Surgical Atlas of pediatric otolaryngology - part 6 ppt

fos-• Difficulty in relocating the duct posterior to the tonsillar fossa indicatesthat the anterior dissection of the submandibular duct off the adjacenttissues was not carried far enoug

420 Surgical Atlas of Pediatric Otolaryngology

Preparation

• A videotape of the nasopharynx during connected speech is viewedimmediately before the operation to determine the level of attemptedvelopharyngeal closure Anatomic landmarks are identified on the tapethat can be used to locate this level in the patient

• The patient is positioned on a shoulder roll to maintain hyperextension

of the neck

Procedure

• A mouth gag is inserted, and the patient is placed into suspension Theposterior pharyngeal wall is visualized and palpated to identify any sig-nificant vessels in the operative field

• Red rubber catheters are placed transnasally and brought out throughthe mouth to symmetrically retract the soft palate

• Landmarks identified on the videotape that localize the exact site ofnasopharyngeal escape are identified in the patient

• Proposed incision lines are infiltrated with 1% lidocaine with 1:100,000units epinephrine to affect vasoconstriction The incisions entail rectan-gular flaps encompassing each posterior tonsillar pillar A horizontalincision is made connecting the medial limbs of the incisions at the level

of velopharyngeal closure (Figure 18–9)

• The soft palate may be split in the midline to facilitate visualizationwithin the nasopharynx

• The mucosa is incised to the prevertebral fascia on the medial incisions.The palatopharyngeus muscle is incorporated into the flap Lateral dis-section is limited in the area of the tonsil

• After making the transverse incision at the level of velopharyngeal sure, the surrounding tissue is elevated superiorly to create a bed withinwhich the flaps may be inset Inferior dissection is avoided to preventinsetting the flaps below the level of velopharyngeal closure

clo-• The base of each flap is undermined superiorly and laterally to tively narrow the lateral velopharyngeal walls when the flaps are rotatedmedially

effec-• The donor sites are closed with interrupted 3-0 Vicryl sutures

• The inferior edge of each flap is medially rotated and sewn to the

later-al limit of the recipient horizontlater-al incision of the opposite side (Figure18–10) One flap will reside above the other

• If the palate was divided for improved exposure, it is closed in three ers Meticulous technique is necessary to minimize fistula formation

lay-Postoperative Care

• The patient is discharged after recovery from general anesthesia

• Perioperative oral antibiotics are prescribed for 1 week

• Postoperative neck pain is expected as the prevertebral fascia has beenirritated

Figure 18–11 Y-V advancement

flap to close a lateral port that is

excessively wide.

LATERAL PORT REVISION - NARROWING

The goal of the operation is to create local advancement flaps to narrow thelateral ports

Indication

• Continued VPI following placement of a pharyngeal flap through anincompetent lateral port

Anesthetic Considerations and Preparation

• General endotracheal anesthesia is required

• Preoperative nasopharyngoscopic evaluation during connected speechhas identified the lateral ports that require revision

• The patient is positioned on a shoulder roll to maintain hyperextension

of the neck

Procedure

• A mouth gag is inserted, and the patient is placed into suspension

• Red rubber catheters are placed transnasally and brought out throughthe mouth to retract the soft palate symmetrically

• The posterior and lateral mucosa of the lateral velopharyngeal port areinfiltrated with 1% lidocaine with 1:100,000 units epinephrine to affectvasoconstriction

• A Y-to-V advancement flap is created where the lateral margin of theport is advanced medially (Figure 18–11) The advancement is on theposterior lateral pharyngeal wall, extending into the nasopharynx, adja-cent to the pedicle of the flap

• Bilateral port procedures may be necessary

Velopharyngeal Insufficiency 423

Postoperative Care

• The patient is discharged after recovery from general anesthesia

• Perioperative oral antibiotics are prescribed for 1 week

• Patients return for a postoperative check at 3 weeks

• Speech therapy begins 1 month postoperatively

• A repeat office evaluation for objective resonance testing occurs at 3months Repeat nasopharyngoscopy is performed if continued hyper-nasality or nasal emission is detected

LATERAL PORT REVISION - ENLARGING

A local advancement flap is used to open and reline the stenotic lateral port

Indication

• Stenosis of the lateral port with obstructive respiration, hyponasality, orboth

Anesthetic Considerations and Preparation

• General endotracheal anesthesia is required

• Preoperative nasopharyngoscopic evaluation during connected speechhas identified the lateral ports that require revision

• The patient is positioned on a shoulder roll to maintain hyperextension

of the neck

Procedure

• A mouth gag is inserted, and the patient is placed into suspension

• An endotracheal tube is passed transnasally through the stenotic port

• A vertical incision of the soft palate in the midportion of the lateral port

is made to release the stenosis (Figure 18–12) Mucosa from the nasalsurface of the soft palate is advanced to cover the raw surface created bythe incision

• If the resulting size of the port is inadequate, multiple incisions can bemade to adequately open the ports

Postoperative Care

• The patient is discharged after recovery from general anesthesia

• Perioperative oral antibiotics are not generally required

• Patients return for a postoperative check at 3 weeks

• Speech therapy begins 1 month postoperatively

• A repeat office evaluation for objective resonance testing occurs at 3months Repeat nasopharyngoscopy is performed if continued hyper-nasality or nasal emission is detected

Figure 18–12 Enlargement of a

stenotic lateral port.

rea-Patients must have an objective evaluation 3-6 months following structive procedures to assess their nasal resonance Precise terminology isnecessary to judge outcome; “normal” is not the same as “acceptable.” Afamily’s satisfaction with the results of surgery does not equate to normal oracceptable resonance Without objective scrutiny of postoperative out-comes, improvement in surgical judgment cannot occur.

recon-Not all patients with continued hypernasality need revision surgery.Developmental delays, compensatory articulation errors, and underlyingsyndromes will affect speech outcomes Creating the structural elementsnecessary for velopharyngeal closure is the essential goal of surgery Collab-oration with speech pathologists is mandatory for maximal outcome

REFERENCES

1 Kummer AW, Curtis C, Wiggs M, et al Comparison of velopharyngeal gap size in patients withhypernasality, hypernasality and nasal emission, or nasal turbulence (rustle) as the primaryspeech characteristic Cleft Palate Craniofac J 1992;29:152–6

2 Croft C, Shprintzen R, Rakoff S Patterns of velopharyngeal valving in normal and cleft palatesubjects: a multi-view videofluoroscopic and nasendoscopic study Laryngoscope1981;91:265–71

3 Shprintzen R, Goldberg R, Lewin M, et al A new syndrome involving cleft palate, cardiacanomalies, typical facies, and learning disabilities: velo-cardio-facial syndrome Cleft Palate J1978;15:56–62

4 Hogan V A clarification of the surgical goals in cleft palate speech and the introduction of thelateral port control (l.p.c.) pharyngeal flap Cleft Palate J 1973;10:331–45

5 Gray SD, Pinborough-Zimmerman J, Catten M Posterior wall augmentation for treatment ofvelopharyngeal insufficiency Otolaryngol Head Neck Surg 1999;121:107–12

6 Smith J, McCabe B Teflon injection in the nasopharynx to improve velopharyngeal closure.Ann Otol Rhinol Laryngol 1977;86:559–63

7 Borgatti R, Tettamanti A, Piccinelli P Brain injury in a healthy child one year after

periureter-al injection of Teflon Pediatrics 1996;98:290–1

8 Jackson I, Silverton J The sphincter pharyngoplasty as a secondary procedure in cleft palates.Plast Reconst Surg 1977;59:518–24

par-SUBMANDIBULAR DUCT RELOCATION WITH SUBLINGUAL GLAND EXCISION

Indications

• Operation of choice1for chronic significant drooling in the cally impaired patient unresponsive to nonsurgical measures, such astherapy to improve oral-motor skills of the tongue, lips, and pharynx.2

• The anesthetic machine is towards the foot of the operating table and tothe left of the patient so that the surgical team has ample access to thepatient’s head

Preparation

• The patient is placed in a slight reverse Trendelenburg position A light is necessary for visualization The surgeon and the assistant sit atthe head of the operating table

head-• If a tonsillectomy has not been done previously, the tonsillar fossae areexamined and the tonsils are removed if they are filling the fossae

Figure 19–1 A, Creating an island of mucosa B, Identifying the left submandibular duct.

• Once both ducts have been found, they are freed of their attachments tothe adjoining tissues down to the anterior aspect of the submandibulargland by blunt dissection along the axis of the duct, utilizing large bluntscissors (Boyd)

♦ For this maneuver, appropriate retraction is crucial: the “anterior”retractor pulls laterally, holding the sublingual gland away from theduct, while the “posterior” retractor pushes the genioglossus musclemedially

♦ Usually, dissection is adequate if the ducts, when gently held, will

reach the vermillion border of the lower lip (Figure 19–2A).

• A 4-0 chromic catgut suture is attached to both lateral corners of themucosal island; the island is then sutured to the undersurface of thetongue to keep the ducts in view while the sublingual glands are excised

Surgery for Drooling 431

Figure 19–3 A, The anterior aspect of the sublingual gland is mobilized B, Sublingual gland is mobilized posteriorly.

Figure 19–4 A, Division of the mucous membrane close to the tongue B, Mobilization of the sublingual gland off the lingual nerve.

• Once the sublingual glands have been excised, the submandibular ductscan be relocated into the tonsillar fossae.

1 The mucosal island containing the submandibular papillae is freed offthe tongue and the suture holding the tip of the tongue is removed

2 The mucosal island is divided in the midline (Figure 19–5A).

3 Leaving the self-retaining retractor in place, the tongue is pulled ward and a Negus clamp is passed forward from the tonsillar fossainto the operative area, staying in the submucous space (Figure

for-19–5B).

4 The suture on the lateral edge of the mucosal island is grasped, andthe island with the duct is pulled into the tonsillar fossa

• Once both ducts have been pulled into the tonsillar fossae, a tonsil gag

is inserted The individual ducts are sutured to the posterior aspect ofthe anterior tonsillar pillar with a single mattress stitch using absorbablesuture (3-0 chromic catgut) At this point, the tonsillar fossae areinspected closely to ensure complete hemostasis

• The Boyle Davis gag is removed and the self-retaining retractor is inserted; the floor of mouth is examined closely to ensure completehemostasis

re-• The anterior incision is closed with five or six simple interrupted

stitch-es of absorbable suture material (4-0 chromic catgut)

Postoperative Care

• Airway obstruction requiring 24-48 hours of nasotracheal intubationmay (rarely) occur if swelling of the tongue is excessive This should beanticipated in patients with retrognathia who were difficult to intubate

• Good pain control is essential to make the patient comfortable and ageable during the first 24-48 hours after surgery Morphine intravenousdrip is utilized routinely

man-• Intravenous fluids are necessary for 24-48 hours postoperatively

• Prophylactic antibiotics are recommended

• Systemic steroids for 2 doses (immediately postoperative and 8 hourslater) are administered

• Antiemetic medications are used as required

• Parental (or other caregiver) involvement in nursing care is encouragedbecause management problems are frequent during the first 48 hours

434 Surgical Atlas of Pediatric Otolaryngology

• The anesthetic machine is at the foot of the operating table and to theleft of the patient so that the surgical team has ample access to thepatient’s head

Preparation

• The patient is placed in a slight reverse Trendelenburg position A light facilitates visualization The surgeon and the assistant sit at thehead of the operating table

head-• If a tonsillectomy has not been done previously, the tonsillar fossae areexamined and the tonsils are removed if they are filling the fossae

Procedure

• Exposure of the floor of the mouth is facilitated by inserting a pronged self-retaining retractor between the upper and lower dentition,and by suturing the tip of the tongue to the soft palate

two-• The floor of the mouth anterior and posterior to the submandibularpapillae is infiltrated with 5 mL of anesthetic agent containing1:200,000 epinephrine

• An island of mucosa 2 cm wide and 1 cm deep, encompassing the

sub-mandibular papillae, is created (see Figure 19–1A).

1 For the right-handed surgeon it is easiest to identify the left mandibular duct first; conversely, for the left-handed surgeon, itwould be the right submandibular duct

sub-2 The duct is identified by grasping the posterior edge of the islandwith forceps about 1 cm from the midline, and then “rolling” the tis-sue towards the lower dentition With a sharp scissors, the dissectionproceeds laterally from the midline, just underneath the edge of the

mucosal island (see Figure 19–1B).

3 The right duct (or the left duct for the left-handed surgeon) is foundwith lateral to medial scissors dissection keeping in mind the position

of the already displayed contralateral duct

• Once both ducts have been found, they are freed of their attachments tothe adjoining tissues down to the anterior aspect of the submandibulargland by blunt dissection along the axis of the duct, utilizing large bluntscissors (Boyd)

♦ For this maneuver, appropriate retraction is crucial: the “anterior”retractor pulls laterally, holding the sublingual gland away from theduct, while the “posterior” retractor pushes the genioglossus musclemedially

♦ Usually, dissection is adequate if the ducts, when gently held, will

reach the vermillion border of the lower lip (see Figure 19–2A).

• A 4-0 chromic catgut suture is attached to both lateral corners of themucosal island; the island is then sutured to the undersurface of thetongue to keep the ducts in view while the sublingual glands are excised

(see Figure 19–2B).

• With a towel clip in the lateral aspect of the tongue for countertraction,

a mucosal tunnel is created from the anterior aspect of the

sub-mandibular gland to the tonsillar fossa by pushing a Kelly clamp

through from the anterior incisional area (Figure 19–6A).

• The Kelly clamp is then used to pull a No 10 suction catheter from thetonsillar fossa into the anterior incisional area The sutures attached to

the mucosal islands are threaded through the catheters (Figure 19–6B),

and then pulled through the submucosal tunnels into the tonsillar sae A single mattress suture attaches the mucosal island to the posterioraspect of the anterior tonsillar pillar close to the base of the tongue

fos-• Difficulty in relocating the duct posterior to the tonsillar fossa indicatesthat the anterior dissection of the submandibular duct off the adjacenttissues was not carried far enough posteriorly

• The anterior incision is closed with five or six simple interrupted

stitch-es of absorbable suture material (4-0 chromic catgut)

Figure 19–6 A, Pulling a catheter into the anterior incisional area B, Threading of the suture through the catheter.

436 Surgical Atlas of Pediatric Otolaryngology

PAROTID DUCT LIGATION Indications

• Patients with chronic significant sialorrhea after submandibular ductrelocation, with or without sublingual gland excision

• Patients with chronic significant sialorrhea and limited access to the oralcavity (ie, temporal mandibular joint ankylosis), thus making it techni-cally impossible to complete submandibular duct relocation with orwithout sublingual gland excision

• Patients with chronic significant sialorrhea who are appropriate surgicalcandidates, but in whom aspiration is significant and of concern

• This procedure may be done in combination with submandibular ductligation

Trende-• The surgeon wears a headlight for visualization The operation is easier

if the surgeon stands to the side of the head opposite the duct havingsurgery (ie, on the left if the right side is being completed) The assistant

is positioned on the controlateral side

Procedure

• The parotid duct is located and cannulated with a lacrimal probe Withthe probe held in place, the soft tissues immediately anterior to the ductorifice are infiltrated with 2 to 3 mL of anesthetic agent containing1:200,000 epinephrine

• With the lacrimal probe held in place, an elliptical incision 1.5 cm in

length is made 0.5 cm anterior to the duct orifice (Figure 19–7A) This

incision should not be too far anterior to the duct orifice, or the ductwill be difficult to locate

• The duct quickly travels obliquely lateral and posterior to the gland;thus, dissection must be done close to the duct orifice until the duct(with the probe inside) is identified

• When the duct is identified, it is cleared of excessive soft tissue forapproximately 1 cm A Mixter clamp is inserted around the duct so that

the ligatures can be grasped and pulled into place (Figure 19–7B) Two

separate ligatures of nonabsorbable suture (3-0 Mersilene) are placedaround the duct (2 turns in each ligature)

• Buccal mucous membrane is closed with interrupted absorbable sutures

TYMPANIC NEURECTOMY Indications

• Chronic sialorrhea when risk of any intraoral procedure is significant

• Persistent sialorrhea following all intraoral procedures

• Tympanotomy is completed using an endomeatal flap (see Chapter 2)

• The chorda tympanic nerve, which contains the parasympathetic tomotor fibers to the submandibular gland, is divided upon entering themiddle-ear space

secre-• The parasympathetic fibers to the parotid gland are in the tympanicplexus located just anterior to the round window niche They are cov-ered in bone approximately 25% of the time

• Nerve fibers in the tympanic plexus are interrupted using an instrumentsuch as the Rosen needle About 2-3 mm of the nerve are removed

• The endomeatal flap is repositioned and held in place with pieces ofGelfoam

• The contralateral ear is now completed in a similar fashion

• Chronic sialorrhea with significant aspiration

• Submandibular duct ligation is usually combined with parotid duct ation.3

Surgery for Drooling 439

Procedure

• Exposure of the floor of the mouth is facilitated by inserting a pronged self-retaining retractor between the upper and lower dentition,and by suturing the tip of the tongue to the soft palate

two-• The floor of the mouth anterior and posterior to the submandibularpapillae is infiltrated with 5 mL of anesthetic agent containing1:200,000 epinephrine

• A 2.5 cm mucosal incision is made approximately 1 cm posterior to the

orifices of the submandibular papillae (Figure 19–8A).

• The left submandibular duct is found first (see Figure 19–1B) by

grasp-ing the posterior edge of the island and by elevatgrasp-ing those tissues towardthe lower dentition The duct is then dissected with sharp scissors in alateral direction from the midline, just underneath the edge of themucosal island

• The right duct is then identified

• A Mixter clamp is passed around each duct in succession and used tograsp the nonabsorbable suture (Mersilene 3-0) used to ligate the ducts

(Figure 19–8B).

• The incision in the floor of mouth is closed with interrupted absorbablesutures

Figure 19–8 A, Location of incision posterior to the submandibular papillae B, Instrument around the submandibular duct to

grasp the nonabsorbable ligature.

CH A P T E R 20

Michael J Cunningham, MD

• Worrisome historical factors include (1) family history of childhood

can-cer, (2) previous primary neoplasm, (3) known predisposition to temic cancer, (4) previous radiation therapy, and (5) prior exposure tocarcinogenic or immunosuppressive drugs

sys-• Clinical findings suggesting a need for urgent biopsy include (1) rapid or

progressive growth, (2) fixation of the mass to the skin or deep neckstructures, (3) supraclavicular mass or adenopathy, and (4) firm neckmass in a child with weight loss or prolonged fever for whom a specificdiagnosis is uncertain

• Additional criteria for concern include (1) firm masses of any size in

neonates, (2) firm masses greater than or equal to 1 cm in children aged6-12 months, and (3) firm masses greater than or equal to 3 cm in diam-eter in children over 1 year of age

In the absence of the above findings, observation with serial ments over several weeks is a reasonable method of discriminating less wor-risome underlying pathology such as benign reactive lymphadenopathyfrom potential neoplastic disease processes Subsequent elective biopsy fordiagnostic confirmation is recommended if the mass in question progres-sively increases in size or fails to decrease in size by 4-6 weeks follow-up The child suspected of having a cervicofacial neoplasm based on theabove historical and clinical features requires a complete otolaryngologicand systemic examination Additional laboratory and imaging studies areperformed as indicated Computed tomography (CT) and magnetic reso-nance imaging (MRI) are the radiologic studies of choice; in specific clini-cal circumstances, radioisotope scans and angiographic procedures maysupply additional information

measure-Neck masses in children may be congenital, inflammatory, or neoplastic Although atric neck masses are rarely malignant, about 5-10% of primary malignancies originate inthe head and neck, and one of every four malignant lesions eventually manifest in thisregion A noninflammatory firm neck mass in a child should be considered of potentialneoplastic etiology until proven otherwise

pedi-Although, with few exceptions, the physical examination and

laborato-ry evaluation may suggest a diagnosis, biopsy is required for diagnostic firmation Biopsy can be performed in either percutaneous or open fashion.The choice between these two techniques is dictated by several factorsdescribed below

con-PERCUTANEOUS NEEDLE BIOPSY

Percutaneous needle biopsy may be used to evaluate cystic and solid hood cervicofacial masses A close working relationship between the sur-geon and pathologist is essential for success The principal role of percuta-neous needle biopsy as a diagnostic tool is to determine whether the mass

child-in question is benign or malignant An aspiration biopsy analyzed by anexperienced cytopathologist can also be highly accurate in predicting thespecific type of tumor

Sampling errors do occur, and a negative finding on a percutaneous dle biopsy should never be considered definitive when there is clinical sus-picion of malignancy A subsequent open surgical biopsy is necessary

• Needle biopsy of superficial lesions in older children and adolescents can

be performed under local anesthesia using topical lidocaine 2.5% andprilocaine 2.5% (EMLA) cream and/or injected 1 or 2% lidocaine with1:100,000 epinephrine solution

• General anesthesia is often necessary for infants and young children

• Concomitant endoscopic evaluation of the aerodigestive tract or biopsy

of deep cervical lesions may require general anesthesia regardless of age

2 The FNA technique uses much smaller 22- to 25-gauge needles from

11⁄2 to 31⁄2 inches in length, depending on the lesion depth (Figure

20–1C) An 18- to 20-gauge needle may be needed to aspirate cystic

lesions containing thick mucoid material

Figure 20–2 The patient is

posi-tioned so that the biopsy site is

easily accessible to the surgeon.

444 Surgical Atlas of Pediatric Otolaryngology

Procedure

• The child is positioned and draped with the proposed biopsy site

readi-ly available to the surgeon, and the surrounding anatomic landmarkseasily visualized (Figure 20–2)

• If only local anesthesia is planned, the topical anesthetic cream is placedover the skin in the region of the planned biopsy tract approximately 30minutes beforehand; in large bore cutting-needle biopsy, infiltration ofanesthetic solution into the skin and immediate subcutaneous tissues isalso recommended These steps are unnecessary with general anesthesia

• The biopsy site is identified:

♦ For superficial lesions, the mass is stabilized with the thumb and theindex finger of the opposite hand (Figure 20–3)

♦ For deep cervical lesions, either specific measurements for needlelocalization and depth placement should have been preoperativelycalculated from radiologic studies, or the biopsy should be performedunder radiologic guidance

No 1 Large bore cutting–needle biopsy

• A 1-2 mm skin incision is made with a No 11 scalpel blade prior toneedle insertion (Figure 20–4)

• The biopsy technique varies with the type of large-bore needle used;the TRU-Cut needle, for example, comes with its own specificinstructions

• In general, the needle is advanced into the mass using a smooth rapidmotion At least two passes are recommended; the second biopsy attemptshould be made through the same incision but at a different angle.

• The specimens obtained are expelled onto filter paper and placed intosaline, formalin fixative, or another special medium, depending onthe suspected pathology

• Pressure is applied to the biopsy site; a small compression dressingmay be necessary

No 2 Fine-needle aspiration

• No skin incision is necessary

• The needle chosen is attached to a 20 mL syringe holder A constantvacuum is applied while the needle is passed at least twice, at differ-ent angles, into the mass (Figure 20–5)

• The vacuum is then released slowly to avoid aspirating material intothe syringe The needle is withdrawn

• The syringe is separated from the needle, filled with air, and tached The material within the needle is then expelled onto glassslides, spread over a small area, and quickly air-dried Ideally, suchslides are passed immediately to the pathologist

reat-• In the absence of readily available pathology consultation, slides areimmediately fixed by placement in 95% alcohol solution Lymphnode aspirates should additionally be placed into saline or special cellculture media for flow cytometry and lymphocyte marker analysis

• Pressure is immediately applied to the biopsy site, followed by a tic adhesive bandage

plas-Complications

• The potential dissemination of malignancy from mechanical trauma is amajor concern in large bore cutting–needle biopsy This implantationproblem has theoretically been eliminated by the FNA technique

• Bleeding with hematoma formation is a potential complication, ularly for vascular masses or in patients with coagulopathies This risk isreduced with FNA

partic-• There are additional site-specific risks, such as pneumothorax whenbiopsying supraclavicular masses

448 Surgical Atlas of Pediatric Otolaryngology

CERVICAL LYMPH NODE BIOPSY

In adults, open surgical excisional or incisional biopsy is typically traindicated due to the high likelihood of a cervical mass representingmetastatic carcinoma Open biopsy is much more frequently performed inchildren and adolescents due to the relatively high incidence of reactivelymphadenopathy and benign neoplasms Excisional biopsy is favored;incisional biopsy is reserved for clinically unresectable lesions

• There is a clinical suspicion of malignancy despite a negative neous biopsy

percuta-• Excision is likely the definitive treatment of the cervical mass in tion

ques-Anesthetic Considerations and Preparation

• The procedure is performed under general anesthesia

• The need for intraoperative frozen section histopathologic assessment isdetermined before surgery Frozen section ensures that adequate tissuehas been obtained for permanent section diagnosis, but is not recom-mended to make a definitive intraoperative diagnosis

• Preoperative pathology consultation is also important in suspected phoma cases so that fresh tissue preparations can be made for cell cul-ture and lymphoma marker studies

lym-• Specific clinical situations may dictate preoperative oncology tion to coordinate additional studies (lumbar puncture, bone marrowbiopsy) while the child is anesthetized

• The skin, subcutaneous tissues, and platysma muscle are transecteddown to the level of the superficial layer of the deep cervical fascia (Fig-ure 20–7) Detailed knowledge of the regional anatomy is necessary toavoid neurovascular injury

• The mass is carefully delineated before removal (Figure 20–8) If ble, the entire mass or the largest of multiple masses should be removed

feasi-to maximize the chances of successful hisfeasi-topathologic diagnosis Frozensection examination is requested when appropriate Tissue specimens areobtained for microbiology and special stains if clinically indicated

• After irrigation and hemostasis, a rubber band or small Penrose drainmay be placed if extensive or deep dissection was required

• Closure is performed in two layers using interrupted absorbable suturesfor platysma muscle and subcutaneous tissue approximation, and eitherinterrupted or a single subcuticular nylon suture in the skin (Figure20–9)

• A pressure dressing is applied to complete the procedure

Par-to the facial nerve and spinal accessory nerve, respectively

452 Surgical Atlas of Pediatric Otolaryngology

FUNCTIONAL (MODIFIED) NECK DISSECTION

The lymph nodes of the neck are anatomically localized into six levels ure 20–10):

(Fig-• Level 1: Submental and submandibular group

• Level 2: Upper jugular group

• Level 3: Middle jugular group

• Level 4: Lower jugular group

• Level 5: Posterior triangle group

• Level 6: Anterior compartment groupNeck dissections are classified based on which level(s) of lymph nodes areremoved and which contiguous structures of the neck are excised In a rad-ical or classic neck dissection, all nodes in levels 1 through 5 are resected incontinuity with the ipsilateral sternocleidomastoid muscle, internal jugularvein, spinal accessory nerve, submandibular gland, and, occasionally, the tail

of the parotid gland This extensive procedure is rarely indicated in children

A complete functional neck dissection also removes all lymph nodeswithin levels 1 through 5; however nonlymphatic structures, particularlythe sternocleidomastoid muscle, internal jugular vein, and spinal accessorynerve, are preserved For comparison, cross section anatomical dissectionsare shown at the levels of the hyoid bone and thyroid cartilage for both aradical neck dissection and a complete functional neck dissection, respec-tively (Figures 20–11 and 20–12)

Limiting the procedure to specific node levels can further modify a tional neck dissection For example, a supraomohyoid neck dissection selec-tively removes the lymphatic tissue from levels 1 through 3, a posterolateral

func-Figure 20–10 Cervical lymph

node groups by anatomic levels.

Anesthetic Considerations and Preparation

• The procedure is performed under general anesthesia

• The patient is positioned with an inflatable thyroid bag under the ders so the head can be turned and extended with the occiput restingagainst the upper end of the operating table

shoul-• Similar draping is used for all neck dissection procedures except fied anterior neck dissection A head drape is used leaving the lobule ofthe ear uncovered Four additional towels are placed: (1) from the chin

modi-to the masmodi-toid over the body of the mandible, (2) horizontally across theupper chest from the midline to the shoulder, (3) from the mastoid tip

to the shoulder, and (4) in the midline vertically

Procedure

• A wide variety of neck dissection incisions and flap designs have beendescribed A modified Conley incision allows excellent access to both thesuperior and inferior neck (Figure 20–13) The S-shape of the verticalcomponent of the modified Conley incision also heals well with mini-mal contracture and comparatively good cosmesis

• The incision is infiltrated with 1% lidocaine with 1:100,000 rine for hemostasis

epineph-Figure 20–13 Child draped in

surgical position with modified

Conley incision outlined.

456 Surgical Atlas of Pediatric Otolaryngology

Surgical exposure and orientation

• The skin flaps are elevated deep to the platysma muscle The rationalefor leaving the platysma muscle with the skin is to provide better bloodsupply to the flaps

• The flaps are raised (Figure 20–14):

♦ superiorly to the lower border of the mandible, extending to the toid tip

mas-♦ inferiorly to the upper border of the clavicle

♦ anteriorly to the midline

♦ posteriorly to the anterior border of the trapezius muscle

• If a concurrent tracheotomy is planned, care is taken not to cate the anterior flap elevation with the tracheotomy site This avoidscontaminating the neck with peristomal secretions, and will enhance theeffectiveness of postoperative suction drainage

communi-• The surgeon must identify and preserve several major anatomical tures:

struc-♦ Structures routinely preserved during all neck dissections, includingradical procedures, are the carotid artery, brachial plexus, phrenicnerve, vagus nerve, hypoglossal nerve, lingual nerve, and ramusmandibularis branch of the facial nerve (Figure 20–15)

♦ Structures additionally preserved during all functional neck tions include the sternocleidomastoid muscle, internal jugular vein,and spinal accessory nerve (Figure 20–16)

dissec-Figure 20–14 Elevation of cervical flaps with identification of important superficial anatomical structures.

• Intimate knowledge of the fascial layers of the neck is mandatory in order

to perform an adequate functional neck dissection (see also Chapter 21):

1 The superficial fascia incorporates the subcutaneous fat and theplatysma muscle

2 The deep fascia is divided into three layers: (1) the superficial layerenvelops the trapezius and sternocleidomastoid muscles, (2) the mid-dle layers surround the strap muscles and the viscera, and (3) the deeplayer covers the deep neck musculature (Figure 20–17)

3 These fascial layers delineate a large lateral space on each side of thetracheoesophageal visceral column containing the cervical lymphnodes, associated areolar tissues, carotid arteries and their branches,internal jugular veins and their branches, and numerous nerves

4 The carotid sheath envelops the carotid artery, internal jugular vein,and vagus nerve; it divides the lateral space on each side of the neck into

a smaller anterior space and a larger posterior space The arterial andvenous branches of the great vessels, as well as the muscles of the neck,further subdivide the anterolateral and posterolateral spaces into thevarious smaller compartments or cervical triangles (Figure 20–18)

5 Successful functional neck dissection entails careful excision of alllymphatic and areolar tissues while preserving the vessels, nerves, andmuscles traversing these compartments

Neurovascular preservation

• A complete step-by-step description of the various modifications offunctional neck dissection is beyond the scope of this subsection Spe-cific intraoperative points will be highlighted to emphasize preservation

of important neurovascular structures

• The standard functional neck dissection requires significant retraction ofthe sternocleidomastoid muscle to access the anterolateral and postero-lateral cervical compartments

• At the junction of the superior one-third and inferior two-thirds of thesternocleidomastoid muscle, the spinal accessory nerve can often beidentified It is typically located 1 cm deeper than Erb’s point, where thegreater auricular nerve turns over the posterior border of the sternoclei-domastoid muscle

• The upper level 2, middle level 3, and lower level 4 jugular lymph nodesare excised by careful dissection along the internal jugular vein and thecarotid sheath; the takeoff of the occipital vessels off the carotid arterymarks the upper limit of the dissection The vagus, spinal accessory, andhypoglossal nerves are at risk and must be identified during the superi-

or portion of this dissection

• Dissection of the level 1 lymph nodes within the submental and mandibular triangles requires identifying and preserving the lingualnerve, hypoglossal nerve, and the ramus mandibular branch of the facialnerve as reviewed in detail in Chapter 23

sub-460 Surgical Atlas of Pediatric Otolaryngology

• During removal of the level 5 lymph nodes within the posterolateral vical compartment, care must be taken to identify and preserve thebrachial plexus and the phrenic nerve The phrenic nerve should beidentified along the anterior scalene muscle; this nerve is partially intra-aponeurotic and can be easily torn

cer-• Careful dissection is also necessary in the supraclavicular fossa in theregion of the junction of the subclavian and internal jugular vein in order

to avoid injury to either the left thoracic duct or the right lymphatic duct

• A variation of the standard functional neck dissection is to divide andmobilize the sternocleidomastoid muscle (Bocca procedure) instead ofretracting it

♦ The sternocleidomastoid muscle is divided at the junction of its rior one-third and superior two-thirds, and is elevated superiorly toenhance clearance of the lymphatic tissues from levels 2 through 5(Figure 20–19)

infe-♦ Once the neck dissection is complete, the sternocleidomastoid cle is re-approximated with absorbable mattress sutures

mus-♦ No significant loss of muscle function is reported with this technique

Closure

• Following completion of a functional neck dissection, the integrity ofthe various neurovascular structures within each cervical compartmentoperated upon is reassessed, and the neck is irrigated with antibioticsaline solution

• A suction catheter is placed via a separate stab incision prior to flapreplacement Continuous suction drainage avoids the need for pressuredressings, and facilitates postoperative monitoring of flap viability

• The platysma muscle and superficial fascial layer are closed with 3-0chromic or Vicryl suture in interrupted fashion

• Skin closure is accomplished with interrupted stitches of 4-0 and 5-0nylon suture or metallic clips Particular care must be taken in closingthe triangle where the flaps intersect in order to avoid strangulating theflap’s blood supply (Figure 20–20)

Postoperative Care and Complications

• Hemorrhage with secondary hematoma or seroma formation reflectsinadequate hemostasis or drainage

• Injury to the spinal accessory nerve may result in inability to lift theshoulder, inferior displacement of the shoulder with a winged scapula,and predisposition to chronic shoulder pain The spinal accessory nerve

is most commonly injured during dissection either within the superiorneck near the internal jugular vein or where it enters the sternocleido-mastoid muscle

• Injury of the phrenic nerve during posterolateral neck dissection results

in ipsilateral paralysis of the diaphragm Visual identification and ulation of the nerve will intraoperatively verify its anatomical integrity.For medicolegal reasons, preoperative documentation of diaphragmaticfunction is valuable

stim-• Injury of the vagus nerve low in the neck causes hoarseness; vagal nerveinjury high in the neck causes severe hoarseness and aspiration Thevagus nerve is most commonly injured during dissection in the superiorneck near the internal jugular vein

• Brachial plexus injury may cause altered motion and sensation of theshoulder, scapula, arm, and hand Injury to the brachial plexus is fortu-nately rare due to its anatomical location beneath the deep layer of thedeep cervical fascia

• Injury to the ramus mandibularis branch of the facial nerve results in anasymmetric smile and, if severe, may cause oral incompetence withdrooling from the corner of the mouth Blunt trauma from stretching ofthe ramus mandibularis during surgical retraction can cause a temporaryparalysis or paresis that typically resolves within several months Con-versely, severing the nerve causes permanent facial asymmetry due toabsence of lower lip innervation Occasionally, paresis of the lower lip isdue to denervation of the platysma muscle and not marginal mandibu-lar nerve injury; this condition resolves with progressive compensation

by adjacent facial musculature

• Unilateral hypoglossal nerve injury may cause moderate speech and ticatory difficulties secondary to unilateral tongue paralysis Visual iden-tification and confirmatory stimulation of this nerve within the floor ofthe submandibular triangle should be performed intraoperatively

mas-• The cervical sympathetic chain can be injured during superior neck section The resulting Horner’s syndrome is characterized by ipsilateralptosis, anhydrosis, and pupil constriction

dis-• Aggressive dissection in the supraclavicular fossa may result in injury tothe left thoracic duct or the right lymphatic duct Failure to intraopera-tively recognize this injury will result in a chylous leak Increased suctiondrainage of milky secretions is observed, and, if voluminous, electrolyteand nutritional imbalance can result A chylous leak will sometimesrespond to conservative postoperative measures such as a fat-free diet,continued suction drainage, and the application of pressure dressings;often a formal surgical re-exploration of the neck is required to stop thechylous flow

• Pneumothorax is a rare complication of neck dissection The ologist may notice an intraoperative change in the respiratory pattern orsigns of circulatory failure Alternatively, immediate postoperative (post-extubation) respiratory distress may occur Chest X-ray confirms thediagnosis Treatment consists of immediate chest tube insertion

anesthesi-• Carotid rupture is a rare event during or following functional neck tion in a nonirradiated field Careful attention to appropriate flap designand meticulous surgical technique decrease the risk of carotid injury

dissec-Cervical Adenopathy 463

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