over time anesthesia of the skin seem& to recover, even when the entire nerve is transected. Deep to the SCM muscle, the parotid gland is attacl1ed to the posterior belly of the digastric muscle, whidl is a key landmark in this operation. The parotid gland must be completely fi:eed from the digastric muscle, all the way to i1! origin on the mutoid; a step that leads to the identification of the main trunk of the facial ncm:. The external jugular vein and the n:tromandibular vein should be preserved during the initial stages of dissection, in order to decrease the intraparotid venous pressure and thus decrease bleeding. While dissecting along the digastric muscle. the subdigutri.c region should be e:nmined for the prcaence of suspicious lymph nodes. The gland is also separated from the anterior aspect of the cartilaginous exU:ma1 a.uditmy means, cutting the fascialattAclunents and exposing the so-called cartilaginous pointer, another landmlr[k helpful in the identification of the facial nerve. It is important to stay against the cartilage duriug this dissection, to decreue bl=ding, to avoid injuring branches of the hcial nerve within the parotid gland. and most importantly to use it as a guide during the diasection. The dissection continues by the identification of the junction between the cartilaginous and bony external auditory meams. During this dissection, the posterior extension of the parotid fascia is scctioncd, as it inserts on the tympanomastoid suture (sometimes refemd to as Lore fascia). The tail of the parotid can be dissected before or after the preauricular dissection. The dissection should not proceed too deep before the nerve trunk is identi1i.ed. On the other hand, a common error is to start looking for the facial nerve too early; the nerve is a deep sttucture and is never superficial to the cartilaginous pointer or to the postmior belly of the digastric muscle. Before trying to identify the facial nerve, good exposure and excellent hemostasis RIC paramount. Good caposure is achieved by the pxeviously described dissection of the posterior aspect of the parotid gland. The gland is retracted anteriorly by a retractor held by an assistant, and the external ear canal is retracted posteriorly by a sutun: abched to a weight or to the drapes (Fig. 25.7). CBICful hemostasis is important because any blood in the wound will collect in ita deepest portion, wbi.ch is where the facial nerve will be found (Fig. 25.8). Above the level of the cartilaginous pointer, a regular monopolar electrocoagulam can be employed, while deep to this level, a fine bipolar forceps is safer.

FIIURE ZS.7 Dissection of the posterior portion of the parotid gland.

212

SECTION 4 Salivary Glands

FliURE21.1 Exposure and landmarks for identification of the main trunk of the facial nerve. The ~ step in parotid surgery is dle identification of the main trunk of dle faci.al nave. In modern parotidectomy, the nerve is identified at the trunk level, and the branches followed forward in dle glandular pa:eru:b.yma. Useful landmarks for the facial nave trunk include • The "cartilaginow pointer' or "tragal pointer," which is actually the anterior tip of dle tragus portion of the external ear cartilage (Fig. 25.8). The main trunk is said to be 1 em deep and 1 em inferior to the pointer. • The posterror beUy oft'lte digastric muscle and its insertion on dle mastoid process, which is slightly laleraJ. to the stylomastoid fomm.en. • The ty1ri{JallfJmlloid Sfltu.re, which can be identified by palpation. The main trunk is said to be 6 to 8 mm from the "inferomedial end of the suture"; unfortunately, some controversy exists on what represents dle end of the sutun:. • The styfumastoid artery running widl its vein a few millimeters lateral to the facial nerve. The stylomastoid artery arises from branches of the external carotid and follows dle facial nerve in the stylomastoid foramen. • The styfuid proce.J.J, which is located deep to dle facial nerve. It can be palpated, but its visualization before identification of dle nerve usually means 1hat the nerve has been injured. Of these anatomicallandmad::s, dle tympanomastoid sutun: is probably the most usc.fut because it is a bony landmark and the least subject to variation in location. The tympanomastoid suture is formed by edge of the tympanic bone lying on the mastoid bone. It starts at the posterior edge of the bony extemal auditmy canal to extend on to the undersurface of the temporal bone. It tcmrinatcs by the stylomastoid foramen, Chrough which the facial nerve exits 1he skull. As pointed out earlier, 1he parotid fascia inserts on the tympanomastoid suture. According to Robertson, the fissun: can be followed safely until this fascial layer, which is often quite tough. The fascia needs to be divided close to the temporal bone, and the dissection should proceed widl gentle spreading of the tissues in dle direction of the facial nave trunk. using a fine mosquito forceps. The nave appears as a white cord-like structure. Usually, the stylomastoid arteiy is coagulated with bipolar fo:rt:eps prior to identifying dle facial nerve trunk:. The nerve must be identified wid!. certainty. One way to identify dle facial nerve is to dissect the length of dle trunk, until the bifun:ation is clearly visualized. This dissection should be very cautious because accessory facial nerve trunks (actually a facial nerve dlat has bifun:atcd in the mastoid canal) have been de8cri.bed. Once dle bifurcation is identified, try to selectively stimulate each division branch, 1hat is, when the cervk:ofaci.al division is stimulated, the eyelids should not twitch and vice versa. Anodler way is to use a facial nerve stimulator using dle lowest possible electric cunent. in order to avoid nerve damage and fatigue. With modern monitoring devices, the minimal amount of cw:rent necessazy to elicit nerve stimulation, ideally without facial muscle contraction, should be used: one gets an BMG n:sponse but not muscle twitching. Bipolar stimulating electrode is more selective, uses less CUllent for stimulation, and is dletefute preferred. The use of "nave pinching" as nerve stimulation technique is to be discouraged, al.1hough a comparative trial of dlese two techniques has not been c:arried out. Sistrunk, as well as Adson and Ott, proposed to identify Che marginal mandibular branch and follow it by n:trograde dissection to 1he main trunk of the facial nerve. Stale identified buccal branches anteriorly in dle parotid gland and used retrograde dissection to find the main trunk of the facial nerve. Bailey identified temporal facial nerve branches, as they cross the zygomatic arch. Wbi.le the routine use of Chese methods has been abandoned, they remain useful in reoperations of the parotid gland where the scar tissue nmders identification of the main tnmk both rather tedious and with a certain clement of danger. A few authors still favor dle identification of a peripheral branch (usually the nwgin.al. mandibular nerve) and its dissection back to Che main trunk of the facial nerve. The branches, the least difficult to identify, are the temporal and the marginal mandibular because they are often away from dle field of dissection and also because they exhibit the least variation. Finally, in difficult cases, the mastoid lip can be removed and the facial nerve identified in dle descending mastoid segment.

213

CHAPTER 25 Superficial Pamlidectomy

FIIIIIE 211.1 Dissection of facial nerve branches

during superficial parotidectomy. Once the main trunk is identified, the facial b111Dches are dissected The usual medlod is to dissect directly on top of a branch with fine hemostats or scissors (Fig. 25.9). The spreading action is in the direction of the "facio-venous plane," which is almost horizontal in supine po!ition. During spreading, the superficial lobe parenehyma is then 1ifiM and scclioned. This section should be performed with the dissected bnmch clearly in view. The instrument most often used is a no. 12-scalpel blade or more rarely aciJaors. The dissection proceeds through the parenchyma of the gland and usually results in some bleeding that needs to be controlled with a bipolar electric coagulator. A prefenm option is to coagulatl: the parotid tissue prior to cutting. Fee and HaDden have advocated the use of the Shaw hemostatic scalpel. but t:hiB device has been associatl:d with higha postparo1i.dectomy facial nerve paresis in other band!. Bipolar e1cctrocoagulalo forceps are often used. l have found that bipolar scissors have been extremely helpful in preventing bleeding by providing vessel coagulation while cutting. Despite the close presence of nerve branches, no facial muscle moveme:nt or evoked BMG in the nerve monitor has been detected. Irrespective of the e1.ectrocoagula device used, it is important that the tissue coagulated/sectioned is 1ifiM from the underlying branch of the nerve since elcctric current does not spread well through air. The dissection usually follows one bram:h and its tributaries to the anterior edge of the parotid gland. Then, the next branch is followed and so on. Some &1ll'.'gCODS begin the dissection with the IIlJIIgi.n.a1 mandibular and cervic:al. branches and proceed in a superior di.tec:tion, others begin with the superior division. and aome 11tart at both end! to finish in the middle of the gland. Actually, the dissection is greatly determined by the po!ition of tumor. Although the facial nerve comes first, I try as much as possible to mmove the supcrliciall.obe and the tumor in monoblock and thereby obtain tumor-free deep margins. During th.i! dissection. no traction is applied to the facial nerve and its branches. For a superficial parotidectomy, the lmmches are left attached to the underlying parenchyma. thereby pi'CilCJ'Vi.ng their blood supply (Fig. 25.10). Coagulation is performed with a bipolar Q08gulator, after reduction of the electric current power. Usually, unless the bleeding is right on a branch of the nerve, no facial nerve paresis results from bipolar coagulation. In C88CS of a bleeding vm:y close to the nerve, a sponge soaked in adrenaline can be used. Peripheral branches of the facial nerve rapidly become superficial at the anterior border of the gland. Special attention should also be paid in large tumors, which tend to displace the branches, making them deeper and more superficial and splaying them. After the delivery of the superficial. lobe $peclmen. it should be inapected for exposed tumor surface (bare capsule). Because of the proximity of the branc:hes of the facial nerve, this cannot be always avoided, but it might require an extra resection of deep lobe parenchyma. masseter muscle, or other adjacent tissues.

FBIIIE 25.to The operative field

superficial parotidectomy.

at the end of

214

SECTION 4 Salivary Glands Usually, there should be no good reason to see exposed tumor inferiorly, laterally, and even superiorly, since SMAS, skin, and SCM muscle are nonessential wsues. During the entire dissection, it is important that Chc traction applied to Chc resected tissue, and thus, the tumor is not excessive. Larger and cystic tumors tend to rupture under too much ttaction or compression resulting in spillage of the tumor contents in the surgical bed, which is thought to be a major cause of recum:nce, especially for pleommphic adenoma. As soon as a 1m:ach in Chc tumor capsule is dctec:tcd, I advise the use of a rhinology type of suction tip and to carefully insert it through the opening in the tumor capsule in order to aspirate the liquid content and to somewhat decompress the tmnor. The opening is then sutured and the insuumcnts used in this maneuver discanlcd. as contaminated. The wound should be copiously irrigated with saline. The handling of Stensens duct is variable: some ligate it., others do not even look for it., and finally, other surgeons think that it should be left in place to drain the wound in the mouth to preserve the function of the remaining deep lobe and prevent the development of postparotidectorny fistula. I never look for it Any lesion of Chc parotid gland should be excised with a margin of healthy salivary gland tissue, but the extent of parotidectomy should probably be adapted. to the degree of malignancy of the lesion. Usually, frozen sections are relied upon to dctmninc the extent of the proccdm:e, although the reliability is net absolute and neither the main trunk of the facial nerve nor its branches should be sacrificed based on the results of the frozen section. A recent meta-analysis found that frozen sections are associated. with 10% false-negative rates for malignancy. The rates for the cmrect diagnosis of the specific histologic cmcer subtype arc even lower. Nevertheless, frozen sections are recommended to diagnose pleomorphic adenoma and cancer. In cancer of the parotid gland and some pleomozphic adenomas at greater risk for re