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Surgery_Schwartz_4202
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within 2 to 3 weeks and complete recovery at 3 to 4 months. Treatment includes oral steroids plus antiviral ther-apy (i.e., valacyclovir). Complete recovery is the norm, but it does not occur universally, and selected cases may benefit from surgical decompression of the nerve within its bony canal. Elec-trophysiologic testing has been used to identify those patients in whom surgery might be indicated.13 The procedure involves decompression of the nerve via exposure in the mastoid and middle cranial fossa.Figure 18-2. Myringotomy and tube.Brunicardi_Ch18_p0613-p0660.indd 61501/03/19 5:22 PM 616SPECIFIC CONSIDERATIONSPART IIVaricella zoster virus may also cause facial nerve paraly-sis when the virus reactivates from dormancy in the nerve. This condition, known as Ramsay Hunt syndrome, is characterized by severe otalgia followed by the eruption of vesicles of the external ear and the soft palate. Treatment is similar to Bell’s palsy, but full recovery is only seen in approximately
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Surgery_Schwartz. within 2 to 3 weeks and complete recovery at 3 to 4 months. Treatment includes oral steroids plus antiviral ther-apy (i.e., valacyclovir). Complete recovery is the norm, but it does not occur universally, and selected cases may benefit from surgical decompression of the nerve within its bony canal. Elec-trophysiologic testing has been used to identify those patients in whom surgery might be indicated.13 The procedure involves decompression of the nerve via exposure in the mastoid and middle cranial fossa.Figure 18-2. Myringotomy and tube.Brunicardi_Ch18_p0613-p0660.indd 61501/03/19 5:22 PM 616SPECIFIC CONSIDERATIONSPART IIVaricella zoster virus may also cause facial nerve paraly-sis when the virus reactivates from dormancy in the nerve. This condition, known as Ramsay Hunt syndrome, is characterized by severe otalgia followed by the eruption of vesicles of the external ear and the soft palate. Treatment is similar to Bell’s palsy, but full recovery is only seen in approximately
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Surgery_Schwartz_4203
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Surgery_Schwartz
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is characterized by severe otalgia followed by the eruption of vesicles of the external ear and the soft palate. Treatment is similar to Bell’s palsy, but full recovery is only seen in approximately two-thirds of cases.Traumatic facial nerve injuries may occur secondary to accidental trauma or surgical injury. Iatrogenic facial nerve trauma most often occurs during mastoidectomy, most com-monly to the vertical segment of the nerve.14 Detailed knowl-edge of facial nerve anatomy and adjunctive use of nerve integrity monitoring systems are imperative in this context. When the facial nerve is injured during an operative procedure, it is explored. Injury to >50% of the neural diameter of the facial nerve is addressed either with primary reanastomosis or recon-structed with the use a nerve graft. Complete recovery of nerve function is uncommon in these cases.Lesions of the Internal Auditory Canal and Cerebello-pontine Angle. The most common lesion affecting the inter-nal auditory canal
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Surgery_Schwartz. is characterized by severe otalgia followed by the eruption of vesicles of the external ear and the soft palate. Treatment is similar to Bell’s palsy, but full recovery is only seen in approximately two-thirds of cases.Traumatic facial nerve injuries may occur secondary to accidental trauma or surgical injury. Iatrogenic facial nerve trauma most often occurs during mastoidectomy, most com-monly to the vertical segment of the nerve.14 Detailed knowl-edge of facial nerve anatomy and adjunctive use of nerve integrity monitoring systems are imperative in this context. When the facial nerve is injured during an operative procedure, it is explored. Injury to >50% of the neural diameter of the facial nerve is addressed either with primary reanastomosis or recon-structed with the use a nerve graft. Complete recovery of nerve function is uncommon in these cases.Lesions of the Internal Auditory Canal and Cerebello-pontine Angle. The most common lesion affecting the inter-nal auditory canal
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Surgery_Schwartz_4204
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Surgery_Schwartz
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graft. Complete recovery of nerve function is uncommon in these cases.Lesions of the Internal Auditory Canal and Cerebello-pontine Angle. The most common lesion affecting the inter-nal auditory canal (IAC) and the cerebellopontine angle (CPA) is vestibular schwannoma (formerly referred to as “acoustic neuroma”). Less commonly encountered lesions of the IAC and CPA include meningioma and epidermoid tumors. Vestibular schwannomas are benign tumors that comprise 60% to 92% of all CPA lesions and 6% to 10% of intracranial tumors. They demon-strate an average growth rate of 1 to 2 mm per year.15 Vestibular schwannomas are most commonly unilateral and sporadic; bilat-eral tumors are the hallmark of neurofibromatosis type 2 (NF2), an autosomal dominant condition linked to mutation of a tumor suppressor gene mapped to chromosome 22. The most common presenting symptoms of vestibular schwannoma are asymmetric sensorineural hearing loss and speech perception deficits often out of proportion to
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Surgery_Schwartz. graft. Complete recovery of nerve function is uncommon in these cases.Lesions of the Internal Auditory Canal and Cerebello-pontine Angle. The most common lesion affecting the inter-nal auditory canal (IAC) and the cerebellopontine angle (CPA) is vestibular schwannoma (formerly referred to as “acoustic neuroma”). Less commonly encountered lesions of the IAC and CPA include meningioma and epidermoid tumors. Vestibular schwannomas are benign tumors that comprise 60% to 92% of all CPA lesions and 6% to 10% of intracranial tumors. They demon-strate an average growth rate of 1 to 2 mm per year.15 Vestibular schwannomas are most commonly unilateral and sporadic; bilat-eral tumors are the hallmark of neurofibromatosis type 2 (NF2), an autosomal dominant condition linked to mutation of a tumor suppressor gene mapped to chromosome 22. The most common presenting symptoms of vestibular schwannoma are asymmetric sensorineural hearing loss and speech perception deficits often out of proportion to
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Surgery_Schwartz_4205
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Surgery_Schwartz
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gene mapped to chromosome 22. The most common presenting symptoms of vestibular schwannoma are asymmetric sensorineural hearing loss and speech perception deficits often out of proportion to degree of hearing loss indicated by audiom-etry. Unilateral tinnitus is also frequently reported. Disequilib-rium or, less commonly, episodic vertigo may be present. Facial nerve weakness or paralysis is rare. Larger tumors may feature facial numbness and loss of the cornea reflex from compression of the trigeminal nerve. Very large lesions can lead to brainstem compression, obstructive hydrocephalus, and death.Gadolinium-enhancement on T1-weighted MRI is the gold standard for diagnosis and detects even very small tumors (Fig. 18-3) The conventional armamentarium for vestibular Figure 18-3. A. Axial T1 magnetic resonance imaging (MRI) post-contrast showing left cerebellopontine angle tumor with avid gadolinium enhancement. Minimal internal auditory canal involvement is noted. B. Axial T2 MRI
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Surgery_Schwartz. gene mapped to chromosome 22. The most common presenting symptoms of vestibular schwannoma are asymmetric sensorineural hearing loss and speech perception deficits often out of proportion to degree of hearing loss indicated by audiom-etry. Unilateral tinnitus is also frequently reported. Disequilib-rium or, less commonly, episodic vertigo may be present. Facial nerve weakness or paralysis is rare. Larger tumors may feature facial numbness and loss of the cornea reflex from compression of the trigeminal nerve. Very large lesions can lead to brainstem compression, obstructive hydrocephalus, and death.Gadolinium-enhancement on T1-weighted MRI is the gold standard for diagnosis and detects even very small tumors (Fig. 18-3) The conventional armamentarium for vestibular Figure 18-3. A. Axial T1 magnetic resonance imaging (MRI) post-contrast showing left cerebellopontine angle tumor with avid gadolinium enhancement. Minimal internal auditory canal involvement is noted. B. Axial T2 MRI
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Surgery_Schwartz_4206
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Surgery_Schwartz
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T1 magnetic resonance imaging (MRI) post-contrast showing left cerebellopontine angle tumor with avid gadolinium enhancement. Minimal internal auditory canal involvement is noted. B. Axial T2 MRI showing left cerebellopontine angle tumor with thin cerebrospinal fluid cleft between tumor and brainstem/cerebellum. C. Axial T1 MRI post-contrast showing left cerebellopontine angle tumor with avid gadolinium enhancement. The lesion is confined to the internal auditory canal with minimal cerebellopontine angle involvement. D. Intraoperative phono during microsurgical resection via translabyrinthine approach. Black arrow indicates cochlear nerve.ABCDBrunicardi_Ch18_p0613-p0660.indd 61601/03/19 5:22 PM 617DISORDERS OF THE HEAD AND NECKCHAPTER 18schwannoma includes observation, microsurgical resection, and stereotactic radiation.16 Management of patients with ves-tibular schwannomas involves weighing a multitude of vari-ables particular to the tumor (location, size, growth pattern), the
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Surgery_Schwartz. T1 magnetic resonance imaging (MRI) post-contrast showing left cerebellopontine angle tumor with avid gadolinium enhancement. Minimal internal auditory canal involvement is noted. B. Axial T2 MRI showing left cerebellopontine angle tumor with thin cerebrospinal fluid cleft between tumor and brainstem/cerebellum. C. Axial T1 MRI post-contrast showing left cerebellopontine angle tumor with avid gadolinium enhancement. The lesion is confined to the internal auditory canal with minimal cerebellopontine angle involvement. D. Intraoperative phono during microsurgical resection via translabyrinthine approach. Black arrow indicates cochlear nerve.ABCDBrunicardi_Ch18_p0613-p0660.indd 61601/03/19 5:22 PM 617DISORDERS OF THE HEAD AND NECKCHAPTER 18schwannoma includes observation, microsurgical resection, and stereotactic radiation.16 Management of patients with ves-tibular schwannomas involves weighing a multitude of vari-ables particular to the tumor (location, size, growth pattern), the
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Surgery_Schwartz_4207
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Surgery_Schwartz
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resection, and stereotactic radiation.16 Management of patients with ves-tibular schwannomas involves weighing a multitude of vari-ables particular to the tumor (location, size, growth pattern), the patient (age, overall health, individual wishes), and the inter-action between tumor and patient (symptoms currently expe-rienced, symptoms likely to develop with lesion progression, degree of residual hearing). For patients who have hearing that may still benefit from acoustic amplification using a hearing aid, either a retrosigmoid or a middle fossa approach may be offered, depending on tumor location, size, patient preference, and provider experience. For patients without serviceable hear-ing preoperatively, a translabyrinthine approach is most com-monly offered.Sinonasal Inflammatory DiseaseRhinosinusitis. Rhinosinusitis is defined as symptomatic inflammation of the nasal cavity and paranasal sinuses. Rhi-nosinusitis is preferred over sinusitis because sinusitis almost always is
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Surgery_Schwartz. resection, and stereotactic radiation.16 Management of patients with ves-tibular schwannomas involves weighing a multitude of vari-ables particular to the tumor (location, size, growth pattern), the patient (age, overall health, individual wishes), and the inter-action between tumor and patient (symptoms currently expe-rienced, symptoms likely to develop with lesion progression, degree of residual hearing). For patients who have hearing that may still benefit from acoustic amplification using a hearing aid, either a retrosigmoid or a middle fossa approach may be offered, depending on tumor location, size, patient preference, and provider experience. For patients without serviceable hear-ing preoperatively, a translabyrinthine approach is most com-monly offered.Sinonasal Inflammatory DiseaseRhinosinusitis. Rhinosinusitis is defined as symptomatic inflammation of the nasal cavity and paranasal sinuses. Rhi-nosinusitis is preferred over sinusitis because sinusitis almost always is
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Surgery_Schwartz_4208
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Surgery_Schwartz
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DiseaseRhinosinusitis. Rhinosinusitis is defined as symptomatic inflammation of the nasal cavity and paranasal sinuses. Rhi-nosinusitis is preferred over sinusitis because sinusitis almost always is accompanied by inflammation of the contiguous nasal mucosa. Rhinosinusitis is a significant health burden, affect-ing nearly 12% of the population.17 Rhinosinusitis is the fifth most common diagnosis responsible for antibiotic prescription and accounts for more than 20% of all antibiotics prescribed to adults. Rhinosinusitis may be broadly classified based on duration of symptomatology. Symptoms lasting <4 weeks may be classified as acute rhinosinusitis (ARS), while symptoms lasting >12 weeks may be classified as chronic rhinosinusitis (CRS). Rhinosinusitis lasting between 4 and 12 weeks has his-torically been defined as “subacute,” although the current clini-cal practice guideline published by the American Academy of Otolaryngology—Head and Neck Surgery does not distinguish rhinosinusitis
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Surgery_Schwartz. DiseaseRhinosinusitis. Rhinosinusitis is defined as symptomatic inflammation of the nasal cavity and paranasal sinuses. Rhi-nosinusitis is preferred over sinusitis because sinusitis almost always is accompanied by inflammation of the contiguous nasal mucosa. Rhinosinusitis is a significant health burden, affect-ing nearly 12% of the population.17 Rhinosinusitis is the fifth most common diagnosis responsible for antibiotic prescription and accounts for more than 20% of all antibiotics prescribed to adults. Rhinosinusitis may be broadly classified based on duration of symptomatology. Symptoms lasting <4 weeks may be classified as acute rhinosinusitis (ARS), while symptoms lasting >12 weeks may be classified as chronic rhinosinusitis (CRS). Rhinosinusitis lasting between 4 and 12 weeks has his-torically been defined as “subacute,” although the current clini-cal practice guideline published by the American Academy of Otolaryngology—Head and Neck Surgery does not distinguish rhinosinusitis
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Surgery_Schwartz_4209
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Surgery_Schwartz
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been defined as “subacute,” although the current clini-cal practice guideline published by the American Academy of Otolaryngology—Head and Neck Surgery does not distinguish rhinosinusitis in this time frame, noting that this group likely represents crossover symptoms from one of the other two sub-classes. Hence, the decision on how to manage this group of patients must be individualized.18 Because common conditions such as atypical migraine headache, laryngopharyngeal reflux, and allergic rhinitis frequently mimic rhinosinusitis, diagno-sis of rhinosinusitis is based not only on symptomatic criteria but also on objective evaluation with either imaging and/or endoscopy.Acute Rhinosinusitis. Acute rhinosinusitis most commonly occurs in the setting of a viral upper respiratory tract infection (URI). Although it is believed that acute bacterial rhinosinusitis (ABRS) typically follows a viral URI, it has been estimated that only up to 2% of viral URIs lead to ABRS.19 The most common
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Surgery_Schwartz. been defined as “subacute,” although the current clini-cal practice guideline published by the American Academy of Otolaryngology—Head and Neck Surgery does not distinguish rhinosinusitis in this time frame, noting that this group likely represents crossover symptoms from one of the other two sub-classes. Hence, the decision on how to manage this group of patients must be individualized.18 Because common conditions such as atypical migraine headache, laryngopharyngeal reflux, and allergic rhinitis frequently mimic rhinosinusitis, diagno-sis of rhinosinusitis is based not only on symptomatic criteria but also on objective evaluation with either imaging and/or endoscopy.Acute Rhinosinusitis. Acute rhinosinusitis most commonly occurs in the setting of a viral upper respiratory tract infection (URI). Although it is believed that acute bacterial rhinosinusitis (ABRS) typically follows a viral URI, it has been estimated that only up to 2% of viral URIs lead to ABRS.19 The most common
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Surgery_Schwartz_4210
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Surgery_Schwartz
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(URI). Although it is believed that acute bacterial rhinosinusitis (ABRS) typically follows a viral URI, it has been estimated that only up to 2% of viral URIs lead to ABRS.19 The most common viruses involved in ARS include rhinovirus, influenza virus, and parainfluenza virus. It is not known whether the viral URI precedes or only occurs along with ABRS. Regardless, viral infection leads to mucosal edema with sinus ostium obstruction, mucus stasis, tissue hypoxia, ciliary dysfunction, and epithelial damage, which may enhance bacterial adherence.20 Other con-ditions that may contribute to ABRS should be investigated, especially in the setting of recurrent ABRS. Such conditions include foreign body, sinus fungal ball (with bacterial secondary infection), and periapical dental disease (Figs. 18-4 and 18-5).The symptomatic criteria used to define ABRS include up to 4 weeks of purulent nasal drainage accompanied by nasal obstruction, facial pain with pressure and fullness, or both.18
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Surgery_Schwartz. (URI). Although it is believed that acute bacterial rhinosinusitis (ABRS) typically follows a viral URI, it has been estimated that only up to 2% of viral URIs lead to ABRS.19 The most common viruses involved in ARS include rhinovirus, influenza virus, and parainfluenza virus. It is not known whether the viral URI precedes or only occurs along with ABRS. Regardless, viral infection leads to mucosal edema with sinus ostium obstruction, mucus stasis, tissue hypoxia, ciliary dysfunction, and epithelial damage, which may enhance bacterial adherence.20 Other con-ditions that may contribute to ABRS should be investigated, especially in the setting of recurrent ABRS. Such conditions include foreign body, sinus fungal ball (with bacterial secondary infection), and periapical dental disease (Figs. 18-4 and 18-5).The symptomatic criteria used to define ABRS include up to 4 weeks of purulent nasal drainage accompanied by nasal obstruction, facial pain with pressure and fullness, or both.18
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Surgery_Schwartz_4211
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Surgery_Schwartz
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18-4 and 18-5).The symptomatic criteria used to define ABRS include up to 4 weeks of purulent nasal drainage accompanied by nasal obstruction, facial pain with pressure and fullness, or both.18 ABFigure 18-4. A. Right periapical abscess (arrow) leading to acute bacterial rhinosinusitis. B. Follow-up scan of the same patients after administration of antibiotics demonstrating resolution of the sinonasal inflammatory changes. Therapy subsequently directed at the offending tooth will prevent recurrent symptoms.Figure 18-5. Computed tomography scan demonstrating a fungal ball of the right maxillary sinus, characterized by heterogeneous opacification of the sinus.Brunicardi_Ch18_p0613-p0660.indd 61701/03/19 5:22 PM 618SPECIFIC CONSIDERATIONSPART IIOther historical factors that may predict the development of ABRS include persistence of symptoms beyond 10 days, or worsening of symptoms, following initial improvement, within 10 days (“double worsening”). Although routine head and neck
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Surgery_Schwartz. 18-4 and 18-5).The symptomatic criteria used to define ABRS include up to 4 weeks of purulent nasal drainage accompanied by nasal obstruction, facial pain with pressure and fullness, or both.18 ABFigure 18-4. A. Right periapical abscess (arrow) leading to acute bacterial rhinosinusitis. B. Follow-up scan of the same patients after administration of antibiotics demonstrating resolution of the sinonasal inflammatory changes. Therapy subsequently directed at the offending tooth will prevent recurrent symptoms.Figure 18-5. Computed tomography scan demonstrating a fungal ball of the right maxillary sinus, characterized by heterogeneous opacification of the sinus.Brunicardi_Ch18_p0613-p0660.indd 61701/03/19 5:22 PM 618SPECIFIC CONSIDERATIONSPART IIOther historical factors that may predict the development of ABRS include persistence of symptoms beyond 10 days, or worsening of symptoms, following initial improvement, within 10 days (“double worsening”). Although routine head and neck
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Surgery_Schwartz_4212
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Surgery_Schwartz
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the development of ABRS include persistence of symptoms beyond 10 days, or worsening of symptoms, following initial improvement, within 10 days (“double worsening”). Although routine head and neck examination may identify anteriorly or posteriorly draining purulent secretions, the utilization of a rigid endoscope may improve diagnostic sensitivity and may also facilitate culture acquisition (Fig. 18-6).The management of ABRS is heavily dependent on anti-biotics, either culture-directed or empirically chosen to cover the most common isolates of ABRS, including S pneumoniae, H influenza, and M catarrhalis. Nosocomial ABRS more com-monly involves P aeruginosa or S aureus. Methicillin-resistant S aureus (MRSA) has been isolated with increasing frequency.20 Other treatments include topical and systemic decongestants, nasal saline spray, topical nasal steroids, and oral steroids in selected cases. In the acute setting, surgery is reserved for com-plications or pending complications, which
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Surgery_Schwartz. the development of ABRS include persistence of symptoms beyond 10 days, or worsening of symptoms, following initial improvement, within 10 days (“double worsening”). Although routine head and neck examination may identify anteriorly or posteriorly draining purulent secretions, the utilization of a rigid endoscope may improve diagnostic sensitivity and may also facilitate culture acquisition (Fig. 18-6).The management of ABRS is heavily dependent on anti-biotics, either culture-directed or empirically chosen to cover the most common isolates of ABRS, including S pneumoniae, H influenza, and M catarrhalis. Nosocomial ABRS more com-monly involves P aeruginosa or S aureus. Methicillin-resistant S aureus (MRSA) has been isolated with increasing frequency.20 Other treatments include topical and systemic decongestants, nasal saline spray, topical nasal steroids, and oral steroids in selected cases. In the acute setting, surgery is reserved for com-plications or pending complications, which
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Surgery_Schwartz_4213
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Surgery_Schwartz
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systemic decongestants, nasal saline spray, topical nasal steroids, and oral steroids in selected cases. In the acute setting, surgery is reserved for com-plications or pending complications, which may include exten-sion to the eye (orbital cellulitis or abscess) or the intracranial space (meningitis or intracranial abscess).Chronic Rhinosinusitis. Chronic rhinosinusitis (CRS) is characterized by symptomatic inflammation of the nose and paranasal sinuses lasting over 12 weeks. CRS has been clini-cally classified into two main groups: those with CRS with nasal polyps (CRSwNP) tend to exhibit a Th2-biased inflammatory profile, and those with CRS without nasal polyps (CRSsNP) tend to exhibit a Th1-biased profile. Although the etiology of CRS is unclear and the development of the clinical subtypes may be distinct, there exists significant overlap not only in phys-iologic manifestations but also in symptomatology. Hence, the sinonasal cavities of patients with both subtypes of CRS tend to
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Surgery_Schwartz. systemic decongestants, nasal saline spray, topical nasal steroids, and oral steroids in selected cases. In the acute setting, surgery is reserved for com-plications or pending complications, which may include exten-sion to the eye (orbital cellulitis or abscess) or the intracranial space (meningitis or intracranial abscess).Chronic Rhinosinusitis. Chronic rhinosinusitis (CRS) is characterized by symptomatic inflammation of the nose and paranasal sinuses lasting over 12 weeks. CRS has been clini-cally classified into two main groups: those with CRS with nasal polyps (CRSwNP) tend to exhibit a Th2-biased inflammatory profile, and those with CRS without nasal polyps (CRSsNP) tend to exhibit a Th1-biased profile. Although the etiology of CRS is unclear and the development of the clinical subtypes may be distinct, there exists significant overlap not only in phys-iologic manifestations but also in symptomatology. Hence, the sinonasal cavities of patients with both subtypes of CRS tend to
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Surgery_Schwartz_4214
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Surgery_Schwartz
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may be distinct, there exists significant overlap not only in phys-iologic manifestations but also in symptomatology. Hence, the sinonasal cavities of patients with both subtypes of CRS tend to exhibit mucosal edema, ostial obstruction, ciliary dysfunction, and an abhorrent inflammatory milieu.Two of the following symptomatic criteria must be pres-ent to diagnose CRS: purulent nasal drainage, nasal obstruc-tion, facial pain-pressure-fullness, and decreased sense of smell. These patients may also experience acute exacerbation, generally signified by an escalation of symptoms. Frequently, this is due to bacterial infection. However, patients with acute exacerbation of CRS may be distinguished from patients with recurrent acute bacterial rhinosinusitis (four or more episodes of ABRS per year) through baseline comparison: patients with CRS are symptomatic, even while at baseline, while patients with recurrent acute bacterial sinusitis are normal at baseline. As with ARS, the diagnosis of
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Surgery_Schwartz. may be distinct, there exists significant overlap not only in phys-iologic manifestations but also in symptomatology. Hence, the sinonasal cavities of patients with both subtypes of CRS tend to exhibit mucosal edema, ostial obstruction, ciliary dysfunction, and an abhorrent inflammatory milieu.Two of the following symptomatic criteria must be pres-ent to diagnose CRS: purulent nasal drainage, nasal obstruc-tion, facial pain-pressure-fullness, and decreased sense of smell. These patients may also experience acute exacerbation, generally signified by an escalation of symptoms. Frequently, this is due to bacterial infection. However, patients with acute exacerbation of CRS may be distinguished from patients with recurrent acute bacterial rhinosinusitis (four or more episodes of ABRS per year) through baseline comparison: patients with CRS are symptomatic, even while at baseline, while patients with recurrent acute bacterial sinusitis are normal at baseline. As with ARS, the diagnosis of
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Surgery_Schwartz_4215
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Surgery_Schwartz
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through baseline comparison: patients with CRS are symptomatic, even while at baseline, while patients with recurrent acute bacterial sinusitis are normal at baseline. As with ARS, the diagnosis of CRS requires objective confirmation utilizing either nasal endoscopy, CT scans, or, less commonly, MRI.Nasal endoscopy is a critical element of the diagnosis of CRS. Abnormalities that may confirm the diagnosis of CRS include• Purulent mucus in the middle meatus or anterior ethmoid region• Edema in the middle meatus or ethmoid region• Polyps in nasal cavity or the middle meatusIn addition to establishing the diagnosis, nasal endoscopy can be valuable in antibiotic selection by facilitating specific culture acquisition. Furthermore, simple polypectomy or ste-roid injection can be performed under topical anesthesia in the appropriate clinical setting.Imaging is also an important clinical tool in the diagnosis of CRS. In general, CT is the modality of choice for diagno-sis and management of
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Surgery_Schwartz. through baseline comparison: patients with CRS are symptomatic, even while at baseline, while patients with recurrent acute bacterial sinusitis are normal at baseline. As with ARS, the diagnosis of CRS requires objective confirmation utilizing either nasal endoscopy, CT scans, or, less commonly, MRI.Nasal endoscopy is a critical element of the diagnosis of CRS. Abnormalities that may confirm the diagnosis of CRS include• Purulent mucus in the middle meatus or anterior ethmoid region• Edema in the middle meatus or ethmoid region• Polyps in nasal cavity or the middle meatusIn addition to establishing the diagnosis, nasal endoscopy can be valuable in antibiotic selection by facilitating specific culture acquisition. Furthermore, simple polypectomy or ste-roid injection can be performed under topical anesthesia in the appropriate clinical setting.Imaging is also an important clinical tool in the diagnosis of CRS. In general, CT is the modality of choice for diagno-sis and management of
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Surgery_Schwartz_4216
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Surgery_Schwartz
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topical anesthesia in the appropriate clinical setting.Imaging is also an important clinical tool in the diagnosis of CRS. In general, CT is the modality of choice for diagno-sis and management of CRS. Usual diagnostic criteria include mucosal thickening, sinus opacification, and bony remodeling (erosion or hyperostosis). It should be underscored, however, that CT scan is not the positive gold standard because many asymptomatic patients will demonstrate findings on a sinus CT scan, and many patients with presumed sinusitis will have negative findings.19 CT scan has excellent negative predic-tive value when performed in the setting of active symptoms. Thus, if a patient complains of rhinosinusitis-like symptoms but has no specific physical (endoscopic) findings, and the scan Figure 18-6. Nasal endoscopy is commonly performed in the clinic setting to aid in the diagnosis and management of rhinosinusitis.Brunicardi_Ch18_p0613-p0660.indd 61801/03/19 5:22 PM 619DISORDERS OF THE HEAD
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Surgery_Schwartz. topical anesthesia in the appropriate clinical setting.Imaging is also an important clinical tool in the diagnosis of CRS. In general, CT is the modality of choice for diagno-sis and management of CRS. Usual diagnostic criteria include mucosal thickening, sinus opacification, and bony remodeling (erosion or hyperostosis). It should be underscored, however, that CT scan is not the positive gold standard because many asymptomatic patients will demonstrate findings on a sinus CT scan, and many patients with presumed sinusitis will have negative findings.19 CT scan has excellent negative predic-tive value when performed in the setting of active symptoms. Thus, if a patient complains of rhinosinusitis-like symptoms but has no specific physical (endoscopic) findings, and the scan Figure 18-6. Nasal endoscopy is commonly performed in the clinic setting to aid in the diagnosis and management of rhinosinusitis.Brunicardi_Ch18_p0613-p0660.indd 61801/03/19 5:22 PM 619DISORDERS OF THE HEAD
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Surgery_Schwartz_4217
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Nasal endoscopy is commonly performed in the clinic setting to aid in the diagnosis and management of rhinosinusitis.Brunicardi_Ch18_p0613-p0660.indd 61801/03/19 5:22 PM 619DISORDERS OF THE HEAD AND NECKCHAPTER 18Figure 18-7. Point-of-care computed tomography system. All components can be fit within an 8′ × 10′ room in an outpatient office setting.Figure 18-8. Triplanar imaging revealing proximity to critical structures such as the orbital wall and skull base. This can be used for diag-nosis of sinus opacification as well as stereotactic intraoperative navigation, where endoscope view (lower right) can be radiologically cor-related with location in the three cardinal planes. This case reflects classic allergic fungal sinusitis where the opacified sinuses are filled with heterogeneous whitish material on computed tomography images. Polyps in the ethmoid cavity are seen on the endoscope image.is negative, other diagnoses (e.g., allergic rhinitis, migraine headache, tension
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Surgery_Schwartz. Nasal endoscopy is commonly performed in the clinic setting to aid in the diagnosis and management of rhinosinusitis.Brunicardi_Ch18_p0613-p0660.indd 61801/03/19 5:22 PM 619DISORDERS OF THE HEAD AND NECKCHAPTER 18Figure 18-7. Point-of-care computed tomography system. All components can be fit within an 8′ × 10′ room in an outpatient office setting.Figure 18-8. Triplanar imaging revealing proximity to critical structures such as the orbital wall and skull base. This can be used for diag-nosis of sinus opacification as well as stereotactic intraoperative navigation, where endoscope view (lower right) can be radiologically cor-related with location in the three cardinal planes. This case reflects classic allergic fungal sinusitis where the opacified sinuses are filled with heterogeneous whitish material on computed tomography images. Polyps in the ethmoid cavity are seen on the endoscope image.is negative, other diagnoses (e.g., allergic rhinitis, migraine headache, tension
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Surgery_Schwartz_4218
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Surgery_Schwartz
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whitish material on computed tomography images. Polyps in the ethmoid cavity are seen on the endoscope image.is negative, other diagnoses (e.g., allergic rhinitis, migraine headache, tension headaches, and laryngopharyngeal reflux) should be sought. This has led to the utility of point-of-care CT (POC-CT) scan that can be performed in the physician’s office. POC-CT utilizes cone beam technology,21 which acquires the equivalent of >100 axial slices in approximately 1 minute at an effective resolution of 0.3 mm or less. The equipment occupies a room of 8’ × 10’ and can thus be accommodated in almost any office setting (Fig. 18-7). Perhaps most important, the radiation dosing for even the most sophisticated protocol is 0.17 mSv, which is <10% the dose of a conventional head CT and equivalent to approximately 20 days of background radia-tion. One theoretical shortcoming of this technology is that it does not permit soft tissue imaging. This is seldom a concern in sinonasal evaluation, as
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Surgery_Schwartz. whitish material on computed tomography images. Polyps in the ethmoid cavity are seen on the endoscope image.is negative, other diagnoses (e.g., allergic rhinitis, migraine headache, tension headaches, and laryngopharyngeal reflux) should be sought. This has led to the utility of point-of-care CT (POC-CT) scan that can be performed in the physician’s office. POC-CT utilizes cone beam technology,21 which acquires the equivalent of >100 axial slices in approximately 1 minute at an effective resolution of 0.3 mm or less. The equipment occupies a room of 8’ × 10’ and can thus be accommodated in almost any office setting (Fig. 18-7). Perhaps most important, the radiation dosing for even the most sophisticated protocol is 0.17 mSv, which is <10% the dose of a conventional head CT and equivalent to approximately 20 days of background radia-tion. One theoretical shortcoming of this technology is that it does not permit soft tissue imaging. This is seldom a concern in sinonasal evaluation, as
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Surgery_Schwartz_4219
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Surgery_Schwartz
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to approximately 20 days of background radia-tion. One theoretical shortcoming of this technology is that it does not permit soft tissue imaging. This is seldom a concern in sinonasal evaluation, as this is typically undertaken in bone windows. The acquired data are immediately formatted into triplanar (axial, sagittal, coronal) reconstructions and is also compatible with devices used for intraoperative stereotactic navigation, which can be used to confirm relationships between the disease process, medial orbital wall, and skull base during surgery (Figs. 18-8 and 18-9).Medical management of CRS is heavily dependent on topical intranasal therapy. The reasons for this lie not only in established effectiveness but also in tolerability and safety—the chronic nature of CRS generally lends to requisite long-term medication administration despite other measures such as surgery. Nasal irrigation and topical nasal steroids are commonplace in the management of CRSwNP and CRSsNP. Oral steroids
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Surgery_Schwartz. to approximately 20 days of background radia-tion. One theoretical shortcoming of this technology is that it does not permit soft tissue imaging. This is seldom a concern in sinonasal evaluation, as this is typically undertaken in bone windows. The acquired data are immediately formatted into triplanar (axial, sagittal, coronal) reconstructions and is also compatible with devices used for intraoperative stereotactic navigation, which can be used to confirm relationships between the disease process, medial orbital wall, and skull base during surgery (Figs. 18-8 and 18-9).Medical management of CRS is heavily dependent on topical intranasal therapy. The reasons for this lie not only in established effectiveness but also in tolerability and safety—the chronic nature of CRS generally lends to requisite long-term medication administration despite other measures such as surgery. Nasal irrigation and topical nasal steroids are commonplace in the management of CRSwNP and CRSsNP. Oral steroids
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requisite long-term medication administration despite other measures such as surgery. Nasal irrigation and topical nasal steroids are commonplace in the management of CRSwNP and CRSsNP. Oral steroids have demonstrated effectiveness in patients with CRSwNP, although the role in CRSsNP is less clear. Although otolaryngologists commonly utilize antibiotics in the man-agement of CRS, indications and administration practices are not uniform. Oral antibiotic therapy given for short duration (<4 weeks) is generally useful in the management of acute exac-erbation related to bacterial infection. Long-term utilization of antibiotics may be necessary in the setting of chronic infection or osteomyelitis. Additionally, long-term macrolide administra-tion may be utilized for anti-inflammatory effects in the appro-priate clinical setting.In most cases, patients considering endoscopic sinus surgery (ESS) for CRS should have significant residual Brunicardi_Ch18_p0613-p0660.indd 61901/03/19 5:22 PM
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Surgery_Schwartz. requisite long-term medication administration despite other measures such as surgery. Nasal irrigation and topical nasal steroids are commonplace in the management of CRSwNP and CRSsNP. Oral steroids have demonstrated effectiveness in patients with CRSwNP, although the role in CRSsNP is less clear. Although otolaryngologists commonly utilize antibiotics in the man-agement of CRS, indications and administration practices are not uniform. Oral antibiotic therapy given for short duration (<4 weeks) is generally useful in the management of acute exac-erbation related to bacterial infection. Long-term utilization of antibiotics may be necessary in the setting of chronic infection or osteomyelitis. Additionally, long-term macrolide administra-tion may be utilized for anti-inflammatory effects in the appro-priate clinical setting.In most cases, patients considering endoscopic sinus surgery (ESS) for CRS should have significant residual Brunicardi_Ch18_p0613-p0660.indd 61901/03/19 5:22 PM
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the appro-priate clinical setting.In most cases, patients considering endoscopic sinus surgery (ESS) for CRS should have significant residual Brunicardi_Ch18_p0613-p0660.indd 61901/03/19 5:22 PM 620SPECIFIC CONSIDERATIONSPART IIsymptomatology despite medical therapy. However, there cur-rently exists no consensus regarding what constitutes a “maxi-mum” course of medical therapy. It should be noted that unless there is suspicion of neoplasm or pending complication of rhinosinusitis, the decision to proceed with surgery is highly individualized. This is because surgery for uncomplicated CRS is elective, and patients who “fail” medical management will exhibit significant variability in symptoms, physical signs, and CT findings. Furthermore, ESS is not necessarily curative—the intent of ESS is to remove the symptoms related to CRS rather than cure the underlying condition itself.Surgery is typically preformed endoscopically where the goals are to remove polyps, enlarge or remove
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Surgery_Schwartz. the appro-priate clinical setting.In most cases, patients considering endoscopic sinus surgery (ESS) for CRS should have significant residual Brunicardi_Ch18_p0613-p0660.indd 61901/03/19 5:22 PM 620SPECIFIC CONSIDERATIONSPART IIsymptomatology despite medical therapy. However, there cur-rently exists no consensus regarding what constitutes a “maxi-mum” course of medical therapy. It should be noted that unless there is suspicion of neoplasm or pending complication of rhinosinusitis, the decision to proceed with surgery is highly individualized. This is because surgery for uncomplicated CRS is elective, and patients who “fail” medical management will exhibit significant variability in symptoms, physical signs, and CT findings. Furthermore, ESS is not necessarily curative—the intent of ESS is to remove the symptoms related to CRS rather than cure the underlying condition itself.Surgery is typically preformed endoscopically where the goals are to remove polyps, enlarge or remove
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of ESS is to remove the symptoms related to CRS rather than cure the underlying condition itself.Surgery is typically preformed endoscopically where the goals are to remove polyps, enlarge or remove obstruct-ing tissue surrounding the natural sinus ostia (Fig. 18-10), and remove chronically infected bone and mucosa to promote both ventilation and drainage of the sinus cavities. Inspissated mucin or pus is drained and cultured. Eventual resolution of the chronic inflammatory process can be attained with a com-bination of meticulous surgery and directed medical therapy, although the patient must understand that surgery may not alter the underlying immunologic pathophysiology. In cases where resection of inflammatory tissue and polyps are not required, recent trends have also included use of angioplasty-type balloons to dilate sinus ostia. The exact role for this tech-nology is unclear, but it appears to have promise in outpatient office management of patients with focal or limited
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Surgery_Schwartz. of ESS is to remove the symptoms related to CRS rather than cure the underlying condition itself.Surgery is typically preformed endoscopically where the goals are to remove polyps, enlarge or remove obstruct-ing tissue surrounding the natural sinus ostia (Fig. 18-10), and remove chronically infected bone and mucosa to promote both ventilation and drainage of the sinus cavities. Inspissated mucin or pus is drained and cultured. Eventual resolution of the chronic inflammatory process can be attained with a com-bination of meticulous surgery and directed medical therapy, although the patient must understand that surgery may not alter the underlying immunologic pathophysiology. In cases where resection of inflammatory tissue and polyps are not required, recent trends have also included use of angioplasty-type balloons to dilate sinus ostia. The exact role for this tech-nology is unclear, but it appears to have promise in outpatient office management of patients with focal or limited
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of angioplasty-type balloons to dilate sinus ostia. The exact role for this tech-nology is unclear, but it appears to have promise in outpatient office management of patients with focal or limited obstruc-tive pathology.Endoscopic Skull Base Surgery. Over the past three decades, the development and expansion of multidisciplinary skull base teams has become somewhat commonplace at large academic institutions. Facilitated mainly by growing cooperation between otolaryngologists and neurosurgeons, a variety of approaches that utilize the sinonasal corridor to treat a plethora of patho-logic processes of the anterior skull base have been developed.Technological advances in endoscopy, instrumentation, and imaging have also facilitated the development of endo-scopic endonasal approaches (EEAs), allowing team members to work simultaneously while maintaining optimal visualization of the relevant anatomy and freedom of movement within the corridor. Although historically the sphenoid sinus has
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Surgery_Schwartz. of angioplasty-type balloons to dilate sinus ostia. The exact role for this tech-nology is unclear, but it appears to have promise in outpatient office management of patients with focal or limited obstruc-tive pathology.Endoscopic Skull Base Surgery. Over the past three decades, the development and expansion of multidisciplinary skull base teams has become somewhat commonplace at large academic institutions. Facilitated mainly by growing cooperation between otolaryngologists and neurosurgeons, a variety of approaches that utilize the sinonasal corridor to treat a plethora of patho-logic processes of the anterior skull base have been developed.Technological advances in endoscopy, instrumentation, and imaging have also facilitated the development of endo-scopic endonasal approaches (EEAs), allowing team members to work simultaneously while maintaining optimal visualization of the relevant anatomy and freedom of movement within the corridor. Although historically the sphenoid sinus has
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allowing team members to work simultaneously while maintaining optimal visualization of the relevant anatomy and freedom of movement within the corridor. Although historically the sphenoid sinus has been the common access route in the management of sellar pathology, a series of modular approaches of varied complexity have been developed that have broadened the reach of EEAs to address lesions at virtually all comportments of the ventral skull base, from the crista galli to the anterior arch of C2.22One of the key tenets of the EEA is that the sinonasal cor-ridor presents the most prudent and safest path to the lesion of interest. Accordingly, the EEA is generally chosen for lesions adjacent to the skull base, without intervening brain parenchyma, cranial nerves, major vessels, or other important anatomical structures. Currently, EEAs are utilized to treat a significant number of pathologic process involving the skull base, including: cerebrospinal fluid leaks, encephaloceles,
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Surgery_Schwartz. allowing team members to work simultaneously while maintaining optimal visualization of the relevant anatomy and freedom of movement within the corridor. Although historically the sphenoid sinus has been the common access route in the management of sellar pathology, a series of modular approaches of varied complexity have been developed that have broadened the reach of EEAs to address lesions at virtually all comportments of the ventral skull base, from the crista galli to the anterior arch of C2.22One of the key tenets of the EEA is that the sinonasal cor-ridor presents the most prudent and safest path to the lesion of interest. Accordingly, the EEA is generally chosen for lesions adjacent to the skull base, without intervening brain parenchyma, cranial nerves, major vessels, or other important anatomical structures. Currently, EEAs are utilized to treat a significant number of pathologic process involving the skull base, including: cerebrospinal fluid leaks, encephaloceles,
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other important anatomical structures. Currently, EEAs are utilized to treat a significant number of pathologic process involving the skull base, including: cerebrospinal fluid leaks, encephaloceles, meningoceles, pseudomeningoceles, benign intracranial tumors (Fig. 18-11), benign sinonasal tumors, malignant sinonasal tumors, and inflammatory or traumatic conditions leading to compression at the craniovertebral junction. Although EEAs tend to be considered “minimally invasive,” the corridor created in the sinonasal cavity is nonetheless comprehensive enough to Figure 18-9. Sphenoid sinus fungal ball. The sinus has been opened revealing cheesy material during this intraoperative endoscopic view (lower right). The crosshairs stereotactically confirm location within the sphenoid sinus radiologically in the cardinal planes.Brunicardi_Ch18_p0613-p0660.indd 62001/03/19 5:22 PM 621DISORDERS OF THE HEAD AND NECKCHAPTER 18ABFigure 18-10. A. Endoscopic view of the right nasal cavity
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Surgery_Schwartz. other important anatomical structures. Currently, EEAs are utilized to treat a significant number of pathologic process involving the skull base, including: cerebrospinal fluid leaks, encephaloceles, meningoceles, pseudomeningoceles, benign intracranial tumors (Fig. 18-11), benign sinonasal tumors, malignant sinonasal tumors, and inflammatory or traumatic conditions leading to compression at the craniovertebral junction. Although EEAs tend to be considered “minimally invasive,” the corridor created in the sinonasal cavity is nonetheless comprehensive enough to Figure 18-9. Sphenoid sinus fungal ball. The sinus has been opened revealing cheesy material during this intraoperative endoscopic view (lower right). The crosshairs stereotactically confirm location within the sphenoid sinus radiologically in the cardinal planes.Brunicardi_Ch18_p0613-p0660.indd 62001/03/19 5:22 PM 621DISORDERS OF THE HEAD AND NECKCHAPTER 18ABFigure 18-10. A. Endoscopic view of the right nasal cavity
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radiologically in the cardinal planes.Brunicardi_Ch18_p0613-p0660.indd 62001/03/19 5:22 PM 621DISORDERS OF THE HEAD AND NECKCHAPTER 18ABFigure 18-10. A. Endoscopic view of the right nasal cavity demonstrating the uncinate process (U), ethmoid bulla (EB), middle turbinate (MT), inferior turbinate (IT), and nasal septum (S). B. Endoscopic view of a microdebrider being used to widen the right maxillary sinus ostium.ABCDFigure 18-11. Preoperative coronal (A) and sagittal (B) magnetic resonance images of a large olfactory groove meningioma removed using endoscopic endonasal approach. Postoperative coronal (C) and sagittal (D) images demonstrating removal of the tumor. The skull base can be reconstructed using local flaps (most commonly a nasoseptal flap pedicled on the posterior nasal artery).Brunicardi_Ch18_p0613-p0660.indd 62101/03/19 5:23 PM 622SPECIFIC CONSIDERATIONSPART IIprovide maximal freedom of movement for the critical compo-nent of the case (i.e., tumor resection near
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Surgery_Schwartz. radiologically in the cardinal planes.Brunicardi_Ch18_p0613-p0660.indd 62001/03/19 5:22 PM 621DISORDERS OF THE HEAD AND NECKCHAPTER 18ABFigure 18-10. A. Endoscopic view of the right nasal cavity demonstrating the uncinate process (U), ethmoid bulla (EB), middle turbinate (MT), inferior turbinate (IT), and nasal septum (S). B. Endoscopic view of a microdebrider being used to widen the right maxillary sinus ostium.ABCDFigure 18-11. Preoperative coronal (A) and sagittal (B) magnetic resonance images of a large olfactory groove meningioma removed using endoscopic endonasal approach. Postoperative coronal (C) and sagittal (D) images demonstrating removal of the tumor. The skull base can be reconstructed using local flaps (most commonly a nasoseptal flap pedicled on the posterior nasal artery).Brunicardi_Ch18_p0613-p0660.indd 62101/03/19 5:23 PM 622SPECIFIC CONSIDERATIONSPART IIprovide maximal freedom of movement for the critical compo-nent of the case (i.e., tumor resection near
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62101/03/19 5:23 PM 622SPECIFIC CONSIDERATIONSPART IIprovide maximal freedom of movement for the critical compo-nent of the case (i.e., tumor resection near vital structures). Once the corridor is created by the otolaryngologist, the neurosurgeon joins, and a two-person, threeto four-hand technique is utilized to address the lesion of interest and reconstruct the skull base (Fig. 18-12).Despite the relatively confined aperture provided by the nostrils, even large tumors can be removed using EEAs, albeit via piecemeal removal. For malignant tumors, this has required a philosophical shift whereby en bloc resection of the entire tumor is replaced by piecemeal removal of the bulk of the tumor followed by complete resection of the pedicle with sufficient margins. Outcomes utilizing EEAs for resection of malignant tumors, when chosen appropriately, parallel those of traditional open approaches. However, EEAs are not favored over tradi-tional approaches when oncological principles would
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Surgery_Schwartz. 62101/03/19 5:23 PM 622SPECIFIC CONSIDERATIONSPART IIprovide maximal freedom of movement for the critical compo-nent of the case (i.e., tumor resection near vital structures). Once the corridor is created by the otolaryngologist, the neurosurgeon joins, and a two-person, threeto four-hand technique is utilized to address the lesion of interest and reconstruct the skull base (Fig. 18-12).Despite the relatively confined aperture provided by the nostrils, even large tumors can be removed using EEAs, albeit via piecemeal removal. For malignant tumors, this has required a philosophical shift whereby en bloc resection of the entire tumor is replaced by piecemeal removal of the bulk of the tumor followed by complete resection of the pedicle with sufficient margins. Outcomes utilizing EEAs for resection of malignant tumors, when chosen appropriately, parallel those of traditional open approaches. However, EEAs are not favored over tradi-tional approaches when oncological principles would
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resection of malignant tumors, when chosen appropriately, parallel those of traditional open approaches. However, EEAs are not favored over tradi-tional approaches when oncological principles would otherwise need to be violated.Pharyngeal and Adenotonsillar DiseaseWaldeyer’s ring consists of the palatine tonsils between the anterior and posterior tonsillar pillars, the lingual tonsils (lym-phoid tissue in the base of tongue), and the adenoid located in the nasopharynx. These four main sites of Waldeyer’s ring are connected by other minor lymphoid tissue along the posterior and lateral pharyngeal wall completing the ring. These are all considered mucosa-associated lymphoid tissue (MALT). These tissues react to inflammatory disease, infection, trauma, acid reflux, and radiotherapy. Even the vibratory effects of chronic snoring have been implicated in the development of adenoton-sillar disease. Inflammation of these tissues can lead to referred pain through cranial nerves IX and X to the
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Surgery_Schwartz. resection of malignant tumors, when chosen appropriately, parallel those of traditional open approaches. However, EEAs are not favored over tradi-tional approaches when oncological principles would otherwise need to be violated.Pharyngeal and Adenotonsillar DiseaseWaldeyer’s ring consists of the palatine tonsils between the anterior and posterior tonsillar pillars, the lingual tonsils (lym-phoid tissue in the base of tongue), and the adenoid located in the nasopharynx. These four main sites of Waldeyer’s ring are connected by other minor lymphoid tissue along the posterior and lateral pharyngeal wall completing the ring. These are all considered mucosa-associated lymphoid tissue (MALT). These tissues react to inflammatory disease, infection, trauma, acid reflux, and radiotherapy. Even the vibratory effects of chronic snoring have been implicated in the development of adenoton-sillar disease. Inflammation of these tissues can lead to referred pain through cranial nerves IX and X to the
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vibratory effects of chronic snoring have been implicated in the development of adenoton-sillar disease. Inflammation of these tissues can lead to referred pain through cranial nerves IX and X to the throat and ear. Adenotonsillar tissue does not have any afferent lymphatics and receives antigen presentation directly, with appropriate produc-tion of memory cells. However, there is no clear immune com-promise after removal.Figure 18-12. Two-surgeon, threeto four-hand technique uti-lized in endoscopic endonasal surgery.Microbiology and Complications. Adenotonsillar infections present with three temporal patterns: acute, recurrent acute, and chronic. Acute infection is typically viral in origin but second-ary bacterial invasion may initiate chronic disease. Viruses do not cause chronic infections; however, Epstein-Barr Virus (EBV) can cause significant hypertrophy. Systemic EBV infection, also known as mononucleosis, can mimic bacterial pharyngitis, but the progression of signs and
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Surgery_Schwartz. vibratory effects of chronic snoring have been implicated in the development of adenoton-sillar disease. Inflammation of these tissues can lead to referred pain through cranial nerves IX and X to the throat and ear. Adenotonsillar tissue does not have any afferent lymphatics and receives antigen presentation directly, with appropriate produc-tion of memory cells. However, there is no clear immune com-promise after removal.Figure 18-12. Two-surgeon, threeto four-hand technique uti-lized in endoscopic endonasal surgery.Microbiology and Complications. Adenotonsillar infections present with three temporal patterns: acute, recurrent acute, and chronic. Acute infection is typically viral in origin but second-ary bacterial invasion may initiate chronic disease. Viruses do not cause chronic infections; however, Epstein-Barr Virus (EBV) can cause significant hypertrophy. Systemic EBV infection, also known as mononucleosis, can mimic bacterial pharyngitis, but the progression of signs and
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infections; however, Epstein-Barr Virus (EBV) can cause significant hypertrophy. Systemic EBV infection, also known as mononucleosis, can mimic bacterial pharyngitis, but the progression of signs and symptoms demonstrates lymphade-nopathy, splenomegaly, and hepatitis. This can be diagnosed on bloodwork (heterophile antibody or atypical lymphocytes). The most common bacterial causes of acute tonsillitis are group A β-hemolytic streptococcus species (GABHS) and S pneumoniae.23 If GABHS is confirmed, then antibiotic therapy is warranted in the pediatric population to decrease the risk (3%) of developing rheu-matic fever. A positive test for GABHS historically meant a throat swab with culture and sensitivity; however, rapid antigen assays have been demonstrated to be reasonably sensitive and specific (85% and 95%, respectively), thus largely replacing cultures.24 If the rapid assay is negative, then a culture is warranted. The remainder of the bacteriology for adenotonsillar disease is
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Surgery_Schwartz. infections; however, Epstein-Barr Virus (EBV) can cause significant hypertrophy. Systemic EBV infection, also known as mononucleosis, can mimic bacterial pharyngitis, but the progression of signs and symptoms demonstrates lymphade-nopathy, splenomegaly, and hepatitis. This can be diagnosed on bloodwork (heterophile antibody or atypical lymphocytes). The most common bacterial causes of acute tonsillitis are group A β-hemolytic streptococcus species (GABHS) and S pneumoniae.23 If GABHS is confirmed, then antibiotic therapy is warranted in the pediatric population to decrease the risk (3%) of developing rheu-matic fever. A positive test for GABHS historically meant a throat swab with culture and sensitivity; however, rapid antigen assays have been demonstrated to be reasonably sensitive and specific (85% and 95%, respectively), thus largely replacing cultures.24 If the rapid assay is negative, then a culture is warranted. The remainder of the bacteriology for adenotonsillar disease is
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specific (85% and 95%, respectively), thus largely replacing cultures.24 If the rapid assay is negative, then a culture is warranted. The remainder of the bacteriology for adenotonsillar disease is similar to otitis media and sinusitis, which includes H influenzae and M catarrhalis. Atypical infections include Corynebacterium diph-theria, Neisseria gonorrhoeae, and Chlamydia trachomatis.Complications of GABHS pharyngitis, typically from S pyogenes, can be systematic and include poststreptococcal glomerulonephritis, scarlet fever, and rheumatic fever. Anti-biotic therapy does not decrease the incidence of glomerulo-nephritis. Scarlet fever, caused by blood-borne streptococcal toxins, causes a strawberry tongue and a punctate rash on the trunk that spreads distally while sparing the palms and soles. Peritonsillar abscess is also a common complication that is treated in an ambulatory setting through a transoral approach after appropriate topicalization and local anesthetic. Deep neck
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Surgery_Schwartz. specific (85% and 95%, respectively), thus largely replacing cultures.24 If the rapid assay is negative, then a culture is warranted. The remainder of the bacteriology for adenotonsillar disease is similar to otitis media and sinusitis, which includes H influenzae and M catarrhalis. Atypical infections include Corynebacterium diph-theria, Neisseria gonorrhoeae, and Chlamydia trachomatis.Complications of GABHS pharyngitis, typically from S pyogenes, can be systematic and include poststreptococcal glomerulonephritis, scarlet fever, and rheumatic fever. Anti-biotic therapy does not decrease the incidence of glomerulo-nephritis. Scarlet fever, caused by blood-borne streptococcal toxins, causes a strawberry tongue and a punctate rash on the trunk that spreads distally while sparing the palms and soles. Peritonsillar abscess is also a common complication that is treated in an ambulatory setting through a transoral approach after appropriate topicalization and local anesthetic. Deep neck
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and soles. Peritonsillar abscess is also a common complication that is treated in an ambulatory setting through a transoral approach after appropriate topicalization and local anesthetic. Deep neck space infections are rare from pharyngitis but can occur from odontogenic and salivary gland infections. These typically require a transcervical approach for incision and drainage.Adenoids and Adenoidectomy. Acute adenoiditis typically presents with purulent rhinorrhea, nasal obstruction, and fever and can be associated with otitis media, particularly in the pedi-atric population. Recurrent acute adenoiditis is defined as four or more acute infections in a 6-month period, but in an adult, this may be difficult to distinguish from recurrent acute sinus-itis, and endoscopy with or without imaging of the sinuses may be warranted to distinguish between the two diagnoses. Chronic adenoiditis presents with persistent nasal discharge, halitosis, chronic congestion, and postnasal drip. In children,
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Surgery_Schwartz. and soles. Peritonsillar abscess is also a common complication that is treated in an ambulatory setting through a transoral approach after appropriate topicalization and local anesthetic. Deep neck space infections are rare from pharyngitis but can occur from odontogenic and salivary gland infections. These typically require a transcervical approach for incision and drainage.Adenoids and Adenoidectomy. Acute adenoiditis typically presents with purulent rhinorrhea, nasal obstruction, and fever and can be associated with otitis media, particularly in the pedi-atric population. Recurrent acute adenoiditis is defined as four or more acute infections in a 6-month period, but in an adult, this may be difficult to distinguish from recurrent acute sinus-itis, and endoscopy with or without imaging of the sinuses may be warranted to distinguish between the two diagnoses. Chronic adenoiditis presents with persistent nasal discharge, halitosis, chronic congestion, and postnasal drip. In children,
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of the sinuses may be warranted to distinguish between the two diagnoses. Chronic adenoiditis presents with persistent nasal discharge, halitosis, chronic congestion, and postnasal drip. In children, obstructive adenoid hyperplasia often requires surgical intervention to help relieve obstructive symptoms such as snoring, obligate mouth breathing, and hyponasal voice.The management of adenoid disease is slightly different than that for tonsillar disease. Chronic infection can be treated with antibiotics, although this often does not lead to a full reso-lution of symptoms. If the adenoid bed appears hyperplastic on lateral X-ray imaging or endoscopy, a 2-month trial of nasal steroids may be helpful. Adenoidectomy is indicated for recur-rent and chronic infections that have failed conservative man-agement. These infections are not limited to the adenoid bed but also involve the sinuses and the middle year. Adenoidectomy with a myringotomy and ventilation tube placement is benefi-cial for
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Surgery_Schwartz. of the sinuses may be warranted to distinguish between the two diagnoses. Chronic adenoiditis presents with persistent nasal discharge, halitosis, chronic congestion, and postnasal drip. In children, obstructive adenoid hyperplasia often requires surgical intervention to help relieve obstructive symptoms such as snoring, obligate mouth breathing, and hyponasal voice.The management of adenoid disease is slightly different than that for tonsillar disease. Chronic infection can be treated with antibiotics, although this often does not lead to a full reso-lution of symptoms. If the adenoid bed appears hyperplastic on lateral X-ray imaging or endoscopy, a 2-month trial of nasal steroids may be helpful. Adenoidectomy is indicated for recur-rent and chronic infections that have failed conservative man-agement. These infections are not limited to the adenoid bed but also involve the sinuses and the middle year. Adenoidectomy with a myringotomy and ventilation tube placement is benefi-cial for
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man-agement. These infections are not limited to the adenoid bed but also involve the sinuses and the middle year. Adenoidectomy with a myringotomy and ventilation tube placement is benefi-cial for recurrent or chronic otitis media in children because the Brunicardi_Ch18_p0613-p0660.indd 62201/03/19 5:23 PM 623DISORDERS OF THE HEAD AND NECKCHAPTER 18adenoid functions as a reservoir for bacteria that can enter the middle ear through the Eustachian tube.25Adenoidectomy is also the first line of surgical manage-ment for children with chronic sinusitis because the adenoid can obstruct mucociliary clearance from the sinonasal tract into the choana and ultimately into the pharynx. Patients with obstruc-tive systems attributable to the adenoids and suspected benign or malignant neoplasms of the adenoid bed are also candidates. However, the procedure is contraindicated in patients with vel-opalatine insufficiency (VPI) and in patients with a cleft pal-ate. Prior to adenoidectomy, patients
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Surgery_Schwartz. man-agement. These infections are not limited to the adenoid bed but also involve the sinuses and the middle year. Adenoidectomy with a myringotomy and ventilation tube placement is benefi-cial for recurrent or chronic otitis media in children because the Brunicardi_Ch18_p0613-p0660.indd 62201/03/19 5:23 PM 623DISORDERS OF THE HEAD AND NECKCHAPTER 18adenoid functions as a reservoir for bacteria that can enter the middle ear through the Eustachian tube.25Adenoidectomy is also the first line of surgical manage-ment for children with chronic sinusitis because the adenoid can obstruct mucociliary clearance from the sinonasal tract into the choana and ultimately into the pharynx. Patients with obstruc-tive systems attributable to the adenoids and suspected benign or malignant neoplasms of the adenoid bed are also candidates. However, the procedure is contraindicated in patients with vel-opalatine insufficiency (VPI) and in patients with a cleft pal-ate. Prior to adenoidectomy, patients
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adenoid bed are also candidates. However, the procedure is contraindicated in patients with vel-opalatine insufficiency (VPI) and in patients with a cleft pal-ate. Prior to adenoidectomy, patients should be examined for a submucous cleft, a lack of midline muscular tissue of the soft palate. Clinical signs of this include a bifid uvula, a translucent portion of the muscular diastasis of the soft palate (zona pel-lucida), and a palpable notched hard palate.26 A number of dif-ferent methods can be used to perform an adenoidectomy: cold steel, suction coagulator, microdebrider, and coblation. Adenoid regrowth and bleeding rates are both low, and no study has been able to demonstrate the superiority of one technique over the other for either outcome.27,28 Adenoidectomy is not without complications though, beyond VPI and bleeding, halitosis and adenoid bed regrowth (∼1%) are common complications. Rare complications include torticollis secondary to inflammation of the prevertebral fascia,
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Surgery_Schwartz. adenoid bed are also candidates. However, the procedure is contraindicated in patients with vel-opalatine insufficiency (VPI) and in patients with a cleft pal-ate. Prior to adenoidectomy, patients should be examined for a submucous cleft, a lack of midline muscular tissue of the soft palate. Clinical signs of this include a bifid uvula, a translucent portion of the muscular diastasis of the soft palate (zona pel-lucida), and a palpable notched hard palate.26 A number of dif-ferent methods can be used to perform an adenoidectomy: cold steel, suction coagulator, microdebrider, and coblation. Adenoid regrowth and bleeding rates are both low, and no study has been able to demonstrate the superiority of one technique over the other for either outcome.27,28 Adenoidectomy is not without complications though, beyond VPI and bleeding, halitosis and adenoid bed regrowth (∼1%) are common complications. Rare complications include torticollis secondary to inflammation of the prevertebral fascia,
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though, beyond VPI and bleeding, halitosis and adenoid bed regrowth (∼1%) are common complications. Rare complications include torticollis secondary to inflammation of the prevertebral fascia, nasopharyngeal stenosis, and cervi-cal spine subluxation, which is more common in patients with Down syndrome.Tonsils and Tonsillectomy Patients with acute tonsillitis present with sore throat, fever, dysphagia, and tender cervi-cal nodes with erythematous or exudative tonsils. The Centor Criteria is used to identify the likelihood of bacterial infection in adult patients complaining of sore throat in the emergency department or walk-in clinic, a point is given for each of the following: fever, tonsillar exudate, lymphadenopathy, and lack of cough.29-31 A score of 0 to 1 warrants no treatment, a score of 2 to 3 warrants GABHS testing, and a score of 4 warrants initiation of antibiotic therapy. First-line treatment is with peni-cillin or a cephalosporin; however, in those with an allergy, a
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Surgery_Schwartz. though, beyond VPI and bleeding, halitosis and adenoid bed regrowth (∼1%) are common complications. Rare complications include torticollis secondary to inflammation of the prevertebral fascia, nasopharyngeal stenosis, and cervi-cal spine subluxation, which is more common in patients with Down syndrome.Tonsils and Tonsillectomy Patients with acute tonsillitis present with sore throat, fever, dysphagia, and tender cervi-cal nodes with erythematous or exudative tonsils. The Centor Criteria is used to identify the likelihood of bacterial infection in adult patients complaining of sore throat in the emergency department or walk-in clinic, a point is given for each of the following: fever, tonsillar exudate, lymphadenopathy, and lack of cough.29-31 A score of 0 to 1 warrants no treatment, a score of 2 to 3 warrants GABHS testing, and a score of 4 warrants initiation of antibiotic therapy. First-line treatment is with peni-cillin or a cephalosporin; however, in those with an allergy, a
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a score of 2 to 3 warrants GABHS testing, and a score of 4 warrants initiation of antibiotic therapy. First-line treatment is with peni-cillin or a cephalosporin; however, in those with an allergy, a macrolide can be considered. Documentation of recurrent acute infections should include a temperature (>38.3oC), cervical adenopathy, tonsillar exudate, and a positive test for GABHS. According to the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) clinical practice guideline on tonsillectomy in children, tonsillectomy is indicated when chil-dren have more than 7 documented episodes per year, 5 epi-sodes per year in the past 2 years, or 3 episodes per year in the past 3 years.23 Tonsillectomy can still be considered in children who do not meet these criteria if they have multiple antibiotic allergies or intolerances, have a history of peritonsillar abscess after the acute inflammation has resolved, or have PFAPA (peri-odic fever, aphthous stomatitis, pharyngitis, and
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Surgery_Schwartz. a score of 2 to 3 warrants GABHS testing, and a score of 4 warrants initiation of antibiotic therapy. First-line treatment is with peni-cillin or a cephalosporin; however, in those with an allergy, a macrolide can be considered. Documentation of recurrent acute infections should include a temperature (>38.3oC), cervical adenopathy, tonsillar exudate, and a positive test for GABHS. According to the American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) clinical practice guideline on tonsillectomy in children, tonsillectomy is indicated when chil-dren have more than 7 documented episodes per year, 5 epi-sodes per year in the past 2 years, or 3 episodes per year in the past 3 years.23 Tonsillectomy can still be considered in children who do not meet these criteria if they have multiple antibiotic allergies or intolerances, have a history of peritonsillar abscess after the acute inflammation has resolved, or have PFAPA (peri-odic fever, aphthous stomatitis, pharyngitis, and
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multiple antibiotic allergies or intolerances, have a history of peritonsillar abscess after the acute inflammation has resolved, or have PFAPA (peri-odic fever, aphthous stomatitis, pharyngitis, and adenitis). A peritonsillar abscess is an infection of the peritonsillar salivary gland (Weber’s gland), located between the tonsil capsule and the muscles of the tonsillar fossa. In selected cases of active peritonsillar abscess, tonsillectomy is required in the acute set-ting to treat systemic toxicity or impending airway compromise. Multiple techniques have been described, including electrocau-tery, sharp dissection, laser, and radiofrequency ablation. There is no consensus as to the best method.Sleep Disordered Breathing and Adenotonsillar Disease. Patients with sleep-disordered breathing (SDB) and tonsil-lar hypertrophy may also benefit from tonsillectomy if they have growth retardation, poor school performance, enuresis, or behavioral problems. The benefits may be accentuated in
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Surgery_Schwartz. multiple antibiotic allergies or intolerances, have a history of peritonsillar abscess after the acute inflammation has resolved, or have PFAPA (peri-odic fever, aphthous stomatitis, pharyngitis, and adenitis). A peritonsillar abscess is an infection of the peritonsillar salivary gland (Weber’s gland), located between the tonsil capsule and the muscles of the tonsillar fossa. In selected cases of active peritonsillar abscess, tonsillectomy is required in the acute set-ting to treat systemic toxicity or impending airway compromise. Multiple techniques have been described, including electrocau-tery, sharp dissection, laser, and radiofrequency ablation. There is no consensus as to the best method.Sleep Disordered Breathing and Adenotonsillar Disease. Patients with sleep-disordered breathing (SDB) and tonsil-lar hypertrophy may also benefit from tonsillectomy if they have growth retardation, poor school performance, enuresis, or behavioral problems. The benefits may be accentuated in
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(SDB) and tonsil-lar hypertrophy may also benefit from tonsillectomy if they have growth retardation, poor school performance, enuresis, or behavioral problems. The benefits may be accentuated in children with abnormal polysomnography; however, DB may require further treatment after tonsillectomy when it is multifac-torial. Clinical documentation of tonsillar grade/size is based on the percentage of the transverse oropharyngeal space measured between the anterior tonsillar pillars: grade 1+ <25%; grade 2+ 25% to 49%; grade 3+ 50% to 74%; grade 4+ ≥75% or more sometimes referred to as “kissing tonsils.”32 Tonsillectomy is effective for control of SDB in 60% to 70% of patients with tonsillar hypertrophy, although this much lower (10%–25%) in obese children, and it is therefore not curative in obese chil-dren but may improve some of their symptoms nonetheless. In patients with Down syndrome, obesity, craniofacial abnormali-ties, neuromuscular disorders, sickle cell disease, or
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Surgery_Schwartz. (SDB) and tonsil-lar hypertrophy may also benefit from tonsillectomy if they have growth retardation, poor school performance, enuresis, or behavioral problems. The benefits may be accentuated in children with abnormal polysomnography; however, DB may require further treatment after tonsillectomy when it is multifac-torial. Clinical documentation of tonsillar grade/size is based on the percentage of the transverse oropharyngeal space measured between the anterior tonsillar pillars: grade 1+ <25%; grade 2+ 25% to 49%; grade 3+ 50% to 74%; grade 4+ ≥75% or more sometimes referred to as “kissing tonsils.”32 Tonsillectomy is effective for control of SDB in 60% to 70% of patients with tonsillar hypertrophy, although this much lower (10%–25%) in obese children, and it is therefore not curative in obese chil-dren but may improve some of their symptoms nonetheless. In patients with Down syndrome, obesity, craniofacial abnormali-ties, neuromuscular disorders, sickle cell disease, or
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curative in obese chil-dren but may improve some of their symptoms nonetheless. In patients with Down syndrome, obesity, craniofacial abnormali-ties, neuromuscular disorders, sickle cell disease, or mucopoly-saccharidoses, polysomnography (PSG) should be performed prior to tonsillectomy.33 When the need for surgery is uncertain or when there is a discordance between tonsillar size on physi-cal examination and the reported severity of SDB, physicians should advocate for PSG prior to tonsillectomy. Tonsillectomy, usually with adenoidectomy if the adenoids are enlarged, is often performed on an outpatient basis unless the patient has documented or strongly suspected obstructive sleep apnea (OSA), is <3 years of age, or has severe OSA (in children, an apnea-hypopnea index ≥10 or more, oxygen saturation <80%, or both). Other reasons for admission include a home >1 hour from a hospital, patients with craniofacial abnormalities, or any other medical issue. There is strong evidence to suggest
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Surgery_Schwartz. curative in obese chil-dren but may improve some of their symptoms nonetheless. In patients with Down syndrome, obesity, craniofacial abnormali-ties, neuromuscular disorders, sickle cell disease, or mucopoly-saccharidoses, polysomnography (PSG) should be performed prior to tonsillectomy.33 When the need for surgery is uncertain or when there is a discordance between tonsillar size on physi-cal examination and the reported severity of SDB, physicians should advocate for PSG prior to tonsillectomy. Tonsillectomy, usually with adenoidectomy if the adenoids are enlarged, is often performed on an outpatient basis unless the patient has documented or strongly suspected obstructive sleep apnea (OSA), is <3 years of age, or has severe OSA (in children, an apnea-hypopnea index ≥10 or more, oxygen saturation <80%, or both). Other reasons for admission include a home >1 hour from a hospital, patients with craniofacial abnormalities, or any other medical issue. There is strong evidence to suggest
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<80%, or both). Other reasons for admission include a home >1 hour from a hospital, patients with craniofacial abnormalities, or any other medical issue. There is strong evidence to suggest the routine administration of a single intraoperative dose of IV dexametha-sone in children undergoing tonsillectomy, though antibiotics should not be administered or prescribed perioperatively in children. The complications from tonsillectomy include peri-operative bleeding (3%–5%), airway obstruction, death, and readmission from postoperative dysphagia leading to dehydra-tion.34 It is recommended that surgeons calculate and quote their own primary and secondary posttonsillectomy hemorrhage rates yearly.23 A rare but serious complication in patients with obstructive adenotonsillar disease post adenotonsillectomy is postobstructive pulmonary edema syndrome, which presents with decreased oxygen saturation and frothy, blood-tinged oral secretions. Patients usually recover with reintubation, positive
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Surgery_Schwartz. <80%, or both). Other reasons for admission include a home >1 hour from a hospital, patients with craniofacial abnormalities, or any other medical issue. There is strong evidence to suggest the routine administration of a single intraoperative dose of IV dexametha-sone in children undergoing tonsillectomy, though antibiotics should not be administered or prescribed perioperatively in children. The complications from tonsillectomy include peri-operative bleeding (3%–5%), airway obstruction, death, and readmission from postoperative dysphagia leading to dehydra-tion.34 It is recommended that surgeons calculate and quote their own primary and secondary posttonsillectomy hemorrhage rates yearly.23 A rare but serious complication in patients with obstructive adenotonsillar disease post adenotonsillectomy is postobstructive pulmonary edema syndrome, which presents with decreased oxygen saturation and frothy, blood-tinged oral secretions. Patients usually recover with reintubation, positive
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is postobstructive pulmonary edema syndrome, which presents with decreased oxygen saturation and frothy, blood-tinged oral secretions. Patients usually recover with reintubation, positive pressure, diuresis, and supportive care.Multilevel Sleep Surgery. SDB surgery is often multilevel and is not limited to adenotonsillar disease. Patients with nasal obstruction may benefit from septoplasty and trubinate reduc-tion, although in the adult population this is most commonly used to allow patients to tolerate their OSA appliances. Simi-larly, patients with significant lingual tonsillar hypertrophy and a large base of tongue may benefit from a base of tongue reduction, tongue base advancement, or geniohyoidopexy. A base of tongue reduction alone does not often provide enough apnea-hypopnea index reduction (30%–60%) for resolution of symptoms and is fraught with a high morbidity rate.35 Rarely, maxillomandibular advance is required to open up the retrolin-gual space. In patients with life
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Surgery_Schwartz. is postobstructive pulmonary edema syndrome, which presents with decreased oxygen saturation and frothy, blood-tinged oral secretions. Patients usually recover with reintubation, positive pressure, diuresis, and supportive care.Multilevel Sleep Surgery. SDB surgery is often multilevel and is not limited to adenotonsillar disease. Patients with nasal obstruction may benefit from septoplasty and trubinate reduc-tion, although in the adult population this is most commonly used to allow patients to tolerate their OSA appliances. Simi-larly, patients with significant lingual tonsillar hypertrophy and a large base of tongue may benefit from a base of tongue reduction, tongue base advancement, or geniohyoidopexy. A base of tongue reduction alone does not often provide enough apnea-hypopnea index reduction (30%–60%) for resolution of symptoms and is fraught with a high morbidity rate.35 Rarely, maxillomandibular advance is required to open up the retrolin-gual space. In patients with life
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reduction (30%–60%) for resolution of symptoms and is fraught with a high morbidity rate.35 Rarely, maxillomandibular advance is required to open up the retrolin-gual space. In patients with life threatening symptoms (right heart failure/cor pulmonale, oxygen saturation <70%, comorbid cardiopulmonary disease) who have failed other measures, the only “cure” for OSA is a tracheotomy.Other Tonsillar Pathology. Unilateral tonsillar hypertrophy is mostly likely benign but can also be the result of Mycobac-terium tuberculosis, atypical mycobacterium, fungi, or Actino-myces. With the epidemic rise in incidence of oropharyngeal Brunicardi_Ch18_p0613-p0660.indd 62301/03/19 5:23 PM 624SPECIFIC CONSIDERATIONSPART IIcancers, neoplasms (squamous cell carcinoma and lymphoma) have increasingly also presented as tonsillar asymmetry.36 Man-agement of these lesions is dependent on the pretest probability of malignancy and the type of malignancy. If squamous cell car-cinoma is suspected, then a
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Surgery_Schwartz. reduction (30%–60%) for resolution of symptoms and is fraught with a high morbidity rate.35 Rarely, maxillomandibular advance is required to open up the retrolin-gual space. In patients with life threatening symptoms (right heart failure/cor pulmonale, oxygen saturation <70%, comorbid cardiopulmonary disease) who have failed other measures, the only “cure” for OSA is a tracheotomy.Other Tonsillar Pathology. Unilateral tonsillar hypertrophy is mostly likely benign but can also be the result of Mycobac-terium tuberculosis, atypical mycobacterium, fungi, or Actino-myces. With the epidemic rise in incidence of oropharyngeal Brunicardi_Ch18_p0613-p0660.indd 62301/03/19 5:23 PM 624SPECIFIC CONSIDERATIONSPART IIcancers, neoplasms (squamous cell carcinoma and lymphoma) have increasingly also presented as tonsillar asymmetry.36 Man-agement of these lesions is dependent on the pretest probability of malignancy and the type of malignancy. If squamous cell car-cinoma is suspected, then a
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presented as tonsillar asymmetry.36 Man-agement of these lesions is dependent on the pretest probability of malignancy and the type of malignancy. If squamous cell car-cinoma is suspected, then a biopsy alone is sufficient so as to not impact the possibility of other future surgical interventions such as transoral robotic surgery. If lymphoma or a nonmalignant pathology is suspected, tonsillectomy is often recommended for diagnostic and therapeutic reasons, and the specimen should be sent fresh to pathology for a lymphoma protocol workup, bacte-rial and fungal culture, and gram stain. Pharyngitis may also be seen in immune-mediated conditions such as erythema multi-forme, bullous pemphigoid, and pemphigus vulgaris.Benign Conditions of the LarynxHoarseness is the most common presenting symptom for patients with a voice complaint. Other complaints include breathiness, weakness/hypophonia, aphonia, and pitch breaks. Voice disor-ders affect a large range of patient ages, occupations, and
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Surgery_Schwartz. presented as tonsillar asymmetry.36 Man-agement of these lesions is dependent on the pretest probability of malignancy and the type of malignancy. If squamous cell car-cinoma is suspected, then a biopsy alone is sufficient so as to not impact the possibility of other future surgical interventions such as transoral robotic surgery. If lymphoma or a nonmalignant pathology is suspected, tonsillectomy is often recommended for diagnostic and therapeutic reasons, and the specimen should be sent fresh to pathology for a lymphoma protocol workup, bacte-rial and fungal culture, and gram stain. Pharyngitis may also be seen in immune-mediated conditions such as erythema multi-forme, bullous pemphigoid, and pemphigus vulgaris.Benign Conditions of the LarynxHoarseness is the most common presenting symptom for patients with a voice complaint. Other complaints include breathiness, weakness/hypophonia, aphonia, and pitch breaks. Voice disor-ders affect a large range of patient ages, occupations, and
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for patients with a voice complaint. Other complaints include breathiness, weakness/hypophonia, aphonia, and pitch breaks. Voice disor-ders affect a large range of patient ages, occupations, and socio-economic statuses and affect both genders equally. They can be associated with dysphagia, globus sensation, laryngopharyngeal reflux (LPR) disease and, rarely, airway obstruction.37 Smoking can both cause and aggravate preexisting benign laryngeal con-ditions and raises the suspicion of malignancy often requiring a biopsy to exclude this diagnosis.Any discussion of laryngeal disorders should start with a review of the anatomy of the vocal cords (Fig. 18-13). The true vocal cords are formed from stratified squamous epithelium, beneath which is the superficial lamina propria (in Reinke’s space). Beneath this is the ligament that includes the middle and deep lamina propria. Beneath this ligament is the muscular layer that includes the thyroarytenoid muscle or vocalis. The cover-body theory
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Surgery_Schwartz. for patients with a voice complaint. Other complaints include breathiness, weakness/hypophonia, aphonia, and pitch breaks. Voice disor-ders affect a large range of patient ages, occupations, and socio-economic statuses and affect both genders equally. They can be associated with dysphagia, globus sensation, laryngopharyngeal reflux (LPR) disease and, rarely, airway obstruction.37 Smoking can both cause and aggravate preexisting benign laryngeal con-ditions and raises the suspicion of malignancy often requiring a biopsy to exclude this diagnosis.Any discussion of laryngeal disorders should start with a review of the anatomy of the vocal cords (Fig. 18-13). The true vocal cords are formed from stratified squamous epithelium, beneath which is the superficial lamina propria (in Reinke’s space). Beneath this is the ligament that includes the middle and deep lamina propria. Beneath this ligament is the muscular layer that includes the thyroarytenoid muscle or vocalis. The cover-body theory
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Beneath this is the ligament that includes the middle and deep lamina propria. Beneath this ligament is the muscular layer that includes the thyroarytenoid muscle or vocalis. The cover-body theory describes the freely mobile cover (mucosa and Reinke’s space) over the more rigid body (vocal ligament and vocalis).38Membranous vocal cord lesions have been notoriously dif-ficult to classify reliably; however, increased availability of vid-eostroboscopic examination and standardized definitions have improved the classification of these lesions.39 These lesions are usually mid cord because that is the site of maximal lateral displacement and amplitude. Vocal fold nodules are typically bilateral, fairly symmetric, and with normal or mild impairment of the mucosal wave, and they almost always resolve with voice therapy. A vocal fold polyp is more often unilateral than bilat-eral, is exophytic, and is associated with unorganized gelatinous debris in the subepithelial space. These can be
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Surgery_Schwartz. Beneath this is the ligament that includes the middle and deep lamina propria. Beneath this ligament is the muscular layer that includes the thyroarytenoid muscle or vocalis. The cover-body theory describes the freely mobile cover (mucosa and Reinke’s space) over the more rigid body (vocal ligament and vocalis).38Membranous vocal cord lesions have been notoriously dif-ficult to classify reliably; however, increased availability of vid-eostroboscopic examination and standardized definitions have improved the classification of these lesions.39 These lesions are usually mid cord because that is the site of maximal lateral displacement and amplitude. Vocal fold nodules are typically bilateral, fairly symmetric, and with normal or mild impairment of the mucosal wave, and they almost always resolve with voice therapy. A vocal fold polyp is more often unilateral than bilat-eral, is exophytic, and is associated with unorganized gelatinous debris in the subepithelial space. These can be
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resolve with voice therapy. A vocal fold polyp is more often unilateral than bilat-eral, is exophytic, and is associated with unorganized gelatinous debris in the subepithelial space. These can be hemorrhagic as is often seen in males secondary to capillary rupture within the mucosa by shearing forces during voice abuse. Hemorrhagic polyps are seen more often in patients on anticoagulants. These lesions usually fail conservative measures (voice rest, voice therapy, smoking cessation, and reflux management) usually requiring micorlaryngeal surgery to remove the lesion while preserving normal mucosa. Vocal fold cyst is an encapsulated lesion within the subepithelial or ligamentous space and is asso-ciated with reduced mucosal wave. It typically does not resolve with voice therapy. These lesions require microlaryngeal sur-gery for complete removal of the cyst while preserving the over-lying mucosa, and this surgery can be performed with cold steel or carbon dioxide (CO2) laser. A fibrous
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Surgery_Schwartz. resolve with voice therapy. A vocal fold polyp is more often unilateral than bilat-eral, is exophytic, and is associated with unorganized gelatinous debris in the subepithelial space. These can be hemorrhagic as is often seen in males secondary to capillary rupture within the mucosa by shearing forces during voice abuse. Hemorrhagic polyps are seen more often in patients on anticoagulants. These lesions usually fail conservative measures (voice rest, voice therapy, smoking cessation, and reflux management) usually requiring micorlaryngeal surgery to remove the lesion while preserving normal mucosa. Vocal fold cyst is an encapsulated lesion within the subepithelial or ligamentous space and is asso-ciated with reduced mucosal wave. It typically does not resolve with voice therapy. These lesions require microlaryngeal sur-gery for complete removal of the cyst while preserving the over-lying mucosa, and this surgery can be performed with cold steel or carbon dioxide (CO2) laser. A fibrous
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require microlaryngeal sur-gery for complete removal of the cyst while preserving the over-lying mucosa, and this surgery can be performed with cold steel or carbon dioxide (CO2) laser. A fibrous mass of the vocal fold is amorphous fibrous material within the subepithelial space or EpiglottisEpitheliumLayers oflamina propriaSuperficialIntermediateDeepVocalisHyoid boneCushion ofepiglottisThyroidcartilageFalse vocal cordLaryngealsinusTrue vocalcordThyroarytenoidmuscleCricoid cartilageAryteno-epiglottideanfoldFigure 18-13. Coronal view of the larynx demonstrate the supraglottic, glottic and subglottis (LEFT) and the layers of the true vocal cord (RIGHT).Brunicardi_Ch18_p0613-p0660.indd 62401/03/19 5:23 PM 625DISORDERS OF THE HEAD AND NECKCHAPTER 18ligament often associated with reduced mucosal wave, and it also does not resolve with voice therapy.Reinke’s edema is characterized by edema in the superfi-cial lamina propria of the vocal cord. Edema is thought to arise from injury to the
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Surgery_Schwartz. require microlaryngeal sur-gery for complete removal of the cyst while preserving the over-lying mucosa, and this surgery can be performed with cold steel or carbon dioxide (CO2) laser. A fibrous mass of the vocal fold is amorphous fibrous material within the subepithelial space or EpiglottisEpitheliumLayers oflamina propriaSuperficialIntermediateDeepVocalisHyoid boneCushion ofepiglottisThyroidcartilageFalse vocal cordLaryngealsinusTrue vocalcordThyroarytenoidmuscleCricoid cartilageAryteno-epiglottideanfoldFigure 18-13. Coronal view of the larynx demonstrate the supraglottic, glottic and subglottis (LEFT) and the layers of the true vocal cord (RIGHT).Brunicardi_Ch18_p0613-p0660.indd 62401/03/19 5:23 PM 625DISORDERS OF THE HEAD AND NECKCHAPTER 18ligament often associated with reduced mucosal wave, and it also does not resolve with voice therapy.Reinke’s edema is characterized by edema in the superfi-cial lamina propria of the vocal cord. Edema is thought to arise from injury to the
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wave, and it also does not resolve with voice therapy.Reinke’s edema is characterized by edema in the superfi-cial lamina propria of the vocal cord. Edema is thought to arise from injury to the capillaries that exist in this layer, with sub-sequent extravasation of fluid. The etiology is multifactorial: smoking, LPR, hypothyroidism, and vocal misuse.40 This pathol-ogy is more common in women (because they present early due to a deep vocal pitch change in their voice) and heavy smokers. The physical examination findings are typically bilateral. Sur-gery typically involves microlaryngoscopy with removal of the gelatinous debris in Reinke’s space with trimming of the excess mucosa. However, smoking cessation and surgery do not fully reverse the structural abnormalities due to the presence of pos-sible structure alterations in fibroblasts caused by the toxicity of cigarette components, resulting in uncontrolled production of fibrous matrix in the lamina propria, thus preventing complete
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Surgery_Schwartz. wave, and it also does not resolve with voice therapy.Reinke’s edema is characterized by edema in the superfi-cial lamina propria of the vocal cord. Edema is thought to arise from injury to the capillaries that exist in this layer, with sub-sequent extravasation of fluid. The etiology is multifactorial: smoking, LPR, hypothyroidism, and vocal misuse.40 This pathol-ogy is more common in women (because they present early due to a deep vocal pitch change in their voice) and heavy smokers. The physical examination findings are typically bilateral. Sur-gery typically involves microlaryngoscopy with removal of the gelatinous debris in Reinke’s space with trimming of the excess mucosa. However, smoking cessation and surgery do not fully reverse the structural abnormalities due to the presence of pos-sible structure alterations in fibroblasts caused by the toxicity of cigarette components, resulting in uncontrolled production of fibrous matrix in the lamina propria, thus preventing complete
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pos-sible structure alterations in fibroblasts caused by the toxicity of cigarette components, resulting in uncontrolled production of fibrous matrix in the lamina propria, thus preventing complete vocal recovery.41Laryngeal granulomas typically occur in the posterior lar-ynx on the arytenoid mucosa (Fig. 18-14). These lesions are typically multifactorial: chronic throat clearing, phonotrauma, endotracheal intubation, compensatory supraglottic squeeze from vocal fold paralysis, and LPR.42 The majority of these lesions (82%) disappear within 48 weeks with conservative measures such as voice therapy, vocal rest, oral steroids, inhaled steroids, and proton pump inhibitors.42 Botulinum toxin of thy-roarytenoid and lateral cricoarytenoid muscles can be used as first-line treatment in patients who prefer a chemically activated voice rest regiment.42 LPR appears to be the most important contributing factor,42 and when aggressive conservative and medical therapy has failed, a Nissen
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Surgery_Schwartz. pos-sible structure alterations in fibroblasts caused by the toxicity of cigarette components, resulting in uncontrolled production of fibrous matrix in the lamina propria, thus preventing complete vocal recovery.41Laryngeal granulomas typically occur in the posterior lar-ynx on the arytenoid mucosa (Fig. 18-14). These lesions are typically multifactorial: chronic throat clearing, phonotrauma, endotracheal intubation, compensatory supraglottic squeeze from vocal fold paralysis, and LPR.42 The majority of these lesions (82%) disappear within 48 weeks with conservative measures such as voice therapy, vocal rest, oral steroids, inhaled steroids, and proton pump inhibitors.42 Botulinum toxin of thy-roarytenoid and lateral cricoarytenoid muscles can be used as first-line treatment in patients who prefer a chemically activated voice rest regiment.42 LPR appears to be the most important contributing factor,42 and when aggressive conservative and medical therapy has failed, a Nissen
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patients who prefer a chemically activated voice rest regiment.42 LPR appears to be the most important contributing factor,42 and when aggressive conservative and medical therapy has failed, a Nissen fundoplication may be indicated. Surgery is rarely required for patients with laryngeal granulomas because it does not address the underlying etiol-ogy and is frequently associated with recurrence. Nonetheless, excision is sometimes required in patients with airway obstruc-tion or the suspicion of malignancy. Careful preservation of the arytenoid perichondrium intraoperatively is required to assist with reepithelialization and to decrease the risk of recurrence postoperatively.Recurrent respiratory papillomatosis (RRP) is pathophysi-ologically associated with human papillomavirus (HPV) within the mucosa of the upper aerodigestive tract. The glottis and supra-glottis are the two most common involved subsites. HPV 6 and 11 are the most often implicated types; however, LPR and herpes simplex
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Surgery_Schwartz. patients who prefer a chemically activated voice rest regiment.42 LPR appears to be the most important contributing factor,42 and when aggressive conservative and medical therapy has failed, a Nissen fundoplication may be indicated. Surgery is rarely required for patients with laryngeal granulomas because it does not address the underlying etiol-ogy and is frequently associated with recurrence. Nonetheless, excision is sometimes required in patients with airway obstruc-tion or the suspicion of malignancy. Careful preservation of the arytenoid perichondrium intraoperatively is required to assist with reepithelialization and to decrease the risk of recurrence postoperatively.Recurrent respiratory papillomatosis (RRP) is pathophysi-ologically associated with human papillomavirus (HPV) within the mucosa of the upper aerodigestive tract. The glottis and supra-glottis are the two most common involved subsites. HPV 6 and 11 are the most often implicated types; however, LPR and herpes simplex
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the mucosa of the upper aerodigestive tract. The glottis and supra-glottis are the two most common involved subsites. HPV 6 and 11 are the most often implicated types; however, LPR and herpes simplex virus (HSV) type-2 are risk factors of adult-onset RRP.43 The disorder typically presents in early childhood (juvenile-onset RR; JoRRP) secondary to HPV acquisition during vaginal deliv-ery; however, children born by caesarean section are also at risk for the disease. JoRRP usually resolves around puberty but can progress into adulthood. Adult-onset RRP is less severe and is more likely to involve extralaryngeal subsites. There is no cure for RRP. Surgery excision is used to improve voice and airway symptoms in a palliative fashion. Surgical excision in the operat-ing room involves microlaryngoscopy with the use of the laser (CO2 for bulky disease or KTP for more superficial disease) or the use of a microdebrider. The microdebrider has been dem-onstrated to have superior voice outcomes in
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Surgery_Schwartz. the mucosa of the upper aerodigestive tract. The glottis and supra-glottis are the two most common involved subsites. HPV 6 and 11 are the most often implicated types; however, LPR and herpes simplex virus (HSV) type-2 are risk factors of adult-onset RRP.43 The disorder typically presents in early childhood (juvenile-onset RR; JoRRP) secondary to HPV acquisition during vaginal deliv-ery; however, children born by caesarean section are also at risk for the disease. JoRRP usually resolves around puberty but can progress into adulthood. Adult-onset RRP is less severe and is more likely to involve extralaryngeal subsites. There is no cure for RRP. Surgery excision is used to improve voice and airway symptoms in a palliative fashion. Surgical excision in the operat-ing room involves microlaryngoscopy with the use of the laser (CO2 for bulky disease or KTP for more superficial disease) or the use of a microdebrider. The microdebrider has been dem-onstrated to have superior voice outcomes in
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with the use of the laser (CO2 for bulky disease or KTP for more superficial disease) or the use of a microdebrider. The microdebrider has been dem-onstrated to have superior voice outcomes in JoRRP; however, CO2 laser is the most commonly used operative ablative tech-nique used in adults.44 Recent advances have made it possible to treat a select group of adult RRP patients in the office using the KTP laser, typically for those with a lower disease burden.45 Several adjuvant treatments are used to increase the intersurgical interval, including intralesional cidofovir injection, oral indole-3-carbinol, oral methotrexate, and retinoic acid. In addition to preventing RRP in some patients, the HPV vaccine has also been demonstrated to increase the intersurgical interval in the most aggressive JoRRP patients.46,47Leukoplakia is a white patch seen on mucosa that can be wiped off on physical examination. This can be seen anywhere in the upper aerodigestive tract. In the larynx, this is
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Surgery_Schwartz. with the use of the laser (CO2 for bulky disease or KTP for more superficial disease) or the use of a microdebrider. The microdebrider has been dem-onstrated to have superior voice outcomes in JoRRP; however, CO2 laser is the most commonly used operative ablative tech-nique used in adults.44 Recent advances have made it possible to treat a select group of adult RRP patients in the office using the KTP laser, typically for those with a lower disease burden.45 Several adjuvant treatments are used to increase the intersurgical interval, including intralesional cidofovir injection, oral indole-3-carbinol, oral methotrexate, and retinoic acid. In addition to preventing RRP in some patients, the HPV vaccine has also been demonstrated to increase the intersurgical interval in the most aggressive JoRRP patients.46,47Leukoplakia is a white patch seen on mucosa that can be wiped off on physical examination. This can be seen anywhere in the upper aerodigestive tract. In the larynx, this is
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JoRRP patients.46,47Leukoplakia is a white patch seen on mucosa that can be wiped off on physical examination. This can be seen anywhere in the upper aerodigestive tract. In the larynx, this is typically seen on the superior surface of the true vocal cords and may represent squamous hyperplasia, dysplasia, and/or carcinoma with an associated risk of malignant transformation of 1% to 3% in hyperplastic lesions and 10% to 30% in dysplastic lesions. Lesions that are not overtly suspicious for malignancy, particularly in patients without a strong smoking or alcohol history, can be managed conservatively (increased hydration, elimination of poor vocal habits, phonotrauma, and manage-ment of LPR) for 1 month before reevaluation with fiberoptic laryngoscopy. Any lesions that progress, persist, or recur could have microlaryngoscopy with complete excision. Similarly, because erythroplasia and ulceration are more suggestive of malignancy, these lesions also require an excisional biopsy in the
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Surgery_Schwartz. JoRRP patients.46,47Leukoplakia is a white patch seen on mucosa that can be wiped off on physical examination. This can be seen anywhere in the upper aerodigestive tract. In the larynx, this is typically seen on the superior surface of the true vocal cords and may represent squamous hyperplasia, dysplasia, and/or carcinoma with an associated risk of malignant transformation of 1% to 3% in hyperplastic lesions and 10% to 30% in dysplastic lesions. Lesions that are not overtly suspicious for malignancy, particularly in patients without a strong smoking or alcohol history, can be managed conservatively (increased hydration, elimination of poor vocal habits, phonotrauma, and manage-ment of LPR) for 1 month before reevaluation with fiberoptic laryngoscopy. Any lesions that progress, persist, or recur could have microlaryngoscopy with complete excision. Similarly, because erythroplasia and ulceration are more suggestive of malignancy, these lesions also require an excisional biopsy in the
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or recur could have microlaryngoscopy with complete excision. Similarly, because erythroplasia and ulceration are more suggestive of malignancy, these lesions also require an excisional biopsy in the operating room.The most common cause of unilateral vocal cord paresis is iatrogenic in origin, following surgery to the thyroid, parathy-roid, carotid, spine through an anterior approach,48 or cardiotho-racic structures.49 It is therefore very important that all patients undergoing thyroid surgery receive preoperative visualization of the larynx, usually in the form of fiberoptic nasolaryngos-copy, although an indirect mirror exam can be used if adequate visualization is possible.50 Postthyroidectomy visualization may also be required to document normal vocal cord move-ment. Less common causes include malignancy of structures near the recurrent laryngeal nerve (RLN) from the skull base jugular foramen to the mediastinum. In the pediatric population, there can be neurologic causes, the
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Surgery_Schwartz. or recur could have microlaryngoscopy with complete excision. Similarly, because erythroplasia and ulceration are more suggestive of malignancy, these lesions also require an excisional biopsy in the operating room.The most common cause of unilateral vocal cord paresis is iatrogenic in origin, following surgery to the thyroid, parathy-roid, carotid, spine through an anterior approach,48 or cardiotho-racic structures.49 It is therefore very important that all patients undergoing thyroid surgery receive preoperative visualization of the larynx, usually in the form of fiberoptic nasolaryngos-copy, although an indirect mirror exam can be used if adequate visualization is possible.50 Postthyroidectomy visualization may also be required to document normal vocal cord move-ment. Less common causes include malignancy of structures near the recurrent laryngeal nerve (RLN) from the skull base jugular foramen to the mediastinum. In the pediatric population, there can be neurologic causes, the
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include malignancy of structures near the recurrent laryngeal nerve (RLN) from the skull base jugular foramen to the mediastinum. In the pediatric population, there can be neurologic causes, the most common of which is the Arnold-Chiari malformation.51 Overall, the left vocal cord is more commonly involved secondary to the longer course of the RLN on that side. Other rare etiologies include trauma, intu-bation injury, atypical infections, and neurotoxic medications. Patients typically present with a weak breathy voice and may have aspiration secondary to diminished supraglottic sensa-tion if the proximal vagal nerve or superior laryngeal nerve is involved. RLN injury is also associated with delayed relaxation Figure 18-14. Laryngeal granuloma.Brunicardi_Ch18_p0613-p0660.indd 62501/03/19 5:23 PM 626SPECIFIC CONSIDERATIONSPART IIof the cricopharyngeus muscle that can lead to dysphagia and decreased sensation in the hypopharynx, which can cause pool-ing of secretions. In children,
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Surgery_Schwartz. include malignancy of structures near the recurrent laryngeal nerve (RLN) from the skull base jugular foramen to the mediastinum. In the pediatric population, there can be neurologic causes, the most common of which is the Arnold-Chiari malformation.51 Overall, the left vocal cord is more commonly involved secondary to the longer course of the RLN on that side. Other rare etiologies include trauma, intu-bation injury, atypical infections, and neurotoxic medications. Patients typically present with a weak breathy voice and may have aspiration secondary to diminished supraglottic sensa-tion if the proximal vagal nerve or superior laryngeal nerve is involved. RLN injury is also associated with delayed relaxation Figure 18-14. Laryngeal granuloma.Brunicardi_Ch18_p0613-p0660.indd 62501/03/19 5:23 PM 626SPECIFIC CONSIDERATIONSPART IIof the cricopharyngeus muscle that can lead to dysphagia and decreased sensation in the hypopharynx, which can cause pool-ing of secretions. In children,
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5:23 PM 626SPECIFIC CONSIDERATIONSPART IIof the cricopharyngeus muscle that can lead to dysphagia and decreased sensation in the hypopharynx, which can cause pool-ing of secretions. In children, stridor, weak cry, and airway com-promise may be presenting symptoms, whereas in adults this is rarely the case unless there is bilateral vocal cord paralysis. When an obvious cause is not identified after a thorough history and physical examination including fiberoptic nasolaryngos-copy, then a more comprehensive workup is required. A workup should not include autoimmune serology as a screen because this is low yield, but this can be included if there is a suspicion of autoimmune disorders. Imaging, in the form of a CT scan, is the mainstay of the workup and should include the skull base to the mediastinum. Repeat imaging is beneficial in this population within a 2-year period because many patients have undiagnosed small malignancies as the primary cause of their paralysis that are too
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Surgery_Schwartz. 5:23 PM 626SPECIFIC CONSIDERATIONSPART IIof the cricopharyngeus muscle that can lead to dysphagia and decreased sensation in the hypopharynx, which can cause pool-ing of secretions. In children, stridor, weak cry, and airway com-promise may be presenting symptoms, whereas in adults this is rarely the case unless there is bilateral vocal cord paralysis. When an obvious cause is not identified after a thorough history and physical examination including fiberoptic nasolaryngos-copy, then a more comprehensive workup is required. A workup should not include autoimmune serology as a screen because this is low yield, but this can be included if there is a suspicion of autoimmune disorders. Imaging, in the form of a CT scan, is the mainstay of the workup and should include the skull base to the mediastinum. Repeat imaging is beneficial in this population within a 2-year period because many patients have undiagnosed small malignancies as the primary cause of their paralysis that are too
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the mediastinum. Repeat imaging is beneficial in this population within a 2-year period because many patients have undiagnosed small malignancies as the primary cause of their paralysis that are too small to detect on initial imaging.52 Laryngeal electro-myography can assist with identifying whether the paresis is a result of a paralysis or cricoarytenoid joint fixation/disloca-tion. It can also help prognosticate a paralysis. This is, however, rarely used in practice. Despite an extensive workup, 20% to 35% of cases are idiopathic.The management of bilateral vocal cord paralysis almost always requires a tracheotomy because the cords are left in a paramedian position leaving a slit light glottic aperture. If the paralysis is permanent, then a cordectomy with or without ary-tenoidectomy can be used to open up the airway in an attempt to eventually decannulate the patient. However, this has obvi-ous implications for voice with a weak and breathing voice. Many patients with a unilateral
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Surgery_Schwartz. the mediastinum. Repeat imaging is beneficial in this population within a 2-year period because many patients have undiagnosed small malignancies as the primary cause of their paralysis that are too small to detect on initial imaging.52 Laryngeal electro-myography can assist with identifying whether the paresis is a result of a paralysis or cricoarytenoid joint fixation/disloca-tion. It can also help prognosticate a paralysis. This is, however, rarely used in practice. Despite an extensive workup, 20% to 35% of cases are idiopathic.The management of bilateral vocal cord paralysis almost always requires a tracheotomy because the cords are left in a paramedian position leaving a slit light glottic aperture. If the paralysis is permanent, then a cordectomy with or without ary-tenoidectomy can be used to open up the airway in an attempt to eventually decannulate the patient. However, this has obvi-ous implications for voice with a weak and breathing voice. Many patients with a unilateral
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be used to open up the airway in an attempt to eventually decannulate the patient. However, this has obvi-ous implications for voice with a weak and breathing voice. Many patients with a unilateral paralysis compensate when the cord is in the paramedian position using supraglottic structure and the contralateral cord on their own or with speech therapy. However, in patients with a less than adequate voice-related quality of life, four techniques have been used to surgically manage patients with a unilateral vocal cord paralysis: injection laryngoplasty, medialization thyroplasty, arytenoid adduction, and laryngeal reinnervation. Injection laryngoplasty involves injecting a temporary filler medial to the vocalis into the liga-ment at the posterior and midmembranous vocal cord. This can be performed in the office or in the operating room, depend-ing on the comfort of the surgeon and patient characteristics. Materials used include autologous (fat, collagen) or alloplastic
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Surgery_Schwartz. be used to open up the airway in an attempt to eventually decannulate the patient. However, this has obvi-ous implications for voice with a weak and breathing voice. Many patients with a unilateral paralysis compensate when the cord is in the paramedian position using supraglottic structure and the contralateral cord on their own or with speech therapy. However, in patients with a less than adequate voice-related quality of life, four techniques have been used to surgically manage patients with a unilateral vocal cord paralysis: injection laryngoplasty, medialization thyroplasty, arytenoid adduction, and laryngeal reinnervation. Injection laryngoplasty involves injecting a temporary filler medial to the vocalis into the liga-ment at the posterior and midmembranous vocal cord. This can be performed in the office or in the operating room, depend-ing on the comfort of the surgeon and patient characteristics. Materials used include autologous (fat, collagen) or alloplastic
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This can be performed in the office or in the operating room, depend-ing on the comfort of the surgeon and patient characteristics. Materials used include autologous (fat, collagen) or alloplastic (hydroxyapatite, hyaluronic acid, micronized cadaveric human collagen) compounds. Early medialization is recommended in patients with mediastinal and thoracic malignancies because it is safe and has been shown to improve quality of life in a palli-ative setting.53 Teflon is historic and is no longer used because of its granulomatous side effects on the larynx. A more per-manent medialization can be performed using a medialization thyroplasty, during which a small window is created in the inferolateral aspect of the thyroid cartilage and a submucosal-carved silastic block is placed in the operating room with the patient under neurolept anesthetic so that vocalization and flex-ible laryngoscopic visualization of the larynx can be improved (Fig. 18-15). In some cases, this is not enough of a
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Surgery_Schwartz. This can be performed in the office or in the operating room, depend-ing on the comfort of the surgeon and patient characteristics. Materials used include autologous (fat, collagen) or alloplastic (hydroxyapatite, hyaluronic acid, micronized cadaveric human collagen) compounds. Early medialization is recommended in patients with mediastinal and thoracic malignancies because it is safe and has been shown to improve quality of life in a palli-ative setting.53 Teflon is historic and is no longer used because of its granulomatous side effects on the larynx. A more per-manent medialization can be performed using a medialization thyroplasty, during which a small window is created in the inferolateral aspect of the thyroid cartilage and a submucosal-carved silastic block is placed in the operating room with the patient under neurolept anesthetic so that vocalization and flex-ible laryngoscopic visualization of the larynx can be improved (Fig. 18-15). In some cases, this is not enough of a
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room with the patient under neurolept anesthetic so that vocalization and flex-ible laryngoscopic visualization of the larynx can be improved (Fig. 18-15). In some cases, this is not enough of a medialization due to a large posterior glottic chink, and an arytenoid adduction is required to provide better closure of the posterior glottis and supraglottis with ensuing improved vocal outcomes. This is a technically challenging procedure that is rarely required, but in select patients it is associated with significant improvements in voice. Lastly, laryngeal reinnervation, typically with the ansa cervicalis that supplies motor function to the strap muscles, can also be performed. This is the best approach in patients who have had a recurrent laryngeal nerve severed during a central or upper mediastinal neck procedure because it is in the field.54 Multiple studies demonstrate favorable outcomes; however, no significant differences between treatment arms has been demon-strated based on
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Surgery_Schwartz. room with the patient under neurolept anesthetic so that vocalization and flex-ible laryngoscopic visualization of the larynx can be improved (Fig. 18-15). In some cases, this is not enough of a medialization due to a large posterior glottic chink, and an arytenoid adduction is required to provide better closure of the posterior glottis and supraglottis with ensuing improved vocal outcomes. This is a technically challenging procedure that is rarely required, but in select patients it is associated with significant improvements in voice. Lastly, laryngeal reinnervation, typically with the ansa cervicalis that supplies motor function to the strap muscles, can also be performed. This is the best approach in patients who have had a recurrent laryngeal nerve severed during a central or upper mediastinal neck procedure because it is in the field.54 Multiple studies demonstrate favorable outcomes; however, no significant differences between treatment arms has been demon-strated based on
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mediastinal neck procedure because it is in the field.54 Multiple studies demonstrate favorable outcomes; however, no significant differences between treatment arms has been demon-strated based on perceptual, acoustic, quality of life, and laryn-goscopic outcomes.55Vascular LesionsVascular lesions can be broadly classified into two groups: hem-angiomas and vascular malformations.56Hemangiomas. Hemangiomas are the most common vascular lesion present in infancy and early childhood. Infantile heman-giomas present largely within the first few weeks of life. Initially they proliferate (2 weeks to 1 year), and then they begin to invo-lute (1–7 years) until they have fully involuted, leaving the child with redundant skin, scar, or a fatty lesion. Children with large facial infantile hemangiomas benefit from regular neurological examinations and brain MRI to rule out PHACES syndrome (Posterior fossa malformations, Hemangiomas, Arterial lesions, Cardiac abnormalities/aortic coarctation, Eye
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Surgery_Schwartz. mediastinal neck procedure because it is in the field.54 Multiple studies demonstrate favorable outcomes; however, no significant differences between treatment arms has been demon-strated based on perceptual, acoustic, quality of life, and laryn-goscopic outcomes.55Vascular LesionsVascular lesions can be broadly classified into two groups: hem-angiomas and vascular malformations.56Hemangiomas. Hemangiomas are the most common vascular lesion present in infancy and early childhood. Infantile heman-giomas present largely within the first few weeks of life. Initially they proliferate (2 weeks to 1 year), and then they begin to invo-lute (1–7 years) until they have fully involuted, leaving the child with redundant skin, scar, or a fatty lesion. Children with large facial infantile hemangiomas benefit from regular neurological examinations and brain MRI to rule out PHACES syndrome (Posterior fossa malformations, Hemangiomas, Arterial lesions, Cardiac abnormalities/aortic coarctation, Eye
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benefit from regular neurological examinations and brain MRI to rule out PHACES syndrome (Posterior fossa malformations, Hemangiomas, Arterial lesions, Cardiac abnormalities/aortic coarctation, Eye abnormalities). Only 10% of these lesions require early intervention because of impairment of vision or swallowing, or airway compromise. Early intervention can include medical management, such as systemic steroids, intralesional steroids, intralesional interferon α-2a, or photocoagulation therapy, and surgical management, including excision with CO2 laser/microdebrider and tracheot-omy. Systemic steroids assist with rapidly proliferating lesions until the child reaches approximately one year of age; however, it is associated with growth retardation and immune suppres-sion. Intralesional interferon α-2a has been largely abandoned because it is a daily subcutaneous injection and is associated Figure 18-15. Hand carved silastic block for thyroplasty.Brunicardi_Ch18_p0613-p0660.indd
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Surgery_Schwartz. benefit from regular neurological examinations and brain MRI to rule out PHACES syndrome (Posterior fossa malformations, Hemangiomas, Arterial lesions, Cardiac abnormalities/aortic coarctation, Eye abnormalities). Only 10% of these lesions require early intervention because of impairment of vision or swallowing, or airway compromise. Early intervention can include medical management, such as systemic steroids, intralesional steroids, intralesional interferon α-2a, or photocoagulation therapy, and surgical management, including excision with CO2 laser/microdebrider and tracheot-omy. Systemic steroids assist with rapidly proliferating lesions until the child reaches approximately one year of age; however, it is associated with growth retardation and immune suppres-sion. Intralesional interferon α-2a has been largely abandoned because it is a daily subcutaneous injection and is associated Figure 18-15. Hand carved silastic block for thyroplasty.Brunicardi_Ch18_p0613-p0660.indd
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interferon α-2a has been largely abandoned because it is a daily subcutaneous injection and is associated Figure 18-15. Hand carved silastic block for thyroplasty.Brunicardi_Ch18_p0613-p0660.indd 62601/03/19 5:23 PM 627DISORDERS OF THE HEAD AND NECKCHAPTER 18with significant neurological side effects, including spastic diplegia. Photocoagulation therapy with either the flashlamp-pumped pulsed-dye laser (FPDL), the potassium titanyl phos-phate (KTP) laser, or the neodymium yttrium-aluminum garnet (Nd:YAG) laser, is repeated every 4 to 6 weeks until the lesion disappears. A randomized trial recently demonstrated that pro-pranolol was effective at a dose of 3mg/kg per day for 5 months in the treatment of infantile hemangioma with a very acceptable and low side-effect profile.57 Other groups have had success at discontinuing propranolol at 1 year of age with excellent out-comes.58 For patients who do not require early intervention, the lesion is observed every 3 months for involution
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Surgery_Schwartz. interferon α-2a has been largely abandoned because it is a daily subcutaneous injection and is associated Figure 18-15. Hand carved silastic block for thyroplasty.Brunicardi_Ch18_p0613-p0660.indd 62601/03/19 5:23 PM 627DISORDERS OF THE HEAD AND NECKCHAPTER 18with significant neurological side effects, including spastic diplegia. Photocoagulation therapy with either the flashlamp-pumped pulsed-dye laser (FPDL), the potassium titanyl phos-phate (KTP) laser, or the neodymium yttrium-aluminum garnet (Nd:YAG) laser, is repeated every 4 to 6 weeks until the lesion disappears. A randomized trial recently demonstrated that pro-pranolol was effective at a dose of 3mg/kg per day for 5 months in the treatment of infantile hemangioma with a very acceptable and low side-effect profile.57 Other groups have had success at discontinuing propranolol at 1 year of age with excellent out-comes.58 For patients who do not require early intervention, the lesion is observed every 3 months for involution
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have had success at discontinuing propranolol at 1 year of age with excellent out-comes.58 For patients who do not require early intervention, the lesion is observed every 3 months for involution after the pro-liferative phase has ended. Surgery is considered if regression has not occurred by 5 years of age because the cosmetic result is less likely to be satisfactory.Congenital hemangiomas differ from infantile heman-giomas in that they reach their maximal size at birth and do not have a proliferative phase. There are two subtypes: rapidly involuting (RICH), which typically disappears by 1 of age with minimal fatty appearance upon resolution, and noninvoluting (NICH). The management is similar to infantile hemangiomas with the exception that medical management is not typically necessary.Vascular Malformations. Vascular malformations, in contrast to infantile hemangioma, are always present at birth, although they may not be apparent for a few months. Although they do not have a
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Surgery_Schwartz. have had success at discontinuing propranolol at 1 year of age with excellent out-comes.58 For patients who do not require early intervention, the lesion is observed every 3 months for involution after the pro-liferative phase has ended. Surgery is considered if regression has not occurred by 5 years of age because the cosmetic result is less likely to be satisfactory.Congenital hemangiomas differ from infantile heman-giomas in that they reach their maximal size at birth and do not have a proliferative phase. There are two subtypes: rapidly involuting (RICH), which typically disappears by 1 of age with minimal fatty appearance upon resolution, and noninvoluting (NICH). The management is similar to infantile hemangiomas with the exception that medical management is not typically necessary.Vascular Malformations. Vascular malformations, in contrast to infantile hemangioma, are always present at birth, although they may not be apparent for a few months. Although they do not have a
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Malformations. Vascular malformations, in contrast to infantile hemangioma, are always present at birth, although they may not be apparent for a few months. Although they do not have a proliferative phase, they grow with the patient, have hormonal growth spurts and do not involute.59 Vascular mal-formations can be classified as low flow (capillary, venous, lymphatic, and mixed), which comprise approximately two-thirds of all vascular malformations, or high flow (arteria and arteriovenous).Capillary malformations arise from the cutaneous super-ficial plexus and are made up of capillary and postcapillary venules with a pink, red, or purple macular-papular appearance. Venous malformations arise from dilated vascular channels lined by normal endothelium; therefore, they are soft, compress-ible, and nonpulsatile. If they are superficial, they will increase in size with Valsalva or dependent positioning. They can grow suddenly with trauma or in association with hormonal changes. Lymphatic
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Surgery_Schwartz. Malformations. Vascular malformations, in contrast to infantile hemangioma, are always present at birth, although they may not be apparent for a few months. Although they do not have a proliferative phase, they grow with the patient, have hormonal growth spurts and do not involute.59 Vascular mal-formations can be classified as low flow (capillary, venous, lymphatic, and mixed), which comprise approximately two-thirds of all vascular malformations, or high flow (arteria and arteriovenous).Capillary malformations arise from the cutaneous super-ficial plexus and are made up of capillary and postcapillary venules with a pink, red, or purple macular-papular appearance. Venous malformations arise from dilated vascular channels lined by normal endothelium; therefore, they are soft, compress-ible, and nonpulsatile. If they are superficial, they will increase in size with Valsalva or dependent positioning. They can grow suddenly with trauma or in association with hormonal changes. Lymphatic
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and nonpulsatile. If they are superficial, they will increase in size with Valsalva or dependent positioning. They can grow suddenly with trauma or in association with hormonal changes. Lymphatic malformations typically present at birth with the majority (90%) being identified by 2 years of age. They can be macrocystic (>2 cm), microcystic (≤2 cm), or a combina-tion. They are most commonly found in the head and neck, particularly on the neck, and on physical examination they are soft and doughy with normal overlying skin. Infrahyoid lesions tend to be macrocystic, well circumscribed, and discrete and can be totally excised, whereas suprahyoid lesions are typically microcystic, infiltrative, and excision is usually incomplete. On MRI, the best imaging modality for this malformation, a sep-tated mass with low-intensity signal on T1 and high-intensity signal on T2 is noted. They grow slowly with the patient but can have a sudden increase in size with hemorrhage or infection. Rarely, they
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Surgery_Schwartz. and nonpulsatile. If they are superficial, they will increase in size with Valsalva or dependent positioning. They can grow suddenly with trauma or in association with hormonal changes. Lymphatic malformations typically present at birth with the majority (90%) being identified by 2 years of age. They can be macrocystic (>2 cm), microcystic (≤2 cm), or a combina-tion. They are most commonly found in the head and neck, particularly on the neck, and on physical examination they are soft and doughy with normal overlying skin. Infrahyoid lesions tend to be macrocystic, well circumscribed, and discrete and can be totally excised, whereas suprahyoid lesions are typically microcystic, infiltrative, and excision is usually incomplete. On MRI, the best imaging modality for this malformation, a sep-tated mass with low-intensity signal on T1 and high-intensity signal on T2 is noted. They grow slowly with the patient but can have a sudden increase in size with hemorrhage or infection. Rarely, they
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mass with low-intensity signal on T1 and high-intensity signal on T2 is noted. They grow slowly with the patient but can have a sudden increase in size with hemorrhage or infection. Rarely, they cause airway compromise, feeding difficulties, and failure to thrive.Treatment of vascular malformations is based on depth, size, and growth pattern. Capillary malformations are typically treated with the pulsed dye laser (585 nm). Venous lesions can be treated with the KTP laser (532 nm) or the Nd:YAG laser (1064 nm), sclerotherapy, and, in select cases, complete surgi-cal excision is possible. Arteriovenous malformations are rare but typically require surgical excision with negative margins often after embolization. Lymphatic malformations are typically treated at least in part with surgical excision, although this is less successful for microcystic lesions. OK-432 is lyophilized low virulence S pyogenes cultured in penicillin. It is used as a sclerotherapy agent for lymphatic malformations
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Surgery_Schwartz. mass with low-intensity signal on T1 and high-intensity signal on T2 is noted. They grow slowly with the patient but can have a sudden increase in size with hemorrhage or infection. Rarely, they cause airway compromise, feeding difficulties, and failure to thrive.Treatment of vascular malformations is based on depth, size, and growth pattern. Capillary malformations are typically treated with the pulsed dye laser (585 nm). Venous lesions can be treated with the KTP laser (532 nm) or the Nd:YAG laser (1064 nm), sclerotherapy, and, in select cases, complete surgi-cal excision is possible. Arteriovenous malformations are rare but typically require surgical excision with negative margins often after embolization. Lymphatic malformations are typically treated at least in part with surgical excision, although this is less successful for microcystic lesions. OK-432 is lyophilized low virulence S pyogenes cultured in penicillin. It is used as a sclerotherapy agent for lymphatic malformations
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although this is less successful for microcystic lesions. OK-432 is lyophilized low virulence S pyogenes cultured in penicillin. It is used as a sclerotherapy agent for lymphatic malformations and has a 94% response rate in macrocystic lesions, a 63% response rate in mixed macromicrocystic lesions, and no response in micro-cystic lesions.60TRAUMA OF THE HEAD AND NECKSoft TissueSoft tissue trauma of the head and neck is managed with the same general surgical principles as any other body subsite with a few particularities. Most lacerations can be closed primarily if there is not soft tissue loss; even some devitalized soft tis-sue should be preserved because of the excellent blood sup-ply to head and neck tissue that allows it to recover at a higher rate. Thus, minimal debridement is usually required. Thor-ough irrigation to remove foreign bodies and clean the tissue is required. This is followed by a careful layered closure. On the face, the deep layers are usually closed with a 3-0 or
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Surgery_Schwartz. although this is less successful for microcystic lesions. OK-432 is lyophilized low virulence S pyogenes cultured in penicillin. It is used as a sclerotherapy agent for lymphatic malformations and has a 94% response rate in macrocystic lesions, a 63% response rate in mixed macromicrocystic lesions, and no response in micro-cystic lesions.60TRAUMA OF THE HEAD AND NECKSoft TissueSoft tissue trauma of the head and neck is managed with the same general surgical principles as any other body subsite with a few particularities. Most lacerations can be closed primarily if there is not soft tissue loss; even some devitalized soft tis-sue should be preserved because of the excellent blood sup-ply to head and neck tissue that allows it to recover at a higher rate. Thus, minimal debridement is usually required. Thor-ough irrigation to remove foreign bodies and clean the tissue is required. This is followed by a careful layered closure. On the face, the deep layers are usually closed with a 3-0 or
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required. Thor-ough irrigation to remove foreign bodies and clean the tissue is required. This is followed by a careful layered closure. On the face, the deep layers are usually closed with a 3-0 or 4-0 Vicryl/Polysorb after a minimal amount of undermining, and interrupted 5-0 or 6-0 Prolene or Nylon is used for the skin. These sutures are removed at 5 days on the face. Antibiotics are reserved for through-and-through mucosal lacerations, con-taminated wounds, bite injuries, and when delayed closure is performed (>72 hours). The chosen antibiotic should cover S aureus. Patients are instructed to avoid sunlight because this can cause pigmentary abnormalities in the suture line as it heals and matures over the first year.Eyelid lacerations are closed in layers with careful reap-proximation of the orbicularis oculi as a separate layer. Another important layer to reapproximate separately is the gray line (con-junctival margin) so as to avoid height mismatch or lid notching. Lip injuries
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Surgery_Schwartz. required. Thor-ough irrigation to remove foreign bodies and clean the tissue is required. This is followed by a careful layered closure. On the face, the deep layers are usually closed with a 3-0 or 4-0 Vicryl/Polysorb after a minimal amount of undermining, and interrupted 5-0 or 6-0 Prolene or Nylon is used for the skin. These sutures are removed at 5 days on the face. Antibiotics are reserved for through-and-through mucosal lacerations, con-taminated wounds, bite injuries, and when delayed closure is performed (>72 hours). The chosen antibiotic should cover S aureus. Patients are instructed to avoid sunlight because this can cause pigmentary abnormalities in the suture line as it heals and matures over the first year.Eyelid lacerations are closed in layers with careful reap-proximation of the orbicularis oculi as a separate layer. Another important layer to reapproximate separately is the gray line (con-junctival margin) so as to avoid height mismatch or lid notching. Lip injuries
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of the orbicularis oculi as a separate layer. Another important layer to reapproximate separately is the gray line (con-junctival margin) so as to avoid height mismatch or lid notching. Lip injuries follow the same principle with a three-layer closure involving the orbicularis oris, which is the strength layer, fol-lowed by careful reapproximation of the vermillion border to avoid a step-deformity (Fig. 18-16). Of course, a mucosal layer closure may also be required for through-and-through defects. Rarely, locoregional flaps or grafts are required for closure when greater than one-fourth of the eyelid width or one-third of the lip width is missing. Auricular hematoma is managed with prompt incision and drainage followed by bolstering technique; anteriorly and posteriorly placed dental pledgets secured with through-and-through sutures. These are to remain in place for at least 4 days to prevent reaccumulation of the hematoma and to prevent a cauliflower ear deformity. Auricular
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Surgery_Schwartz. of the orbicularis oculi as a separate layer. Another important layer to reapproximate separately is the gray line (con-junctival margin) so as to avoid height mismatch or lid notching. Lip injuries follow the same principle with a three-layer closure involving the orbicularis oris, which is the strength layer, fol-lowed by careful reapproximation of the vermillion border to avoid a step-deformity (Fig. 18-16). Of course, a mucosal layer closure may also be required for through-and-through defects. Rarely, locoregional flaps or grafts are required for closure when greater than one-fourth of the eyelid width or one-third of the lip width is missing. Auricular hematoma is managed with prompt incision and drainage followed by bolstering technique; anteriorly and posteriorly placed dental pledgets secured with through-and-through sutures. These are to remain in place for at least 4 days to prevent reaccumulation of the hematoma and to prevent a cauliflower ear deformity. Auricular
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pledgets secured with through-and-through sutures. These are to remain in place for at least 4 days to prevent reaccumulation of the hematoma and to prevent a cauliflower ear deformity. Auricular lacerations are typically closed primarily with perichondrial sutures to preserve the precarious cartilage blood supply followed by a primary clo-sure of the skin, making sure to cover the cartilage to prevent chondritis. Given the rich vascular supply to the face and neck, many soft-tissue components that appear devitalized will indeed survive, and therefore minimal debridement of devitalized tissue is required.Facial lacerations resulting in facial nerve injury are not explored if they are anterior to a vertical line dropped from the lateral cantus as there is excellent collateral innervation in the anterior midface. Posterior to this line, the nerve should be repaired, primarily if possible, using 8-0 to 10-0 monofila-ment suture to approximate the epineurium under the operative
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Surgery_Schwartz. pledgets secured with through-and-through sutures. These are to remain in place for at least 4 days to prevent reaccumulation of the hematoma and to prevent a cauliflower ear deformity. Auricular lacerations are typically closed primarily with perichondrial sutures to preserve the precarious cartilage blood supply followed by a primary clo-sure of the skin, making sure to cover the cartilage to prevent chondritis. Given the rich vascular supply to the face and neck, many soft-tissue components that appear devitalized will indeed survive, and therefore minimal debridement of devitalized tissue is required.Facial lacerations resulting in facial nerve injury are not explored if they are anterior to a vertical line dropped from the lateral cantus as there is excellent collateral innervation in the anterior midface. Posterior to this line, the nerve should be repaired, primarily if possible, using 8-0 to 10-0 monofila-ment suture to approximate the epineurium under the operative
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in the anterior midface. Posterior to this line, the nerve should be repaired, primarily if possible, using 8-0 to 10-0 monofila-ment suture to approximate the epineurium under the operative Brunicardi_Ch18_p0613-p0660.indd 62701/03/19 5:23 PM 628SPECIFIC CONSIDERATIONSPART IImicroscope. If primary reapproximation is not possible due to a missing segment, cable nerve grafts can be performed using the sural nerve or the greater auricular nerve. If the buccal branch is injured, this raises suspicion regarding injury to the parotid duct, which lies along an imaginary line drawn from the tragus to the midline upper lip. The duct should be repaired over a 22-gauge stent or marsupialized into the oral cavity.Facial FracturesThe most common facial fracture involves the mandible. Fig. 18-17 demonstrates the most common sites of fracture, which include the condyle (36%), body (35%), and angle (20%). In most cases, more than one site is involved due to reciprocating forces. The vector
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Surgery_Schwartz. in the anterior midface. Posterior to this line, the nerve should be repaired, primarily if possible, using 8-0 to 10-0 monofila-ment suture to approximate the epineurium under the operative Brunicardi_Ch18_p0613-p0660.indd 62701/03/19 5:23 PM 628SPECIFIC CONSIDERATIONSPART IImicroscope. If primary reapproximation is not possible due to a missing segment, cable nerve grafts can be performed using the sural nerve or the greater auricular nerve. If the buccal branch is injured, this raises suspicion regarding injury to the parotid duct, which lies along an imaginary line drawn from the tragus to the midline upper lip. The duct should be repaired over a 22-gauge stent or marsupialized into the oral cavity.Facial FracturesThe most common facial fracture involves the mandible. Fig. 18-17 demonstrates the most common sites of fracture, which include the condyle (36%), body (35%), and angle (20%). In most cases, more than one site is involved due to reciprocating forces. The vector
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demonstrates the most common sites of fracture, which include the condyle (36%), body (35%), and angle (20%). In most cases, more than one site is involved due to reciprocating forces. The vector forces from the muscles of mastication, vertical from the masseter and horizontal from the pterygoid muscles, can cause a fracture to be favorable or unfavorable depending on the angle of the fracture line. After taking a history and performing a physical examination, imaging is performed in the form of a Panorex or a CT scan. Where closed reduction can be achieved, patients are placed in maxillomandibular fixation (MMF) with arch bars applied via circumdental wiring, and these are left in place for 4 to 6 weeks depending on patient factors and the fracture location. In elderly patients, this is kept in for 6 to 8 weeks. In children and patients with condylar fractures only 2 to 3 weeks is required, and this is important to prevent condylar ankylosis. During this time, patients are placed on
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Surgery_Schwartz. demonstrates the most common sites of fracture, which include the condyle (36%), body (35%), and angle (20%). In most cases, more than one site is involved due to reciprocating forces. The vector forces from the muscles of mastication, vertical from the masseter and horizontal from the pterygoid muscles, can cause a fracture to be favorable or unfavorable depending on the angle of the fracture line. After taking a history and performing a physical examination, imaging is performed in the form of a Panorex or a CT scan. Where closed reduction can be achieved, patients are placed in maxillomandibular fixation (MMF) with arch bars applied via circumdental wiring, and these are left in place for 4 to 6 weeks depending on patient factors and the fracture location. In elderly patients, this is kept in for 6 to 8 weeks. In children and patients with condylar fractures only 2 to 3 weeks is required, and this is important to prevent condylar ankylosis. During this time, patients are placed on
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in for 6 to 8 weeks. In children and patients with condylar fractures only 2 to 3 weeks is required, and this is important to prevent condylar ankylosis. During this time, patients are placed on a liquid diet and are provided with wire cutters in case of aspiration or airway emergency. Open reduction and fixation is indicated in patients with open, comminuted, displaced, or unfavorable fractures. In these patients, MMF is usually only temporary with a soft diet starting almost immediately in the postoperative setting. Because the MMF is temporary with rigid fixation, it is per-formed usually using the 4-point fixation technique, where the maxilla and mandible are held in occlusion by wires attached to intraoral cortical bone screws, with two screws above and below the occlusal line anteriorly. This is a benefit of open reduction and internal fixation because prolonged MMF is associated with gingival and dental disease, as well as with significant weight loss and malnutrition, during
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Surgery_Schwartz. in for 6 to 8 weeks. In children and patients with condylar fractures only 2 to 3 weeks is required, and this is important to prevent condylar ankylosis. During this time, patients are placed on a liquid diet and are provided with wire cutters in case of aspiration or airway emergency. Open reduction and fixation is indicated in patients with open, comminuted, displaced, or unfavorable fractures. In these patients, MMF is usually only temporary with a soft diet starting almost immediately in the postoperative setting. Because the MMF is temporary with rigid fixation, it is per-formed usually using the 4-point fixation technique, where the maxilla and mandible are held in occlusion by wires attached to intraoral cortical bone screws, with two screws above and below the occlusal line anteriorly. This is a benefit of open reduction and internal fixation because prolonged MMF is associated with gingival and dental disease, as well as with significant weight loss and malnutrition, during
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This is a benefit of open reduction and internal fixation because prolonged MMF is associated with gingival and dental disease, as well as with significant weight loss and malnutrition, during the fixation period. After fixation, the fracture is exposed, more commonly from a transcervical compared to a transoral approach. Care is made not to injure the marginal mandibular branch of the facial nerve during this exposure. A rigid, locking, load-bearing mandibular plate is used. In edentulous patients, determining the baseline occlusion is of less significance because dentures may be refashioned once healing is complete.Midface fractures are rarely isolated and include multiple subsites. However, isolated zygoma fractures are typically dis-placed inferior inferiorly and medially with disruption of the suture lines between the temporal, frontal, and maxillary bones and the zygoma. If multiple zygoma fractures are present or if the zygomatic arch is significantly displaced, a coronal
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Surgery_Schwartz. This is a benefit of open reduction and internal fixation because prolonged MMF is associated with gingival and dental disease, as well as with significant weight loss and malnutrition, during the fixation period. After fixation, the fracture is exposed, more commonly from a transcervical compared to a transoral approach. Care is made not to injure the marginal mandibular branch of the facial nerve during this exposure. A rigid, locking, load-bearing mandibular plate is used. In edentulous patients, determining the baseline occlusion is of less significance because dentures may be refashioned once healing is complete.Midface fractures are rarely isolated and include multiple subsites. However, isolated zygoma fractures are typically dis-placed inferior inferiorly and medially with disruption of the suture lines between the temporal, frontal, and maxillary bones and the zygoma. If multiple zygoma fractures are present or if the zygomatic arch is significantly displaced, a coronal
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of the suture lines between the temporal, frontal, and maxillary bones and the zygoma. If multiple zygoma fractures are present or if the zygomatic arch is significantly displaced, a coronal incision is required to perform the reduction and fixation. However, if it is an isolated depressed fracture, a Gilles reduction can be achieved inferiorly (transorally) or superiorly (along temporalis muscle). The pathophysiology of orbital blow-out fractures is (a) hydraulic from increased intraocular pressure or (b) buckling from direct bone conduction. This requires surgical intervention if there is a defect of >2 cm2 or >50% of the floor with herniation.61 A forced duction test, where the muscular attachment of the inferior oblique is grasped with forceps and manipulated to determine passive ocular mobility, is performed to ensure that there is not inferior rectus entrapment. If there is entrapment, this would also result in diploplia with upward gaze. Blowout fractures demonstrating
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Surgery_Schwartz. of the suture lines between the temporal, frontal, and maxillary bones and the zygoma. If multiple zygoma fractures are present or if the zygomatic arch is significantly displaced, a coronal incision is required to perform the reduction and fixation. However, if it is an isolated depressed fracture, a Gilles reduction can be achieved inferiorly (transorally) or superiorly (along temporalis muscle). The pathophysiology of orbital blow-out fractures is (a) hydraulic from increased intraocular pressure or (b) buckling from direct bone conduction. This requires surgical intervention if there is a defect of >2 cm2 or >50% of the floor with herniation.61 A forced duction test, where the muscular attachment of the inferior oblique is grasped with forceps and manipulated to determine passive ocular mobility, is performed to ensure that there is not inferior rectus entrapment. If there is entrapment, this would also result in diploplia with upward gaze. Blowout fractures demonstrating
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ocular mobility, is performed to ensure that there is not inferior rectus entrapment. If there is entrapment, this would also result in diploplia with upward gaze. Blowout fractures demonstrating significant entrapment or enophthal-mos are treated by orbital exploration and reinforcement of the floor with titanium mesh, hydroxyapatite, or split calvarial bone grafts. Sometimes, the anterior maxillary bone that has been fractured and is accessed in the process of repairing other factures can also be used.62There are three classic patterns of more extensive mid-face fractures: Le Fort I, II, and III. However, fractures rarely follow this exact pattern, and the two sides of the face may have different Le Fort fractures. Nonetheless, a full under-standing of midface buttresses is central in understanding these fractures (Fig. 18-18). There are three vertical buttresses: the nasofrontal-maxillary, the frontozygomaticomaxillary, and Key stitchFigure 18-16. Approximation of the vermilion
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Surgery_Schwartz. ocular mobility, is performed to ensure that there is not inferior rectus entrapment. If there is entrapment, this would also result in diploplia with upward gaze. Blowout fractures demonstrating significant entrapment or enophthal-mos are treated by orbital exploration and reinforcement of the floor with titanium mesh, hydroxyapatite, or split calvarial bone grafts. Sometimes, the anterior maxillary bone that has been fractured and is accessed in the process of repairing other factures can also be used.62There are three classic patterns of more extensive mid-face fractures: Le Fort I, II, and III. However, fractures rarely follow this exact pattern, and the two sides of the face may have different Le Fort fractures. Nonetheless, a full under-standing of midface buttresses is central in understanding these fractures (Fig. 18-18). There are three vertical buttresses: the nasofrontal-maxillary, the frontozygomaticomaxillary, and Key stitchFigure 18-16. Approximation of the vermilion
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understanding these fractures (Fig. 18-18). There are three vertical buttresses: the nasofrontal-maxillary, the frontozygomaticomaxillary, and Key stitchFigure 18-16. Approximation of the vermilion border is the key step in the repair of lip lacerations.3%3%36%2%20%21%14%Figure 18-17. Sites of common mandible fractures.Brunicardi_Ch18_p0613-p0660.indd 62801/03/19 5:23 PM 629DISORDERS OF THE HEAD AND NECKCHAPTER 18pterygomaxillary. There are five horizontal buttresses: the fron-tal bone, nasal bones, upper alveolus, zygomatic arches, and the infraorbital region.63 Signs of midface fractures include subcon-junctival hemorrhage, ocular signs/symptoms, malocclusion, facial asymmetry, midface hypoesthesia (V2), hematoma, and a mobile maxillary complex. Transverse maxillary alveolus frac-tures above the teeth are Le Fort I fractures, which may result in a mobile hard palate. When this fracture extends superiorly to include the nasofrontal buttress, medial orbital wall, and even as
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Surgery_Schwartz. understanding these fractures (Fig. 18-18). There are three vertical buttresses: the nasofrontal-maxillary, the frontozygomaticomaxillary, and Key stitchFigure 18-16. Approximation of the vermilion border is the key step in the repair of lip lacerations.3%3%36%2%20%21%14%Figure 18-17. Sites of common mandible fractures.Brunicardi_Ch18_p0613-p0660.indd 62801/03/19 5:23 PM 629DISORDERS OF THE HEAD AND NECKCHAPTER 18pterygomaxillary. There are five horizontal buttresses: the fron-tal bone, nasal bones, upper alveolus, zygomatic arches, and the infraorbital region.63 Signs of midface fractures include subcon-junctival hemorrhage, ocular signs/symptoms, malocclusion, facial asymmetry, midface hypoesthesia (V2), hematoma, and a mobile maxillary complex. Transverse maxillary alveolus frac-tures above the teeth are Le Fort I fractures, which may result in a mobile hard palate. When this fracture extends superiorly to include the nasofrontal buttress, medial orbital wall, and even as
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above the teeth are Le Fort I fractures, which may result in a mobile hard palate. When this fracture extends superiorly to include the nasofrontal buttress, medial orbital wall, and even as high as the infraorbital rim and zygomaticomaxillary articula-tion laterally, it is considered a Le Fort II. Mobility includes the palate, nasal dorsum, which is separated from the upper face, and the inferomedial aspect of the orbital rim. When the frac-ture disrupts the frontozygomaticomaxillary, frontomaxillary, and frontonasal suture line, there craniofacial disjunction, a Le Fort III fracture. Of note, all of the Le Fort fractures involve the pterygoid plates posteriorly (Fig. 18-19).Temporal Bone FracturesTemporal bone fractures occur in approximately one fifth of skull fractures. Temporal bone fractures were previously clas-sified as longitudinal or transverse describing the path along the temporal bone of the fracture line, but this has been largely replaced by the more relevant otic
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Surgery_Schwartz. above the teeth are Le Fort I fractures, which may result in a mobile hard palate. When this fracture extends superiorly to include the nasofrontal buttress, medial orbital wall, and even as high as the infraorbital rim and zygomaticomaxillary articula-tion laterally, it is considered a Le Fort II. Mobility includes the palate, nasal dorsum, which is separated from the upper face, and the inferomedial aspect of the orbital rim. When the frac-ture disrupts the frontozygomaticomaxillary, frontomaxillary, and frontonasal suture line, there craniofacial disjunction, a Le Fort III fracture. Of note, all of the Le Fort fractures involve the pterygoid plates posteriorly (Fig. 18-19).Temporal Bone FracturesTemporal bone fractures occur in approximately one fifth of skull fractures. Temporal bone fractures were previously clas-sified as longitudinal or transverse describing the path along the temporal bone of the fracture line, but this has been largely replaced by the more relevant otic
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bone fractures were previously clas-sified as longitudinal or transverse describing the path along the temporal bone of the fracture line, but this has been largely replaced by the more relevant otic capsule sparing or involv-ing classification given that most fractures are oblique.64 Otic capsule sparing fractures present with conductive hearing loss, ossicular injury, bloody otorrhea, and labyrinthine concussion.65 The facial nerve is rarely injured nor cerebrospinal fluid (CSF) leak common with this fracture pattern. However, in patients with otic capsule involving temporal bone fractures, typically caused by occipitomastoid impact, sensorineural hearing loss, vestibular dysfunction, facial nerve paralysis, and CSF leak are far more common.65 Regardless of the fracture pattern, when CSF leak is suspected, it usually resolves with conservative measures including bed rest, elevation of the head of the bed, stool softeners, and avoiding sneezing or straining. In some cases, a CSF
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Surgery_Schwartz. bone fractures were previously clas-sified as longitudinal or transverse describing the path along the temporal bone of the fracture line, but this has been largely replaced by the more relevant otic capsule sparing or involv-ing classification given that most fractures are oblique.64 Otic capsule sparing fractures present with conductive hearing loss, ossicular injury, bloody otorrhea, and labyrinthine concussion.65 The facial nerve is rarely injured nor cerebrospinal fluid (CSF) leak common with this fracture pattern. However, in patients with otic capsule involving temporal bone fractures, typically caused by occipitomastoid impact, sensorineural hearing loss, vestibular dysfunction, facial nerve paralysis, and CSF leak are far more common.65 Regardless of the fracture pattern, when CSF leak is suspected, it usually resolves with conservative measures including bed rest, elevation of the head of the bed, stool softeners, and avoiding sneezing or straining. In some cases, a CSF
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CSF leak is suspected, it usually resolves with conservative measures including bed rest, elevation of the head of the bed, stool softeners, and avoiding sneezing or straining. In some cases, a CSF drain can be placed if there is a delay in spontane-ous resolution. Rarely will surgical repair be required. Unlike CSF leaks with temporal bone fractures, the facial nerve needs to be assessed and managed urgently. An incomplete or delayed facial nerve paralysis almost always resolves spontaneously with conservative measures, including oral steroids. An imme-diate complete paralysis that does not recover within 1 week should be prognosticated to consider nerve decompression. Electroneurography (ENoG), EMG, and nerve stimulation tests have been used to help determine which patients with delayed-onset complete paralysis will benefit from surgical decompres-sion. The finding of >90% degeneration more than 72 hours after the onset of complete paralysis is considered an indica-tion for
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Surgery_Schwartz. CSF leak is suspected, it usually resolves with conservative measures including bed rest, elevation of the head of the bed, stool softeners, and avoiding sneezing or straining. In some cases, a CSF drain can be placed if there is a delay in spontane-ous resolution. Rarely will surgical repair be required. Unlike CSF leaks with temporal bone fractures, the facial nerve needs to be assessed and managed urgently. An incomplete or delayed facial nerve paralysis almost always resolves spontaneously with conservative measures, including oral steroids. An imme-diate complete paralysis that does not recover within 1 week should be prognosticated to consider nerve decompression. Electroneurography (ENoG), EMG, and nerve stimulation tests have been used to help determine which patients with delayed-onset complete paralysis will benefit from surgical decompres-sion. The finding of >90% degeneration more than 72 hours after the onset of complete paralysis is considered an indica-tion for
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delayed-onset complete paralysis will benefit from surgical decompres-sion. The finding of >90% degeneration more than 72 hours after the onset of complete paralysis is considered an indica-tion for surgery.66 A nerve excitability test, where thresholds are increased to elicit visible muscle contraction on each side, can indicate advanced degeneration when there is a difference of >3.0 to 3.5 mA between sides. Whether surgical intervention is indicated or not for facial nerve paresis, it is crucial to pro-tect the eye because a corneal drying and abrasion can lead to blindness in the abscess of eye closure and a blink reflex. This requires application of ocular lubricant at night with the eye taped shut, frequent artificial tears application while awake, and a humidity chapter.67TUMORS OF THE HEAD AND NECKSquamous cell carcinoma (SCC) comprises >90% of all of the malignant pathology of the mucosal lining of the upper aerodi-gestive tract. Naturally, a discussion of tumors of the head
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Surgery_Schwartz. delayed-onset complete paralysis will benefit from surgical decompres-sion. The finding of >90% degeneration more than 72 hours after the onset of complete paralysis is considered an indica-tion for surgery.66 A nerve excitability test, where thresholds are increased to elicit visible muscle contraction on each side, can indicate advanced degeneration when there is a difference of >3.0 to 3.5 mA between sides. Whether surgical intervention is indicated or not for facial nerve paresis, it is crucial to pro-tect the eye because a corneal drying and abrasion can lead to blindness in the abscess of eye closure and a blink reflex. This requires application of ocular lubricant at night with the eye taped shut, frequent artificial tears application while awake, and a humidity chapter.67TUMORS OF THE HEAD AND NECKSquamous cell carcinoma (SCC) comprises >90% of all of the malignant pathology of the mucosal lining of the upper aerodi-gestive tract. Naturally, a discussion of tumors of the head
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THE HEAD AND NECKSquamous cell carcinoma (SCC) comprises >90% of all of the malignant pathology of the mucosal lining of the upper aerodi-gestive tract. Naturally, a discussion of tumors of the head and neck typically focuses on this pathology presenting from the lips and oral cavity to the larynx and hypopharynx. Management of these tumors requires a systematic approach.The ideal treatment protocol varies by subsite, stage, patient comorbidity, and center preference/experience. Given the relative rarity of these tumors, multidisciplinary management is of the utmost importance to provide the patient with a balanced perspective. This can be performed in the form of a multidisciplinary clinic where radiation and surgical oncologists simultaneously see the patient or through a tumor board where a new patient’s history, physical examination findings, imaging, and prior pathology Frontal barLateralzygomatico-maxillarybuttressesMedial nasomaxillary buttressesFigure 18-18. Major buttresses
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Surgery_Schwartz. THE HEAD AND NECKSquamous cell carcinoma (SCC) comprises >90% of all of the malignant pathology of the mucosal lining of the upper aerodi-gestive tract. Naturally, a discussion of tumors of the head and neck typically focuses on this pathology presenting from the lips and oral cavity to the larynx and hypopharynx. Management of these tumors requires a systematic approach.The ideal treatment protocol varies by subsite, stage, patient comorbidity, and center preference/experience. Given the relative rarity of these tumors, multidisciplinary management is of the utmost importance to provide the patient with a balanced perspective. This can be performed in the form of a multidisciplinary clinic where radiation and surgical oncologists simultaneously see the patient or through a tumor board where a new patient’s history, physical examination findings, imaging, and prior pathology Frontal barLateralzygomatico-maxillarybuttressesMedial nasomaxillary buttressesFigure 18-18. Major buttresses
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a new patient’s history, physical examination findings, imaging, and prior pathology Frontal barLateralzygomatico-maxillarybuttressesMedial nasomaxillary buttressesFigure 18-18. Major buttresses of the midface.IIIIIIFigure 18-19. Classic Le Fort fracture patterns.Brunicardi_Ch18_p0613-p0660.indd 62901/03/19 5:23 PM 630SPECIFIC CONSIDERATIONSPART IIspecimens are reviewed. This encourages discussion from multiple points of view concerning the most appropriate treatment options available. In addition to radiation and surgical oncology, medical oncology, dentistry, speech language pathologists, radiologists, and pathologists contribute to the decision-making in this patient population. Some of the greatest advances in head and neck oncology over the last several decades include the development of standardized organ preservation protocols, advances in free flap reconstruction with microvascular techniques, and vaccinations. The future of head and neck oncology is bright with advances
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Surgery_Schwartz. a new patient’s history, physical examination findings, imaging, and prior pathology Frontal barLateralzygomatico-maxillarybuttressesMedial nasomaxillary buttressesFigure 18-18. Major buttresses of the midface.IIIIIIFigure 18-19. Classic Le Fort fracture patterns.Brunicardi_Ch18_p0613-p0660.indd 62901/03/19 5:23 PM 630SPECIFIC CONSIDERATIONSPART IIspecimens are reviewed. This encourages discussion from multiple points of view concerning the most appropriate treatment options available. In addition to radiation and surgical oncology, medical oncology, dentistry, speech language pathologists, radiologists, and pathologists contribute to the decision-making in this patient population. Some of the greatest advances in head and neck oncology over the last several decades include the development of standardized organ preservation protocols, advances in free flap reconstruction with microvascular techniques, and vaccinations. The future of head and neck oncology is bright with advances
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of standardized organ preservation protocols, advances in free flap reconstruction with microvascular techniques, and vaccinations. The future of head and neck oncology is bright with advances in molecular biology, immunotherapy, and preventative methods with vaccination. These have the potential of significantly decreasing incidence rates and improving survival and quality of life for those with the disease.Etiology and EpidemiologyThe main etiological factors associated with head and neck cancers are tobacco products and alcohol. Overall, there has been a decline in incidence of head and neck cancers of the oral cavity and larynx/hypopharynx subsites,68 likely related to public health campaigns and government taxation policies as it relates to cigarette consumption.69 Similarly, the incidence of head and neck cancer between countries varies widely and is strongly associated with the incidence of cigarette smok-ing. Cigarette smoking triples the likelihood of developing an oral
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Surgery_Schwartz. of standardized organ preservation protocols, advances in free flap reconstruction with microvascular techniques, and vaccinations. The future of head and neck oncology is bright with advances in molecular biology, immunotherapy, and preventative methods with vaccination. These have the potential of significantly decreasing incidence rates and improving survival and quality of life for those with the disease.Etiology and EpidemiologyThe main etiological factors associated with head and neck cancers are tobacco products and alcohol. Overall, there has been a decline in incidence of head and neck cancers of the oral cavity and larynx/hypopharynx subsites,68 likely related to public health campaigns and government taxation policies as it relates to cigarette consumption.69 Similarly, the incidence of head and neck cancer between countries varies widely and is strongly associated with the incidence of cigarette smok-ing. Cigarette smoking triples the likelihood of developing an oral
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incidence of head and neck cancer between countries varies widely and is strongly associated with the incidence of cigarette smok-ing. Cigarette smoking triples the likelihood of developing an oral cavity cancer, while the addition of alcohol synergistically increases the likelihood by 10to 15-fold.70 The risk increases as the number of years smoking and number of cigarettes smoked per day increases. Individuals who both smoke (two packs per day) and drink (four units of alcohol per day) had a 35-fold increased risk for the development of a carcinoma compared to controls.71The preoperative and perioperative periods are excellent opportunities for head and neck oncologists to pursue a smok-ing cessation intervention. Continued smoking after completion of treatment is associated with a 3to 4-fold increased risk of developing a second primary or recurrent tumor.72-74 A study assessing patients diagnosed with a new head and neck cancer demonstrated that of the patients that were smoking
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Surgery_Schwartz. incidence of head and neck cancer between countries varies widely and is strongly associated with the incidence of cigarette smok-ing. Cigarette smoking triples the likelihood of developing an oral cavity cancer, while the addition of alcohol synergistically increases the likelihood by 10to 15-fold.70 The risk increases as the number of years smoking and number of cigarettes smoked per day increases. Individuals who both smoke (two packs per day) and drink (four units of alcohol per day) had a 35-fold increased risk for the development of a carcinoma compared to controls.71The preoperative and perioperative periods are excellent opportunities for head and neck oncologists to pursue a smok-ing cessation intervention. Continued smoking after completion of treatment is associated with a 3to 4-fold increased risk of developing a second primary or recurrent tumor.72-74 A study assessing patients diagnosed with a new head and neck cancer demonstrated that of the patients that were smoking
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4-fold increased risk of developing a second primary or recurrent tumor.72-74 A study assessing patients diagnosed with a new head and neck cancer demonstrated that of the patients that were smoking at diagno-sis, only 54% were able to quit, highlighting the difficulty this population has with smoking cessation.75Betel nut/quid chewing, which is a product of the areca catechu tree, is endemic to some parts of Asia and India, and in these regions oral cavity cancer is one of the most common can-cers.76,77 Betel nut when chewed acts as a mild stimulant similar to that of coffee but can be associated with submucous fibrosis that adds an additional challenge in the management of patients who present with a concurrent oral cavity cancer.77 These prod-ucts are associated with particular subsites secondary to direct contact (e.g., buccal mucosa) as well as subsites with depen-dent saliva drainage (e.g., floor of mouth, mandibular alveolus, and wet lip). Reverse smoking, where the lighted
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Surgery_Schwartz. 4-fold increased risk of developing a second primary or recurrent tumor.72-74 A study assessing patients diagnosed with a new head and neck cancer demonstrated that of the patients that were smoking at diagno-sis, only 54% were able to quit, highlighting the difficulty this population has with smoking cessation.75Betel nut/quid chewing, which is a product of the areca catechu tree, is endemic to some parts of Asia and India, and in these regions oral cavity cancer is one of the most common can-cers.76,77 Betel nut when chewed acts as a mild stimulant similar to that of coffee but can be associated with submucous fibrosis that adds an additional challenge in the management of patients who present with a concurrent oral cavity cancer.77 These prod-ucts are associated with particular subsites secondary to direct contact (e.g., buccal mucosa) as well as subsites with depen-dent saliva drainage (e.g., floor of mouth, mandibular alveolus, and wet lip). Reverse smoking, where the lighted
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secondary to direct contact (e.g., buccal mucosa) as well as subsites with depen-dent saliva drainage (e.g., floor of mouth, mandibular alveolus, and wet lip). Reverse smoking, where the lighted portion of the tobacco product is placed within the mouth during inhalation is also associated with oral cavity cancer, specifically hard palate carcinoma. The risk for this cancer is 47 times greater in patients that exhibit this behavior compared to nonsmokers.78In Europe and North America there has been an increas-ing interest in decriminalizing marijuana smoking. There is a strong correlation between this activity and head and neck can-cers (OR 2.5; 95% CI 1.1–6.6) when compared to nonusers.79 Furthermore, there is a dose-response relationship that is stron-ger in young patients (55 years of age or less). Ultraviolet light VermilionBuccal mucosaHard palateSoft palateRetromolar trigoneCircumvallate papillaeLower gingivaPalatine raphePalatine tonsilFigure 18-20. Oral cavity
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Surgery_Schwartz. secondary to direct contact (e.g., buccal mucosa) as well as subsites with depen-dent saliva drainage (e.g., floor of mouth, mandibular alveolus, and wet lip). Reverse smoking, where the lighted portion of the tobacco product is placed within the mouth during inhalation is also associated with oral cavity cancer, specifically hard palate carcinoma. The risk for this cancer is 47 times greater in patients that exhibit this behavior compared to nonsmokers.78In Europe and North America there has been an increas-ing interest in decriminalizing marijuana smoking. There is a strong correlation between this activity and head and neck can-cers (OR 2.5; 95% CI 1.1–6.6) when compared to nonusers.79 Furthermore, there is a dose-response relationship that is stron-ger in young patients (55 years of age or less). Ultraviolet light VermilionBuccal mucosaHard palateSoft palateRetromolar trigoneCircumvallate papillaeLower gingivaPalatine raphePalatine tonsilFigure 18-20. Oral cavity
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(55 years of age or less). Ultraviolet light VermilionBuccal mucosaHard palateSoft palateRetromolar trigoneCircumvallate papillaeLower gingivaPalatine raphePalatine tonsilFigure 18-20. Oral cavity landmarks.exposure is associated with cutaneous malignancies of the head and neck as well as lip cancer. The lower lip is at a higher risk due to its increased anterior-posterior projection, and the major-ity of squamous cell carcinomas of the lip arise along the ver-milion border of the lower lip. Immunocompromised patients, particularly those who have received solid organ and bone mar-row transplants are at an increased risk of head and neck can-cers.80 Similarly, HIV-infected patients have a higher incidence of head and neck cancers, and despite aggressive treatment have poorer results compared to HIV-negative patients.81,82 Other conditions associated with oral cancer include Plummer-Vinson syndrome (iron-deficiency anemia, dysphagia, glossitis, cheilo-sis, and esophageal webs),
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Surgery_Schwartz. (55 years of age or less). Ultraviolet light VermilionBuccal mucosaHard palateSoft palateRetromolar trigoneCircumvallate papillaeLower gingivaPalatine raphePalatine tonsilFigure 18-20. Oral cavity landmarks.exposure is associated with cutaneous malignancies of the head and neck as well as lip cancer. The lower lip is at a higher risk due to its increased anterior-posterior projection, and the major-ity of squamous cell carcinomas of the lip arise along the ver-milion border of the lower lip. Immunocompromised patients, particularly those who have received solid organ and bone mar-row transplants are at an increased risk of head and neck can-cers.80 Similarly, HIV-infected patients have a higher incidence of head and neck cancers, and despite aggressive treatment have poorer results compared to HIV-negative patients.81,82 Other conditions associated with oral cancer include Plummer-Vinson syndrome (iron-deficiency anemia, dysphagia, glossitis, cheilo-sis, and esophageal webs),
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compared to HIV-negative patients.81,82 Other conditions associated with oral cancer include Plummer-Vinson syndrome (iron-deficiency anemia, dysphagia, glossitis, cheilo-sis, and esophageal webs), dyskeratosis congenita,83,84 Bloom’s syndrome,85,86 and Fanconi anemia.87HPV is a double stranded DNA virus that is transmitted through sexual contact. Over the last two decades, this virus, specifically the 16 and 18 subtypes,88 has been associated with an epidemic rise in oropharyngeal squamous cell carcinoma.89,90 The p16 protein is a surrogate for HPV positivity. HPV status in oropharynx cancer has prognostic and therefore treatment-related implications.91,92Anatomy and HistopathologyThe upper aerodigestive tract is divided into several distinct sites that include the oral cavity, pharynx, larynx, and nasal cav-ity/paranasal sinuses. Each of these sites has separate subsites as alluded to earlier with specific etiological, pathological, prog-nostic, and treatment-related peculiarities.
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Surgery_Schwartz. compared to HIV-negative patients.81,82 Other conditions associated with oral cancer include Plummer-Vinson syndrome (iron-deficiency anemia, dysphagia, glossitis, cheilo-sis, and esophageal webs), dyskeratosis congenita,83,84 Bloom’s syndrome,85,86 and Fanconi anemia.87HPV is a double stranded DNA virus that is transmitted through sexual contact. Over the last two decades, this virus, specifically the 16 and 18 subtypes,88 has been associated with an epidemic rise in oropharyngeal squamous cell carcinoma.89,90 The p16 protein is a surrogate for HPV positivity. HPV status in oropharynx cancer has prognostic and therefore treatment-related implications.91,92Anatomy and HistopathologyThe upper aerodigestive tract is divided into several distinct sites that include the oral cavity, pharynx, larynx, and nasal cav-ity/paranasal sinuses. Each of these sites has separate subsites as alluded to earlier with specific etiological, pathological, prog-nostic, and treatment-related peculiarities.
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larynx, and nasal cav-ity/paranasal sinuses. Each of these sites has separate subsites as alluded to earlier with specific etiological, pathological, prog-nostic, and treatment-related peculiarities. Locoregional tumor spread is determined by weaknesses in the framework, fascial planes, and the course of neurovascular and lymphatic channels.The oral cavity extends from the vermilion border of the lip to the hard-palate/soft-palate junction superiorly, to circumval-late papillae inferiorly, and to the anterior tonsillar pillars later-ally. It is divided into eight subsites including the (a) mucosal lip, (b) the mandibular alveolus, (c) floor of mouth, (d) tongue (ante-rior two-thirds), (e) buccal mucosa, (f) retromolar trigone, (g) maxillary alveolus, and (e) hard palate (Fig. 18-20). Advanced oral cavity cancer can present with mandibular and/or maxillary invasion requiring resection, at least in part, of these structures. Oral cavity cancers typically metastasize to the submental,
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Surgery_Schwartz. larynx, and nasal cav-ity/paranasal sinuses. Each of these sites has separate subsites as alluded to earlier with specific etiological, pathological, prog-nostic, and treatment-related peculiarities. Locoregional tumor spread is determined by weaknesses in the framework, fascial planes, and the course of neurovascular and lymphatic channels.The oral cavity extends from the vermilion border of the lip to the hard-palate/soft-palate junction superiorly, to circumval-late papillae inferiorly, and to the anterior tonsillar pillars later-ally. It is divided into eight subsites including the (a) mucosal lip, (b) the mandibular alveolus, (c) floor of mouth, (d) tongue (ante-rior two-thirds), (e) buccal mucosa, (f) retromolar trigone, (g) maxillary alveolus, and (e) hard palate (Fig. 18-20). Advanced oral cavity cancer can present with mandibular and/or maxillary invasion requiring resection, at least in part, of these structures. Oral cavity cancers typically metastasize to the submental,
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Surgery_Schwartz_4293
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oral cavity cancer can present with mandibular and/or maxillary invasion requiring resection, at least in part, of these structures. Oral cavity cancers typically metastasize to the submental, sub-mandibular, and upper jugular lymph nodes (levels I-III).Brunicardi_Ch18_p0613-p0660.indd 63001/03/19 5:23 PM 631DISORDERS OF THE HEAD AND NECKCHAPTER 18The pharynx is divided into three regions: nasopharynx, oropharynx, and hypopharynx (Fig. 18-21). The nasopharynx extends from the posterior nasal septum and choana to the skull base and includes the fossa of Rosenmüller and torus tubarius of the Eustachian tubes laterally. The inferior margin of the nasopharynx is the superior surface of the soft palate. In adults, the adenoids are typically absent secondary to invo-lution during late adolescence, but these can be seen in some adults in the posterior aspect of this subsite. Isolated posterior triangle (level V) lymphadenopathy in an adult should be con-sidered nasopharyngeal carcinoma
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Surgery_Schwartz. oral cavity cancer can present with mandibular and/or maxillary invasion requiring resection, at least in part, of these structures. Oral cavity cancers typically metastasize to the submental, sub-mandibular, and upper jugular lymph nodes (levels I-III).Brunicardi_Ch18_p0613-p0660.indd 63001/03/19 5:23 PM 631DISORDERS OF THE HEAD AND NECKCHAPTER 18The pharynx is divided into three regions: nasopharynx, oropharynx, and hypopharynx (Fig. 18-21). The nasopharynx extends from the posterior nasal septum and choana to the skull base and includes the fossa of Rosenmüller and torus tubarius of the Eustachian tubes laterally. The inferior margin of the nasopharynx is the superior surface of the soft palate. In adults, the adenoids are typically absent secondary to invo-lution during late adolescence, but these can be seen in some adults in the posterior aspect of this subsite. Isolated posterior triangle (level V) lymphadenopathy in an adult should be con-sidered nasopharyngeal carcinoma
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Surgery_Schwartz_4294
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but these can be seen in some adults in the posterior aspect of this subsite. Isolated posterior triangle (level V) lymphadenopathy in an adult should be con-sidered nasopharyngeal carcinoma (NPC) until proven other-wise. Due to its midline location, bilateral regional metastatic spread is common in nasopharyngeal carcinoma. Given the epi-demic rise oropharyngeal cancers, isolated level V adenopathy in an adult may also represent oropharyngeal cancer, although cancers at this site typically drain to the upper and lower cervi-cal nodes (levels II–IV) as well as the retropharyngeal nodes. The oropharynx has a number of subsites including the tonsillar region, base of tongue, soft palate, and posterolateral pharyn-geal walls. The hypopharynx extends from the vallecula to the lower border of the cricoid posterior and lateral the larynx. It includes several subsites as well including the pyriform fossa, the postcricoid space, and the posterior pharyngeal wall. Lym-phatic drainage is to the
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Surgery_Schwartz. but these can be seen in some adults in the posterior aspect of this subsite. Isolated posterior triangle (level V) lymphadenopathy in an adult should be con-sidered nasopharyngeal carcinoma (NPC) until proven other-wise. Due to its midline location, bilateral regional metastatic spread is common in nasopharyngeal carcinoma. Given the epi-demic rise oropharyngeal cancers, isolated level V adenopathy in an adult may also represent oropharyngeal cancer, although cancers at this site typically drain to the upper and lower cervi-cal nodes (levels II–IV) as well as the retropharyngeal nodes. The oropharynx has a number of subsites including the tonsillar region, base of tongue, soft palate, and posterolateral pharyn-geal walls. The hypopharynx extends from the vallecula to the lower border of the cricoid posterior and lateral the larynx. It includes several subsites as well including the pyriform fossa, the postcricoid space, and the posterior pharyngeal wall. Lym-phatic drainage is to the
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cricoid posterior and lateral the larynx. It includes several subsites as well including the pyriform fossa, the postcricoid space, and the posterior pharyngeal wall. Lym-phatic drainage is to the mid and lower cervical nodes (levels III–IV); however, usually the upper cervical nodes (level II) are addressed at the same time for tumors at this site.The larynx is divided into three regions: the supraglottis, glottis, and subglottis (Fig. 18-22). The supraglottis includes sev-eral subsites: the epiglottis, false vocal cords, medial surface of the aryepiglottic folds, and the upper half of the laryngeal ventri-cles. The glottic larynx includes the true vocal cords, the anterior and posterior commissure, and the lower half of the laryngeal ventricles. The subglottis extends from below the true vocal SoftpalateHardpalateUvulaNasopharynxOropharynxLaryngopharynxPalatinetonsilsLingualtonsilsEpiglottisOesophagusTracheaLarynxHyoid boneFigure 18-21. Sagittal view of the head and neck
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Surgery_Schwartz. cricoid posterior and lateral the larynx. It includes several subsites as well including the pyriform fossa, the postcricoid space, and the posterior pharyngeal wall. Lym-phatic drainage is to the mid and lower cervical nodes (levels III–IV); however, usually the upper cervical nodes (level II) are addressed at the same time for tumors at this site.The larynx is divided into three regions: the supraglottis, glottis, and subglottis (Fig. 18-22). The supraglottis includes sev-eral subsites: the epiglottis, false vocal cords, medial surface of the aryepiglottic folds, and the upper half of the laryngeal ventri-cles. The glottic larynx includes the true vocal cords, the anterior and posterior commissure, and the lower half of the laryngeal ventricles. The subglottis extends from below the true vocal SoftpalateHardpalateUvulaNasopharynxOropharynxLaryngopharynxPalatinetonsilsLingualtonsilsEpiglottisOesophagusTracheaLarynxHyoid boneFigure 18-21. Sagittal view of the head and neck
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the true vocal SoftpalateHardpalateUvulaNasopharynxOropharynxLaryngopharynxPalatinetonsilsLingualtonsilsEpiglottisOesophagusTracheaLarynxHyoid boneFigure 18-21. Sagittal view of the head and neck demonstrating the distinction between the nasopharynx, oropharynx and larynx/hypopharynx including the boundaries of each.SupraglottisGlottisHyoid boneLarynxSubglottisCricoidcartilageArytenoidcartilageFalse cordVocal cordPre-epiglotticspaceThyroid cartilageVentricle of MorganiFigure 18-22. Sagittal view of the larynx with the divisions of the supraglottis, glottis, and subglottis demonstrated.cords to the superior cricoid border from within. The supraglottis has a high rate of bilateral metastatic spread secondary to its rich lymphatic drainage, whereas isolated glottic cancers rarely have lymphatic spread. Laryngeal cancers, in addition to having the propensity for lymphatic spread, particularly in advanced cases, can have preepiglottic and paraglottic invasion as well as inva-sion of the
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Surgery_Schwartz. the true vocal SoftpalateHardpalateUvulaNasopharynxOropharynxLaryngopharynxPalatinetonsilsLingualtonsilsEpiglottisOesophagusTracheaLarynxHyoid boneFigure 18-21. Sagittal view of the head and neck demonstrating the distinction between the nasopharynx, oropharynx and larynx/hypopharynx including the boundaries of each.SupraglottisGlottisHyoid boneLarynxSubglottisCricoidcartilageArytenoidcartilageFalse cordVocal cordPre-epiglotticspaceThyroid cartilageVentricle of MorganiFigure 18-22. Sagittal view of the larynx with the divisions of the supraglottis, glottis, and subglottis demonstrated.cords to the superior cricoid border from within. The supraglottis has a high rate of bilateral metastatic spread secondary to its rich lymphatic drainage, whereas isolated glottic cancers rarely have lymphatic spread. Laryngeal cancers, in addition to having the propensity for lymphatic spread, particularly in advanced cases, can have preepiglottic and paraglottic invasion as well as inva-sion of the
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Surgery_Schwartz_4297
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spread. Laryngeal cancers, in addition to having the propensity for lymphatic spread, particularly in advanced cases, can have preepiglottic and paraglottic invasion as well as inva-sion of the laryngeal framework (thyroid and cricoid cartilage). Furthermore, glottic and subglottic lesions, in addition to poten-tial spread to the upper and lower cervical nodes (levels II–IV), have the propensity for spread to the central neck (level VI) in the paralaryngeal and paratracheal region.Second Primary Tumors in the Head and NeckPatients with head and neck squamous cell carcinoma (HNSCC) are at increased risk for the development of a second primary malignancy (SPM), which is defined as a second malignancy that presents either simultaneously or after the diagnosis of an index tumor. A synchronous SPM is diagnosed simultaneously or within 6 months of the index tumor, while a metachronous SPM is diagnosed >6 months after the index tumor. SPMs need to be distinguished from local recurrences or
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Surgery_Schwartz. spread. Laryngeal cancers, in addition to having the propensity for lymphatic spread, particularly in advanced cases, can have preepiglottic and paraglottic invasion as well as inva-sion of the laryngeal framework (thyroid and cricoid cartilage). Furthermore, glottic and subglottic lesions, in addition to poten-tial spread to the upper and lower cervical nodes (levels II–IV), have the propensity for spread to the central neck (level VI) in the paralaryngeal and paratracheal region.Second Primary Tumors in the Head and NeckPatients with head and neck squamous cell carcinoma (HNSCC) are at increased risk for the development of a second primary malignancy (SPM), which is defined as a second malignancy that presents either simultaneously or after the diagnosis of an index tumor. A synchronous SPM is diagnosed simultaneously or within 6 months of the index tumor, while a metachronous SPM is diagnosed >6 months after the index tumor. SPMs need to be distinguished from local recurrences or
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Surgery_Schwartz_4298
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Surgery_Schwartz
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SPM is diagnosed simultaneously or within 6 months of the index tumor, while a metachronous SPM is diagnosed >6 months after the index tumor. SPMs need to be distinguished from local recurrences or metastasis of the primary tumor. The incidence of SPM ranges from 2% to 7% per year,93-95 and this risk remains constant from the time of initial diagnosis throughout the lifetime of the patient.93 Sec-ond primary malignancies represent the second leading cause of death in patients with HNSCC.96 One-quarter to one-third of deaths in these patients are attributable to SPM,96-98 highlight-ing the importance of SPM in the successful management of HNSCC.The classic criteria for defining second primary malig-nancy (SPM) were proposed by Warren and Gates and are: (a) histologic confirmation of malignancy in both the index and secondary tumors; (b) two malignancies that are anatomically Brunicardi_Ch18_p0613-p0660.indd 63101/03/19 5:23 PM 632SPECIFIC CONSIDERATIONSPART IIseparated by normal
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Surgery_Schwartz. SPM is diagnosed simultaneously or within 6 months of the index tumor, while a metachronous SPM is diagnosed >6 months after the index tumor. SPMs need to be distinguished from local recurrences or metastasis of the primary tumor. The incidence of SPM ranges from 2% to 7% per year,93-95 and this risk remains constant from the time of initial diagnosis throughout the lifetime of the patient.93 Sec-ond primary malignancies represent the second leading cause of death in patients with HNSCC.96 One-quarter to one-third of deaths in these patients are attributable to SPM,96-98 highlight-ing the importance of SPM in the successful management of HNSCC.The classic criteria for defining second primary malig-nancy (SPM) were proposed by Warren and Gates and are: (a) histologic confirmation of malignancy in both the index and secondary tumors; (b) two malignancies that are anatomically Brunicardi_Ch18_p0613-p0660.indd 63101/03/19 5:23 PM 632SPECIFIC CONSIDERATIONSPART IIseparated by normal
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in both the index and secondary tumors; (b) two malignancies that are anatomically Brunicardi_Ch18_p0613-p0660.indd 63101/03/19 5:23 PM 632SPECIFIC CONSIDERATIONSPART IIseparated by normal mucosa; and (c) the possibility of the SPM being a metastasis from the index tumor must be excluded. Most investigators use these criteria to define an SPM. However, dis-agreement exists regarding the application of the second and third criteria. For example, when both tumors appear in the same anatomic subsite, there is no agreement on the distance that should exist between the tumors, with some investigators favoring 1.5 cm99 and others requiring 2 cm.100 Furthermore, when the tumors occur in the same anatomic subsite, some investigators add that the SPM must present at least three years after the diagnosis of the index tumor,100 while others require that the SPM present at least five years after the index tumor.101 Others suggest that molecular analysis is required to classify a tumor as an
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Surgery_Schwartz. in both the index and secondary tumors; (b) two malignancies that are anatomically Brunicardi_Ch18_p0613-p0660.indd 63101/03/19 5:23 PM 632SPECIFIC CONSIDERATIONSPART IIseparated by normal mucosa; and (c) the possibility of the SPM being a metastasis from the index tumor must be excluded. Most investigators use these criteria to define an SPM. However, dis-agreement exists regarding the application of the second and third criteria. For example, when both tumors appear in the same anatomic subsite, there is no agreement on the distance that should exist between the tumors, with some investigators favoring 1.5 cm99 and others requiring 2 cm.100 Furthermore, when the tumors occur in the same anatomic subsite, some investigators add that the SPM must present at least three years after the diagnosis of the index tumor,100 while others require that the SPM present at least five years after the index tumor.101 Others suggest that molecular analysis is required to classify a tumor as an
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Surgery_Schwartz_4300
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diagnosis of the index tumor,100 while others require that the SPM present at least five years after the index tumor.101 Others suggest that molecular analysis is required to classify a tumor as an SPM.102Treatment of SPMs of the upper aerodigestive tract is site specific. In general, the SPM should be treated as a sep-arate entity, in the same manner as a primary index tumor at the anatomic subsite. In many cases, particularly in metachro-nous SPMs, patients have already received a full complement of treatment, including primary or adjuvant radiation and/or chemoradiation treatment. In these cases, surgical treatment of the SPM is often indicated when feasible. Reirradiation is an option in carefully selected cases when salvage surgery is not possible. Proper patient selection for reirradiation is criti-cal, and only patients with minimal comorbidity and toxicity of previous radiation treatment should be considered.103 Patients at high risk for local recurrence after salvage surgery
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Surgery_Schwartz. diagnosis of the index tumor,100 while others require that the SPM present at least five years after the index tumor.101 Others suggest that molecular analysis is required to classify a tumor as an SPM.102Treatment of SPMs of the upper aerodigestive tract is site specific. In general, the SPM should be treated as a sep-arate entity, in the same manner as a primary index tumor at the anatomic subsite. In many cases, particularly in metachro-nous SPMs, patients have already received a full complement of treatment, including primary or adjuvant radiation and/or chemoradiation treatment. In these cases, surgical treatment of the SPM is often indicated when feasible. Reirradiation is an option in carefully selected cases when salvage surgery is not possible. Proper patient selection for reirradiation is criti-cal, and only patients with minimal comorbidity and toxicity of previous radiation treatment should be considered.103 Patients at high risk for local recurrence after salvage surgery
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Surgery_Schwartz_4301
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is criti-cal, and only patients with minimal comorbidity and toxicity of previous radiation treatment should be considered.103 Patients at high risk for local recurrence after salvage surgery may benefit from increased locoregional control from adjuvant reirradiation, although there is no survival advantage compared with salvage surgery alone.103 Survival in patients with SPM depends upon the stage and location of the primary site of the SPM. Patients with SPM arising in the head and neck have significantly improved survival when compared with patients with SPM aris-ing in the lung and esophagus.104StagingStaging for upper aerodigestive tract malignancies is defined by the American Joint Committee on Cancer and follows the TNM (primary tumor, regional nodal metastases, distant metastasis) staging format which was recently updated in the 8th edition in 2017.105 The T stage for each subsite incorporates relevant anatomy; for instance, T3 lesions of the glottis are associated with vocal
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Surgery_Schwartz. is criti-cal, and only patients with minimal comorbidity and toxicity of previous radiation treatment should be considered.103 Patients at high risk for local recurrence after salvage surgery may benefit from increased locoregional control from adjuvant reirradiation, although there is no survival advantage compared with salvage surgery alone.103 Survival in patients with SPM depends upon the stage and location of the primary site of the SPM. Patients with SPM arising in the head and neck have significantly improved survival when compared with patients with SPM aris-ing in the lung and esophagus.104StagingStaging for upper aerodigestive tract malignancies is defined by the American Joint Committee on Cancer and follows the TNM (primary tumor, regional nodal metastases, distant metastasis) staging format which was recently updated in the 8th edition in 2017.105 The T stage for each subsite incorporates relevant anatomy; for instance, T3 lesions of the glottis are associated with vocal
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