Ebook An atlas of head and neck surgery (Vol II- 4/E): Part 1

(BQ) Part 1 book An atlas of head and neck surgery has contents: Sectional radiographic anatomy and scanning, emergency procedures, basic considerations, diagnostic endoscopy, the sinuses and maxilla,... and other contents.

Distinguished Member (Clinical Research) Medical Staff, Roswell Park Cancer Institute.

Professor Emeritus, School of Medicine, State University of New York at Buffalo.

Medical Director Emeritus, John M Lore, Jr., Head and Neck Center, Sisters of Charity Hospital Former Head, Department of Otolaryngology-Head and Neck Surgery, Sisters of Charity Hospital University Chief, Department of Otolaryngology, Buffalo Children's Hospital and Erie County Medical Center.

Consultant, Veterans Administration Medical Center Consultant, Roswell Park Cancer Institute Director of Surgery, Good Samaritan Hospital, Suffern, New York.

Jesus E Medina, M.D.

Paul and Ruth Jonas Professor and Chair, Department of Otorhinolaryngology,

University of Oklahoma Health Sciences Center College of Medicine, Oklahoma City, Oklahoma.

AN ATLAS OF HEAD AND NECK SURGERY, FOURTH EDITION

Copyright c 2005, Elsevier Inc.

All rights reserved.

ISBN 0·7216-7319-8

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NOTICE

Surgery is an ever-changing field Standard safety precautions must be followed, but as new

research and clinical experience broaden our knowledge, changes in treatment and drug therapy may become necessary or appropriate Readers are advised to check the most current product infor-

mation provided by the manufacturer of each drug to be administered to verify the recommended dose, the method and duration of administration, and contraindications It is the responsibility of the licensed prescriber, relying on experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient Neither the publisher nor the author assumes any liability for any injury and/or damage to persons or property arising from this publication.

Previous editions copyrighted 1988, 1973, 1962

Library of Congress Control Number: 2003114446

International Standard Book Number 0-7216-7319-8

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Developmental Editor: Arlene Chappelle

Publishins Services Manager: Tina Rebane

Senior Project Manager: Mary Anne Folcher

Cover Designer and In/erior Design Coordinator: Ellen Zanolle

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Last digit is the print number: 9 8 7 6 5 4 3 2

AHMED ABDEHALlM, M.D.

Clinical Assistant Professor of Diagnostic Radiology,

State University of New York at Buffalo School

of Medicine and Biomedical Sciences;

Neuroradiologist, Roswell Park Cancer Institute;

Neuroradiologist, Women and Children's Hospital

of Buffalo (Kaleida Health System), Buffalo,

New York

Advanced Techniques for CT in the Head and Neck

(Chapter 1)

RONALD A ALBERICO, M.D.

Associate Professor of Radiology and Assistant

Clinical Professor of Neurosurgery, State University

of New York at Buffalo School of Medicine and

Biomedical Sciences; Director of Neuroradiology

and Head and Neck Imaging, Roswell Park Cancer

Institute; Director of Pediatric Neuroradiology,

Women and Children's Hospital of Buffalo

(Kaleida Health System), Buffalo, New York

Advanced Techniques for CT in the Head and Neck

(Chapter 1)

JOSEPH M ANAIN, M.D.

Assistant Clinical Professor, Otolaryngology,

State University of New York at Buffalo School

of Medicine and Biomedical Sciences; Chief,

Division of Vascular Surgery, Sisters of Charity

Hospital, Buffalo, New York

Vascular Procedures (Chapter 22)

SHIRLEY A ANAIN, M.D.

Assistant Clinical Professor, State University

of New York at Buffalo School of Medicine

and Biomedical Sciences, Buffalo, New York

Facial Paralysis (Chapter 7)

JOHN E ASIRWATHAM, M.D.

Clinical Associate Professor of Pathology,

State University of New York at Buffalo School

of Medicine and Biomedical Sciences;

Department of Pathology, Sisters of Charity

Hospital, Buffalo, New York

Bone Imaging and Pathology (Chapter 3); Pathology

of the Parathyroid Glands (Chapter 18)

ANGELA BONTEMPO, F.A.C.H.E.

President and CEO, Saint Vincent Health System, Erie, Pennsylvania

A Comprehensive, Interdisciplinary Head and Neck Service (Chapter 3)

DANIEL BRODERICK, M.D.

Assistant Professor of Radiology, Mayo Clinic, Jacksonville, Florida

Bone Imaging and Pathology (Chapter 3)

DANiEl SETTE CAMARA, M.D.

Clinical Associate Professor of Medicine, State University of New York at Buffalo School

of Medicine and Biomedical Sciences;

Gastroenterology Service, Sisters of Charity Hospital, Buffalo, New York

Percutaneous Endoscopic Gastrostomy (Chapter 21)

Dental and Prosthetic Considerations in Head and Neck Surgery (Chapter 3); Maxillofacial Prostheses (Chapter 3)

of Medicine and Biomedical Sciences; Associate

Chief of Pathology, Department of Pathology,

Sisters of Charity Hospital, Buffalo, New York

Malignant Mixed Tumor (Chapter 17); Endocrine

Surgery (Chapter 18); Vascular Procedures

(Chapter 22)

KANDALA CHARY, M.D.

Medical Oncology, Sisters of Charity Hospital,

Buffalo, New York

Preoperative Chemotherapy, Uncompromised Surgery,

and Selective Radiotherapy in the Management

of Advanced Squamous Cell Carcinoma of the

Head and Neck (Chapter 3)

SCOTT CHOLEWINSKI, M.D.

Director, Department of Magnetic Resonance Imaging,

Sisters of Charity Hospital, Buffalo, New York

CT and MRI (Chapter 1); Bone Imaging and Pathology

(Chapter 3)

KEITH F CLARK, M.D., Ph.D.

Clinical Professor, Department of Otorhinolaryngology,

University of Oklahoma Health Sciences Center

College of Medicine, Oklahoma City, Oklahoma

Endoscopic Sinus Surgery (Chapter 5)

ERNESTO A DIAZ-ORDAZ, M.D.

Assistant Professor of Otolaryngology and Assistant

Professor of Communicative and Speech Disorders,

State University of New York at Buffalo School

of Medicine and Biomedical Sciences; Acting Chair,

Department of Otolaryngology, Sisters of Charity

Hospital, Buffalo, New York

Infratemporal Approach to the Skull Base (Chapter 23)

ROBERT W DOLAN, M.D.

Surgeon, Department of Otolaryngology, Head and Neck

Surgery, Lahey Clinic, Burlington, Massachusetts

Microvascular Surgery (Chapter 24)

MEGAN FARRELL,M.D.

Endocrinologist, John M Lore, Jr., M.D Head and

Neck Center, Sisters of Charity Hospital, Buffalo,

New York

Endocrine Surgery (Chapter 18)

of Medicine and Biomedical Sciences;

Chair, Department of Diagnostic Imaging, Sisters of Charity Hospital, Buffalo, New York

CT and MRI (Chapter 1); Ultrasound (Chapter 1)

l NELSON HOPKINS, M.D.

Chief of Neurosurgery, State University of New York

at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York

Vascular Procedures (Chapter 22)

R LEE JENNINGS, M.D.

Assistant Clinical Professor of Surgery, University of Colorado Health Sciences Center School of Medicine; Colorado Surgical Oncology Associates, Denver, Colorado

Preoperative and Postoperative Care (Chapter 3)

CONSTANTINE P KARAKOUSIS, M.D., PH.D.

Professor of Surgery, State University of New York

at Buffalo School of Medicine and Biomedical Sciences; Millard Fillmore Hospital

(Kaleida Health System), Buffalo, New York

Malignant Melanoma (Chapter 3); Soft Tissue Sarcoma (Chapter 3)

Surgeon in Private Practice, Tampa, Florida

Fractures of Facial Bones (Chapter 13)

ASHOK KOUL, M.D.

Clinical Assistant Professor of Pathology, State University of New York at Buffalo School

of Medicine and Biomedical Sciences;

Director of Pathology and Laboratory Medicine, Sisters of Charity Hospital, Buffalo, New York

Commonly Used Terminology for Squamous Epithelium (Chapter 3)

JOHN LAURIA, M.D.

Professor and Chair Emeritus, Department of

Anesthesiology, State University of New York

at Buffalo School of Medicine and Biomedical

Sciences and Sisters of Charity Hospital, Buffalo,

New York

Venous Air Embolism (Chapter 2); Malignant

Hyperthermia (Chapter 2)

KEUN Y LEE, M.D

Assistant Clinical Professor, Department of

Otolaryngology, State University of New York

at Buffalo School of Medicine and Biomedical

Sciences; Attending in Otolaryngology-Head and

Neck Surgery, Sisters of Charity Hospital; Buffalo

Otolaryngology Group, Buffalo, New York

Posterior Neck Dissection (Chapter 16)

JOHN S LEWIS, M.D

Associate Clinical Professor Emeritus of Otolaryngology,

Columbia University College of Physicians and

Surgeons, New York, New York

Temporal Bone Resection (Chapter 23)

THOM R LOREE, M.D

Chief, Department of Head and Neck Surgery,

Roswell Park Cancer Institute, Buffalo, New York

Management of Salivary Gland Tumors (Chapter 17)

A CHARLES MASSARO, M.D

Senior Vice President, Medical Affairs,

Sisters Healthcare System, Buffalo,

University of Oklahoma Health Sciences Center

College of Medicine, Oklahoma City, Oklahoma

The Neck (Chapter 16)

ROBERT S MILETICH, M.D., Ph.D

Associate Professor of Clinical Nuclear Medicine,

Department of Nuclear Medicine,

State University of New York at Buffalo School

of Medicine and Biomedical Sciences; Staff Physician,

Veterans Affairs Western New York Healthcare

System, Buffalo, New York; Staff Physician,

Dent Neurologic Institute, Amherst, New York

Positron Emission Tomography (Chapter 1)

DOUGLAS B MORELAND, M.D

Director, Buffalo Neurosurgery Group;

Chief of Neurosurgery, Sisters of Charity Hospital; Co-Director, Gamma Knife Center,

Roswell Park Cancer Institute, Buffalo, New York

Endoscopic Endonasal Transsphenoidal Approach to the Pituitary Gland (Chapter 23)

WILLIAM M MORRIS, M.D

Buffalo, New York

Cardiopulmonary Resuscitation (Chapter2)

WILLIAM R NElSON, M.D

Clinical Professor Emeritus of Surgery, University of Colorado Health Sciences Center School of Medicine, Denver, Colorado

Preoperative and Postoperative Care (Chapter 3)

ROBERT J PERRY, M.D

Clinical Associate Professor of Surgery (Plastic), State University of New York at Buffalo School

of Medicine and Biomedical Sciences;

Chief, Division of Plastic Surgery, Women and Children's Hospital of Buffalo (Kaleida Health System), Buffalo, New York

Cleft Lip and Palate (Chapter 10)

JOACHIM PREIN, M.D., D.M.D

Professor of Maxillofacial Surgery and Chair, Clinic for Reconstructive Surgery,

Unit for Maxillofacial Surgery, University Clinics

of Basel; Chair, European Maxillofacial Education Committee, Basel, Switzerland

Compression Plating for Ireatment of Mandibular Fractures (Chapter 13)

Voice, Speech, and Swallowing Rehabilitation of the Head and Neck Patient (Chapter 3)

ARTHUR J SCHAEFER, M.D.t

Clinical Professor of Ophthalmology and Clinical Assistant Professor of Otolaryngology,

State University of New York at Buffalo School

of Medicine and Biomedical Sciences, Buffalo, New York

Blindness and Ophthalmic Complications of Surgery

of the Head and Neck (Chapter 2)

t Deceased.

of Ophthalmology; Clinical Assistant Professor

of Otolaryngology, State University of New York

at Buffalo School of Medicine and Biomedical

Sciences, Buffalo, New York

Blindness and Ophthalmic Complications of Surgery

of the Head and Neck (Chapter 2); Thyroid-Related

Orbitopathy (Chapter 3); Supraorbital Approach to

the Orbit and Paranasal Sinuses (Chapter 23)

DHIREN K SHAH, M.D.

Medical Director, Cancer Treatment Services;

Assistant Clinical Professor, State University

of New York at Buffalo School of Medicine and

Biomedical Sciences, Buffalo, New York

Radiation Therapy for Laryngeal Cancer

(Chapter 20)

DONALD P SHEDD, M.D.

Professor Emeritus, Department of Head and Neck

Surgery, Roswell Park Cancer Institute, Buffalo,

The Place for Chemotherapy in Management

of Squamous Cell Carcinoma of the Head and Neck (Chapter 3)

MAUREEN SULLIVAN, D.D.S.

Chief, Department of Dentistry and Maxillofacial Prosthetics, Roswell Park Cancer Institute, Buffalo, New York

Osseointegrated Implants in Head and Neck Reconstruction (Chapter 3)

Dr John M Lore, Jr., passed away on January 12,2004 He continued active medical

practice and cared for his patients until shortly before his death Dr Lore was world

renowned as a head and neck surgeon After receiving his medical degree from New

YorkUniversity, he completed residencies in both otolaryngology and general surgery

He was the Chairman of the Department of Otolaryngology-Head and Neck Surgery

at the State University of New York at Buffalo School of Medicine, 1966 to 1991 He

later joined the Department of Head and Neck Surgery at Roswell Park Cancer Institute

Dr Lore was one of the founders of the American Society of Head and Neck Surgery

He was a past president of that society as well as of the Society of Head and Neck

Surgeons He contributed to the early efforts to combine the two Head and Neck

Societies He was also a founding member, and former chairman of the Joint Council

for Advanced Training in Head and Neck Oncologic Surgery, which was instrumental

in establishing the fellowship programs in advanced Head and Neck Surgical Oncology,

accredited by the American Head and Neck Society During his long and distinguished

career, Dr Lore received many honors and awards recognizing his many

contribu-tions to the specialty of Head and Neck Oncology He was passionate and tenacious

in the practice of his profession; he was an early pioneer and champion of the use

of adjuvant chemotherapy in the treatment of head and neck cancer

Jack was equally passionate and tenacious in his many nonprofessional interests

and pursuits He was an avid and accomplished skier, sailor, and photographer

Professionally, his most enduring and cherished attribute was his compassion and

his dedication to his patients When I first met Dr Lore, he was one of the leading

members of our specialty I then became one of his collaborators and colleagues

Eventually, 1 came to know Jack as my friend He will be greatly missed An Atlas

of Head and Neck Surgery,4th edition, serves as a legacy and tribute to his memory

Thom R. Loree, M.D.

JOHN M LORE, M.D., F.A.C.S.

1892-1950whose energy and devotion both in his chosen field in medicine-otolaryngology-

and in his dedicated aim in medical education-a new medical center for his

medical school, New York University-were and still are an inspiration

His desire for cooperation in and plans for a consolidated surgical training program

in the field of head and neck surgery provided the impetus for this Atlas

Dr Lore, Sr was born in Caleane, Sicily, and came to the United States of

America at age5. He was a naturalized citizen of the United States and served in

World War I as an officer in the United States Navy.

Over 40 years have passed since the publication of the

first edition of An Atlas of Head and Neck Surgery,

including three English editions and one Spanish

edition This Fourth Edition has further broadened its

background-an increased scope of each chapter with

an additional number of contributors

Jesus E Medina, M.D., is welcomed as an associate

editor to this Fourth Edition He has been instrumental

in a number of facets, namely in obtaining Robert W

Dolan, M.D., Department of Otolaryngology, Head and

Neck Surgery, Lahey Clinic, to author the new chapter

on Microvascular Surgery, and Keith F Clark, M.D.,

Ph.D., for the addition of Endoscopic Sinus Surgery to

Chapter 5 Dr Medina also has contributed to a number

of other areas

The additions, it is believed, cover items that hit the

highlights of a number of aspects of head and neck

surgery, which are available to the surgeon as

up-to-the-minute help It is not a cookbook of surgery,

how-ever This could be an inherent danger in an atlas The

surgeon must be experienced with the various

proce-dures and modifications thereof No dabblers.! The

choice of the surgical procedure must not be based on

the easiest and quickest minimum resection but rather

must be aggressive'> There is a danger of preserving

soft tissue and bone with disease-free minimum margins

and even no margins

Reference is made to Dr Murray F Brennan's

presi-dential address to the Society of Surgical Oncologists

in 1996.3 There should be no such attitude as "leave

disease right up to the line of resection." It appears that

widespread use of radiotherapy as a routine

postoper-ative modality is fraught with the misconception for

the surgeon that if a little tumor is left behind it is

really no worry since routine radiotherapy is the

catch-all Margins in this methodology mean little since

ion-izing radiation will handle all that the surgeon neglects

Radiotherapy, as well as chemotherapy, plays an

impor-tant part in the management of head and neck

squa-mous cell carcinoma, Stage III and Stage IV, but is not

meant to give a false sense of security to the surgeon

Hence, it is believed that radiotherapy should not be

routinely used postoperatively but rather selectively This

spares the patient of the side effects of radiotherapy, as

well as making radiotherapy available during the entire

follow-up period if indicated With the use of therapy, the surgeon must not compromise the scope ofsurgical resection when there is a favorable response tothe chemotherapy Please confer preoperative chemo-therapy in Chapter 3

chemo-As more tissue and bone are removed, the tive measures must be further improved and expandedfrom a cosmetic and a functional point A caveat thatmust be emphasized is that wherever possible or prac-tical the reconstructive measures should not mask early

reconstruc-or late recurrence of disease At times this is not possible

As an expansion of the reference to microvascularsurgery in the preface of the Third Edition, a newChapter 24 has been added The indication for micro-vascular surgery has broadened and has served well in

a number of reconstructive problems, especially free skinflaps for major skin defects of the cheek, as well as muscleand bone transfers This new chapter by Dr Dolan servestwo purposes: (1) to demonstrate to the head and neckoncologic surgeon what can be achieved by microvas-cular surgery and (2) to present the techniques involved.These techniques are not for the dabblers-only forexperienced microvascular surgeons

Take time to evaluate and record the extent of diseaseutilizing tattoo, when possible, prior to any manage-ment plan Do not depend on the site evaluation at thetime of the initial surgical procedure This admonition

is an absolute with the use of preoperative chemotherapy

or, for that matter, radiotherapy, especially if salvagesurgery becomes necessary following any recurrenceafter the radiotherapy

Regular careful and thorough follow-up of patientsmust be carried out to the best possible degree Follow-

up must be done by the surgeon and by those expert inthe field of head and neck examination and knowledge

of the natural history of the disease The primary sibility is the surgeon's and not the primary care physi-cian's Keep records, which will be valuable as an eval-uation of outcome-not only the physical examination,but also the quality of life When evaluating the quality

respon-of life, take into account the family support or lack

in evaluation This approach is time consuming both

for the medical professionals as well as the patient,

and sometimes it's shattering for the HMOs These

follow-up examinations should be based on a regular

schedule-usually one time per month for the first year

and then every two months for the second year and so

on up to five years They continue every 5 to 6 months,

as enumerated later There is some indication or

recur-rence following preoperative chemotherapy New

pri-maries may appear between the seventh and the tenth

year Follow-up should not be more than every 5 to

6 months; sooner if there appears to be a predisposing

factor to squamous cell carcinoma

Follow-up is for life A patient who continues to smoke

or who has an indication of field carcinogenesis is an

example Frequencies may be increased or decreased,

depending on the anticipated natural history of the

disease This is time consuming yet most important

Review all images-not just reports CT, MRl, MRA,

angiograms, and PET scans, when appropriate, must

be reviewed by the surgeon It is not unusual to spend

upwards of one hour in this type of preoperative

evalu-ation Postoperative examination, especially long-term,

likewise involves considerable time and effort This is

another problem for those from the HMOs to

compre-hend even though they may be physician consultants

One HMO recognized this "unique specialty practice"

involving training in both otolaryngology and general

surgery All this is a significant and tremendous

respon-sibility for the surgeon and all those concerned

In the Preface of the Third Edition, the concept of

centers of excellence was introduced in the

manage-ment of neoplasms of the head and neck In 1993, this

concept was initiated at Sisters of Charity Hospital in

Buffalo, NY The following is a description of such a

center It has flourished well and its weekly tumor

conferences with surgery, medical oncology, radiation

oncology, and endocrinology, as well as with its

special-ized nurses and support personnel, has attracted local

physicians from other hospitals in the Buffalo area Since

its inception, it has trained fellows with backgrounds

in otolaryngology, general surgery, and plastic surgery

The center supports the concept of excellence in patient

care plus the important addition of academia and

ecu-menism The academia in itself is desirable, and when

joined in a single service including all of the disciplines

involved becomes a sine qua non in the management

of head and neck neoplasms, including thyroid diseases

A dedicated interest in academia produces interest

in newer concepts-for example, molecular biology

with gene therapy-which may well become the basis

of future treatment of head and neck squamous cell

carcinoma

Over the years, management of neoplastic disease as well

as other diseases has crossed time-honored establisheddisciplines In head and neck neoplasia, including thy-roid malignancy; surgical, medical, and radiation oncol-ogy; and endocrinology, other supportive disciplinesand services are involved The input from these disci-plines is usually achieved by multidisciplinary confer-ences To further develop this ecumenical approach, toavoid "turf battles," and to further enhance cooperativeand close exchange of ideas regarding diagnosis andmanagement of head and neck neoplasia, a Head andNeck Oncology Service within the John M Lore, Jr.,M.D., Head and Neck Center at Sisters Hospital, Buffalo,

NY, was established 8 years ago This service passes the aforementioned disciplines plus all othergermane disciplines and services, including GeneralOtolaryngology, Reconstructive Surgery, Vascular Sur-gery, Microvascular Surgery, Neuro-otology, Skull BaseSurgery, Oncologic Ophthalmology, Diagnostic Imag-ing, Head and Neck Pathology, Nuclear Medicine,Psychiatry, Maxillofacial Prosthetics, Dental Pathology,Swallowing and Speech Pathology, Nutrition andBiostatistics

encom-The main purpose is to render the best possiblepatient care, to attract the best qualified physicians andother professionals (thus sifting out the dabblers), and

to promote an academic atmosphere This oncologyservice functions as an autonomous service with thecooperation and support of the Chairman of the Depart-ment of Surgery and the Chairman of the Department

of Internal Medicine The Service is responsible forits own quality review data, which is supplied to theQuality Review hospital committee Outpatient; in-patient; speech and swallowing professionals with labo-ratory staff, physicians, fellows, and nurse clinicians;

as well as oncologic dentistry, conference rooms, libraryand nutritional offices are all contiguous and on thesame floor of the hospital

On the same floor is the Pathology Department and

up one flight are the OR and ICU Down one flight isDiagnostic Imaging and Nuclear Medicine On anotherfloor is the Microsurgical Laboratory

It appears that this approach to head and neck plasia, including thyroid and parathyroid tumors, trulyimproves patient care without the stigma of "treatment

neo-by committee." We may agree or disagree yet each vidual is free to treat the patient as he or she sees fit.This type of service avoids the wasted time involved inturf conflicts The Head and Neck Oncology Service is

indi-a complete system where the sum of indi-all the components

is much better for patient care than any independentpart At the very beginning of this project was and still

is Robert E Rich, the founder of Rich Products, who

gave me the impetus to go ahead with this idea He

produced the wherewithal to start basically a

"one-step" facility, which minimizes "wasted time" in the

diagnosis and management of head and neck

neo-plastic disease

There are four team players who helped in the

inau-guration of this multiple discipline service: Kenneth

Eckhert, M.D., Chief of Surgery; Nelson Torre, M.D.,

Chief of Medicine; Sister Angela Bontempo,

Adminis-trator at Sisters of Charity Hospital; and Charles Massaro,

M.D., Vice President of Medical Affairs at Sisters of

Charity Hospital Without the cooperation of these

indi-viduals this service could never have been developed

It had previously been proposed when I was Chairman

of the Department of Otolaryngology at the State

University of New York at Buffalo to the dean, and

twice he turned this concept down saying, "We are not

ready for anything like that just yet." Hence, the medical

school was bypassed in this endeavor

The amalgamation of the Society of Head and Neck

Surgeons, founded by Hayes Martin and Grant Ward

in 1954, and the American Society for Head and Neck

Surgeons, established in 1958 by the hard work of George

Sisson, M.D., along with other dedicated head and neck

surgeons, was a great step forward Among the other

dedicated surgeons as founders of the American Society

for Head and Neck Surgery was Edwin W Cocke, M.D.,

John S Lewis, M.D., W Franklin Keim, M.D., William

M Trible, M.D., and John M Lore, Jr., M.D This

amal-gamation in 1999 united the two societies into one

society, now known as The American Head and Neck

Society This joined the disciplines of otolaryngology,

general surgery, and plastic surgery into one endeavor

There are many benefits to this amalgamation, not the

least of which, of course, is improvement of patient

care by the sharing of various ideas among the various

disciplines all present at the same meeting

The main downside as I see it is the fact that the

larger the society is, the less discussion there is from

the floor and membership I would strongly suggest

that adequate time be allowed in meetings for this type

of discussion, because this enhances the exchange of

different ideas and different methodologies of treatment

There is an interesting and laudable result of this

amalgamation in that it should and will eliminate the

striving of one society to have more members than the

other This inherent danger, which previously existed,

should be eliminated once and for all This attempt at

getting more members led to the admission of surgeons

regardless of background who were not fully qualified

in the field of head and neck oncology There is no need

for an unlimited supply of head and neck surgeons

since, to quote from the Third Edition, "There are only

about 50,000 new patients each year with head and neck

cancer, and only approximately 35 to 75 new, well-trained

head and neck oncologic surgeons are necessary each

year to maintain an adequate workforce of some 400

to 1,000 head and neck oncologic surgeons to managethis number of patients Thus, we must minimize thenumber of 'dabblers.'] There is simply no reason toaccept physicians who are not well-trained in this field.Quality and not quantity is the objective

There is no doubt that, except in the rare case, theresidents interested in this field must be dedicated to itand spend extra time in a fellowship, preferably approved

by the American Head and Neck Society This wouldhelp them reach near perfection in their chosen field asbest as possible This concept in medicine has beenuseful in the training of hand surgeons, since it involvesthe disciplines of general surgery, orthopedic surgery,and plastic surgery In hand surgery, this has been recog-nized by the three boards as an important facet in thetraining of a hand surgeon Unfortunately, in head andneck surgery, the three boards involved, namely, otolaryn-gology, general surgery, and plastic surgery, have notseen fit to endorse this concept Unless the individual

is a genius, there is simply no way to adequately train aresident in the various facets of head and neck oncologyand endocrinology in a residency training program,since the training in that particular specialty involves anumber of other aspects over and above head and neckoncology As Harvey Baker, M.A.,s discussed in hispresidential address to the Society of Head and NeckSurgeons entitled Head and Neck Surgery: The Pursuit

of Excellencein 1971 and pointed out that to be active,for example in general otolaryngology, simply doesnot afford the time and effort needed to become a well-trained and practicing and active head and neck onco-logic surgeon

Logical conclusion to these standards is the activeparticipation in one of the approved fellowships Havingbeen the originator of this additional fellowship train-ing plus having the position of president of both headand neck societies, I have had, and I say this withhumility, experience in the endeavor Changes in thefellowship curriculum were made from time to timeand rightly so The latest one of admitting graduates ofwell-trained foreign programs is strongly commended.Remember, American surgeons at the time of the late1800s and early 1900s were afforded the benefits oflearning from their European counterparts We havethe same obligation and advantage today to share allour ideas and techniques with our European colleagues

We learn from one another

Some flexibility is worthy of implementation, namely,possibly one or two types of fellowships The one-yearfellowship would primarily focus on the clinical aspects

of head and neck oncology but would also include areasonable amount of clinical research The two-yearfellowship would involve basic research along withclinical exposure in a suitable institution where thecandidate's desires can be realized Selected arrange-

methodologies in the overall management of head and

neck neoplasia

Again, it is my strong admonition that two years

of basic surgical training in an approved general

surgi-cal training program is highly recommended for those

who wish to pursue a head and neck oncologic

fellow-ship The exposure to basic surgical principles cannot

be achieved, I believe, in a single discipline-oriented

program I can attest to this again by personal

experi-ence, having completed the approved residency in the

American Board of Otolaryngology and the American

Board of Surgery I am not inferring that double boards

are necessary But otolaryngology residents would

cer-tainly benefit from two years of general surgery The

reverse, namely, dedicated training in otolaryngology,

is also true for the general surgery and plastic surgery

residents Ideally, another year of plastic surgery would

be fortuitous

The next step in the joint venture of all three

disci-plines, namely, general surgery, otolaryngology, and

plastic surgery, would be the recognition by the three

boards concerned relative to an approval of this

fellow-ship To attempt to achieve this objective, plans were

modeled after the three boards of general surgery, plastic

surgery, and orthopedic surgery, agreeing on a

post-residency hand training program Dr George Omer,

from Albuquerque, New Mexico, was the driving force

in this venture It appears that they have succeeded

with the cooperation of the three boards recognizing an

acceptable fellowship in hand surgery

Following this concept that was developed in hand

surgery, an attempt was made to achieve the same type

of recognition by the three boards involved in training

of head and neck oncologic surgeons The initial

data-gathering trip was made by Dr William Nelson and me

going to Albuquerque to review with Dr George Omer

how he achieved the cooperation of the three boards

Following his ideas, Dr Elliott Strong and I developed

a similar concept for the recognition of head and neck

oncologic surgery by the American Boards of

Otolaryn-gology, Surgery, and Plastic Surgery as "added

qualifi-cations." Unfortunately, we failed despite our efforts at

the board level and at the American College of Surgeons

level and it was then that we simply gave up the

endeavor I decided then to take the next step and that

was to develop a center of excellence in our particular

field and, hence, the development of the Head and Neck

Oncologic Service at Sisters of Charity Hospital

Another aspect that is most important in the

develop-ment of our field is the realization that we are a

profes-sion and not a business This is aptly referred to in

Dr Robert M Beyers's presidential address to the Society

of Head and Neck Surgeons in 1996 entitled, Barberpoles,

used to describe us such as healthcare providers andour patients as clients." Dr Beyers goes on to quoteSimon H Rifkind, a lawyer, who expressed his viewsabout how a profession loses its professionalism It isrecommended that Dr Beyers's presidential address beread in its entirety

And Now a Few Caveats

Insecurity is the main stumbling block for a joint venture.For management with the best overall survival foradvanced squamous cell carcinoma of the head andneck, aggressive surgery is the mainstay.2 RadiationOncology and Medical Oncology are ancillary andrequired fine-tuning Molecular Biology may alter thissequence in years ahead

For organ preservation in advanced squamous cellcarcinoma of the head and neck, chemotherapy andradiotherapy are the primary modalities with salvagesurgery for failures and backup Patients must be aware

of the complications and effect on survival and quality

of life, specifically the significant complications of vage surgery These complications were experiencedsome 40 to 50 years ago when radiation was the firsttreatment modality followed by surgery Because ofthese complications, the sequence of treatment waschanged to surgery followed by radiotherapy

sal-Physicians must be the real leaders in medicine.Unfortunately, from time to time, physicians have abro-gated this responsibility and opportunity Do not admitphysicians into the American Head and Neck Societywho are not adequately and completely trained Qualityand not quantity is the objective Our prime objective

is the best of care, the highest quality for patients, less of the pressures of paperwork and other limitations

regard-by insurance companies and government Closely related

to the prime objective is evaluation of each and everyservice's end results, performance data, and quality oflife- "evaluate your track record." Just because a pro-cedure can be done, that is not the reason to do it.Develop the atmosphere of academia, which stimulatesintellectual curiosity and improves quality of patientcare

Randomization-Is this always necessary? Does itmake any and every presentation valid? Review the prosand cons of randomized study techniques when youreport your end results.8 (Suggest review of this refer-ence by Drs Fung and Lore.)

There are shadows that surround us Namely, theinsurance companies, the paperwork, and the loss ofvaluable time in the encountering and fighting of theseobstacles In any event, we must not be complacentand discouraged We must not lose the main objective

of our calling in life We must not be dabblers I We

must assume our responsibilities.? We must return to

the philosophy of the founding fathers of our country

and Constitution when they saw fit to engrave on our

coins In God WeTrust.

Recommendations

It is recommended that the head and neck surgeon,

especially the younger ones who are not aware of the

background of this entire field, review a number of

excellent resumes and books They are as follows:

The Head and Neck Story, by George A Sisson, M.D.,

1983, published by the American Society for Head

and Neck Surgery, produced by Kascot Media,

Chicago, IL

The Making of a Specialty, Hayes Martin Lecture, by

Jatin P Shah, M.D., American Journal of Surgery,

Vol 176, Nov 1998, pp 398-403

History of Head and Neck Surgery, by Jerome C Goldstein,

M.D., and George A Sisson, M.D., Otolaryngology

Head and Neck Surgery, Vol 1, US, #5, 1996

Donald P Shedd, Historical Landmarks in Head andNeck Cancer Surgery, 2000, American Head andNeck Society

4 Lore, JM, Jr., Massaro, M: Description of Head and Neck Services

at Sisters Hospital Abstract submitted.

5 Baker, HW: Head and neck surgery: The pursuit of excellence. Am

First, I wish to once again thank my wife, Chalis, for all

the ancillary work she did as well as her quiet support

despite the mess of "paper" that I managed to disperse

throughout our home during these more than five years

of work on this Fourth Edition.

Shortly after deciding to go ahead with the Fourth

Edition, Robert Wabnitz, our master illustrator, suffered

a stroke, which to everyone, especially his wife, Sue,

was a terrible shock He could no longer continue on

with this venture Fortunately, he had taught medical

illustration at the University of Rochester Medical Center.

Margaret Pence, one of his students, took over for Robert.

She uses the same style that her teacher taught her, and

she has done an excellent and professional job Not only

for her expertise as an illustrator are we all grateful, but

also her pleasant cooperation in anything and

every-thing we asked of her in her chosen field She is a

superb Medical Illustrator.

I wish to also thank Jesus E Medina, our associate

editor, and all of our contributors-in the previous

editions and in this edition-for their time, interest,

and expertise They are all detailed in the list of

contri-butors Many, many thanks The extent of their

contribu-tions is noted in the various chapters These included

contributions for an entire chapter, for example, Chapter

24, to major portions, inserts, and commentaries.

To a very grateful patient, supporter, and sponsor of

the John M Lore, Jr., M.D., Head and Neck Center at

Sisters Hospital-Robert E Rich He recognized the

importance of an ecumenical approach in the

develop-ment of a medical and surgical service to achieve quality

of patient care The center is a byproduct of this atlas,

and I am deeply appreciative of Bob's involvement and

support.

The next expression of gratitude goes to the two

transcriptionists: Lauri L Hess, of Dr Medina's office,

who, in dedicated fashion, transcribed my illegible

inserts onto the disks, and Leslie Berry, a freelance

transcriber par excellence, who, under considerable

pressure, completed the final draft Dottie Kane, who

did most of the transcribing for the Third Edition, helped

us with initial note-taking relative to this Edition of An

Atlas of Head and Neck Surgery.

Other acknowledgements go to the staff of our Head and Neck Service at Sisters of Charity Hospital in Buffalo, NY: Karen Stawiasz, MS, RN, NP, OCN (Oncology Certified Nurse), an incredible person who is Jill-of-all- trades and master of all and, specifically, our Oncology Clinical Nurse Specialist and Nurse Practitioner To all our specially trained head nurses, who tolerated my idiosyncrasies during this protracted period, to complete this edition: Joyce Clemons, our patient coordinator, Jennifer Feltz, Maureen Heatley and Nancy Wojtulski, Kathleen Killion, RN, OCN, Tracy Trifilo, RN, Jean Errington, RN, Elizabeth Gryzybowski, RN, and James Sped ding, a key helper and patient Thanks to Barbara Lowe, MS, RD, our nutritionist Thanks goes to a num- ber of other transcribers: Becky Lonczak, Sandra Ochs, and Linda Eick To the office secretaries and adminis- trative assistants over the years, I'm indebted to Dottie, and Linda Runfola My deepest appreciation goes to Sharon Eagles who bridged the gap from one Hospital

to another, Sisters of Charity Hospital to Roswell Park Cancer Institute.

Many thanks to Elsevier Saunders, especially to Rebecca Schmidt Gaertner, Stephanie Smith-Donley, Christian Elton, and Arlene Chappelle, who were of exceptional help in manuscript review, as well as all the previous medical editors and associates, for with- out them this publication could not have existed Among these are John Dusseau, Robert Rowan, and Sam Mink.

My condolences to the families of William Bukowski and Paul Milley-both contributors who have passed away since the Third Edition Their contributions were valued Bill was my personal primary care physician Paul was an excellent head and neck pathologist (I remember when he examined 137 sections of a thyroid gland for the primary tumor in a patient who had an incidental finding of metastatic papillary carcinoma of the thyroid in a radical neck dissection, which was done for squamous cell carcinoma.)

Many thanks to all and to all Ave atque Vale.

JOHN M LORE,JR.

TO THE THIRD EDITION

Twenty-six years have elapsed since the first edition of

this atlas, and 15 years since the second edition This

third edition has in some respects departed from the

original concept of being simply an atlas It contains

much more information, with background material in a

number of subjects, such as endocrine surgery of the

head and neck and chemotherapy This background

material is most important if the surgeon is not to be

relegated to the position of being solely a technician,

which, sad to say, is occurring in a number of surgical

disciplines This is not to say that diagnosis and

manage-ment of problems such as endocrine diseases involving

the head and neck are to be performed solely and

inde-pendently by the head and neck surgeon The

endocri-nologist, specialists in nuclear medicine, and imaging

and surgical pathologists are all necessary, integral

mem-bers of the management team It does mean, however,

that the surgeon operating on, for example, the thyroid

gland and parathyroid glands must have more than just

a superficial knowledge of these endocrine organs

The third edition has been expanded in a number of

facets The number of chapters has been increased

from21to23with the addition and further clarification

of Emergency Procedures (Chapter 2) and Base of the

Skull Surgery (Chapter 23) Although both these new

chapters include some procedures that were covered in

the previous editions, this material has now been

signifi-cantly revised and relegated to these two new chapters

Virtually every chapter has been enlarged with new

and other time-proven procedures, encompassing

addi-tional text and plates The reader has simply to refer

to the table of contents to see the increased amount

of material To emphasize these additions, examples

include the following: expanded listing of complications

following most procedures along with air embolism and

blindness and pitfalls; adjuvant chemotherapy; carbon

dioxide laser surgery; myocutaneous and myomucosal

flaps; updated management of cleft lip and palate;

compression plates in the management of facial

frac-tures; various types of neck dissections and their

appli-cations; expansion of thyroid and parathyroid surgery;

rehabilitation following laryngectomy; expansion of

various reconstructive procedures related to the pharynx

and esophagus; and updated vascular procedures and

tissue expanders that lead to interesting possibilities forreconstruction The number of contributors has alsoincreased

The anatomic sectional x-ray plates in Chapter 1 havebeen related to the newer techniques of imaging Thesereproductions can be of great aid in the correlationwith both CT scans and MRI

The comments in the preface of the previous editionsare still valid for the most part Progress has been made

in the training of head and neck oncologic surgeons bythe formation by the American Society for Head andNeck Surgery and the Society of Head and NeckSurgeons of a Joint Council for Approval of AdvancedTraining in Head and Neck Oncologic Surgery This wasaccomplished during 1976 to 1977 with the result beingthe formation of a carefully structured fellowship follow-ing the completion of a residency in otolaryngology,general surgery, or plastic surgery This fellowship is theonly one of its kind in head and neck surgery having acarefully structured evaluation system, site visits, andreview by the executive councils of both head and necksurgical societies A diploma is awarded by these twosocieties to those candidates who follow the rigid criteriaand successfully complete the fellowship The fellow-ship encompasses three phases: Phase [-basic surgicaltraining involving 1 or 2 years; Phase II-residency inone of the aforementioned disciplines; and Phase [[[-the fellowship portion of 1 or 2 yeats Details of thisfellowship have been previously reported (Lore, J.M.,Jr.: Head and neck oncologic training: Where we havebeen and where we are going Am J Surg 142:504-505,

1981) Sixteen programs are now approved for this type

of training-IS in the United States and one in Canada.The term head and neck oncology might be the betterterm applied to this fellowship, since it involves notonly surgical training but also a knowledge of radio-therapy, chemotherapy, and, where applicable, the future

of immunotherapy This facet of head and neck ogy is only one of five categories involved in head andneck surgery, with the others being congenitallesions,cosmetic surgery, and infectious disease Likewiseinvolved in head and neck surgery is reconstructivesurgery, which relates to both head and neck oncologicsurgery and cosmetic surgery

oncol-xxi

established Stumbling blocks still remain, one of them

being the cliche "fragmentation" of the parent

disci-plines Interestingly enough, it all depends on one's

biases as to whether the changes of a specific aspect of

a major discipline are termed "fragmentation" or

"spe-cialization." Regardless, it is the marketplace that sets

the pace-specifically, the number of patients available

To borrow the words of James Humphreys, M.D.,

"sur-gery was fragmented when the surgeon left the barber

shop." The bottom line, however, is the search for

excellence in patient care and physician training These

two aspects must not be compromised

The thrust of head and neck oncologic surgery is a

cooperative and joint venture encompassing all

disci-plines that can and should contribute to this endeavor

The initial step has been made with the two head and

neck surgical societies setting up the guidelines, site

evaluations, approval, and awarding of a diploma The

next step is the formal implementation and recognition

of these postresidency fellowships by the residency review

committees and the specialty boards involved, an

exam-ination, and board recognition Currently, it appears that

this recognition could be achieved by "added

qualifica-tions" in head and neck oncology by the boards These

"added qualifications" could then be affixed to the

exist-ing certificate of each board It is hoped that this would

be accomplished by the three boards jointly agreeing

on the same guidelines and examination An excellent

example of this type of joint venture is the solution of

education in hand surgery, which has been worked out

by the two hand societies and the three boards of

ortho-pedics, general surgery, and plastic surgery George

Omer, after many years of dedicated work developing

articles of agreement, is to be congratulated on its fruition

I hope that a similar modus operandi will be achieved

in head and neck oncology

To date, this concept of added qualifications has

been stalled by the concern of the three boards and the

three residency review committees as well as a number

of practicing surgeons in the three disciplines Their

fears surround the worry of fragmentation of their

disciplines as well as the misgivings that such added

qualifications will lead to "a special club" of head and

neck oncologic surgeons and thus restrict their

prac-tice It must be remembered that there are only about

50,000 new patients each year with head and neck

cancer and that only approximately 35 to 75new

well-trained head and neck oncologic surgeons are

neces-sary each year to maintain an adequate work force of

some 400 to 1000 head and neck oncologic surgeons to

manage this number of patients Thus, we must

mini-mize the number of "dabblers." No one who requires

coronary artery bypass surgery would seek treatment

solution for us Yet with all this protectionism, generalsurgery has in fact been fragmented Otolaryngologistsare going down the same course with the fear of frag-mentation Hence, it appears that this concern onlyenhances fragmentation rather than alleviating it Thebasic problem is that the profession of medicine andits physicians and specialty societies react to obviouschanges that are in the making, rather than acting.Physicians must be the leaders in this change, ratherthan the followers They must shape these changes,since they are the ones who know the problem and canbest suggest and initiate the changes best suited toexcellency in patient care and physician training.Unless this is achieved, a number of legitimate con-cerns that exist will become aggravated Following is

a list of such concerns (from Lore, J.M., Jr.: Issues incommunity hospital or cancer center care of head andneck cancer patients In Myers, E N., Barofsky, I., andYates, J W [eds.]: Rehabilitation and Treatment of Headand Neck Cancer Washington, D.C., U.S Department

of Health and Human Services, Public Health Service,National Institutes of Health [NIH Publication No

86-2762], 1986, pp 155-165).

1 The occasional patient manager or "dabbler."

2 Loss of expertise and proficiency for even the trained physician

well-3 Marginal and then inadequate treatment for headand neck cancer patients

4 Loss of concentration of training clinical material

5 Loss of any significant number of patients for ation as to treatment methods, old and new

evalu-6 Increased morbidity, mortality, and cost of medicalcare

To achieve the solution to these problems, it appearsthat the three boards and the three residency reviewcommittees should pursue the concept of added qualifi-cations and recognize the additional training beyondthe residency years so necessary to achieve the desiredexcellency In other words, support the fellowship con-cept and officially recognize the fellowship concept

To aid in the solution to these problems in a nized manner, several additional steps are suggested

recog-Training

1 The American Board of Surgery should develop nized training in basic surgery that might encom-pass 2 years, with examination and certification forthe trainee

recog-2 The trainee then completes the standard residency

in general surgery, otolaryngology, or plastic surgery

3 The trainee enrolls in a fellowship approved by the

three boards An alternate route could be a similarly

approved preceptorship

Centers of Excellence

Centers of excellence in head and neck oncology can

either be achieved in a university or community hospital

center with adequate patient load, professional

person-nel, and support staff The interested reader is referred

to the aforementioned NIH publication as well as the

author's Presidential Address at the annual meeting

of the American Society for Head and Neck Surgery

(Dabbling in head and neck oncology-A plea for

added qualifications Arch Otolaryngol 113:1165-1168,

1987).

Controversial Items

There are a number of controversial items quite apart

from the preceding that this author wishes to enumerate

Correct and Exact Terminology

In the evaluation of statistics relative to survival with

or without disease, a distinction should be made at the

onset of treatment as to whether a patient is "operable"

and whether the lesion is "resectable" for cure or

palliation Operability refers to whether the patient can

safely undergo a major surgical procedure, whereas

resectability refers to whether a neoplasm can in fact

be totally removed by the surgeon Nonresectability

distinctly implies advanced disease and actually further

implies a stage beyond stage IV, namely a stage V

disease This concept has been previously suggested in

a publication entitled Head and Neck Cancer;

Proceed-ings of the First International Conference, The Society

of Head and Neck Surgeons (Chretien et aI., St Louis,

C.V Mosby, 1985, p 434).

Another point of contention are the words partial,

subtotal, near total, and total in regard to the various

surgical procedures, especially thyroidectomy Granted,

there are fine lines that separate these terms and defy

total exactness, but regardless a more accurate

designa-tion of the surgical procedure is warranted as well as a

close adherence to the exact implication of these terms

The same goes for the terms referring to the various

types of neck dissections, e.g., radical neck dissection,

classical neck dissection, modified radical neck

dissec-tion, functional neck dissecdissec-tion, and conservation neck

dissection

Indications for Surgical Procedure

As for indications for surgery, my bone of contention is

a fundamental philosophical and, for that matter,

practical problem, which can best be summarized asfollows: Just because a procedure can be technicallyperformed, that is not the indication to perform theprocedure Advances in medicine and surgery requirethe development and trial elfnew procedures Neverthe-less, these trials must be tempered to a certain degree

by past as well as present experience Again, there

is the "gray zone." Specifically, a number of techniques

and procedures come to mind, for example, cular surgery These procedures have a selected place

microvas-in head and neck surgery relative to the followmicrovas-ingsurgical problems:

1 Augmentation of soft tissue with microvascular tomosis, e.g., involving massive defects of the top ofthe scalp that cannot easily be reached by a myocu-taneous flap (tissue expanders may have a signifi-cant application in closing such defects)

anas-2 Certain congenital lesions in which a transposed flap

or myocutaneous flap is not indicated

On the other hand, microvascular techniques do notappear routinely warranted in, for example, thefollowing:

1 Reconstruction of the mandible (associated withablative surgery) with an iliac bone graft and over-lying skin The added time necessary to accomplishthese procedures must be taken into account whenablative surgery has already consumed a significantnumber of hours of operating time These microvas-cular techniques on the other hand are applicable tomassive defects resulting from trauma

2 Reconstruction of the laryngopharynx with a freejejunal graft or gastric pull-up The latter procedure

or colon interposition is definitely indicated when atotal esophagectomy is necessary

Often, a much simpler reconstructive procedure does

in fact achieve the same end results related to thereconstructive surgery For example:

1 Mandibular resection that is reconstructed with thesimple use of a bent Kirschner wire with tie wires

2 Total laryngectomy with total hypopharyngeal, pharyngeal, and partial nasopharyngeal resectionreconstructed with a myomucosal tongue flap withdermal graft or pectoralis major flap with dermalgraft These simpler forms of reconstructive sur-gery make total hypopharyngectomy a very feasibleand relatively easy procedure These techniques arebelieved to afford a much better chance of resectingthe entire structure, thus leading to improved survivalrates Preserving a narrow strip of posterior hypo-pharyngeal mucosa for reconstruction of the gullethardly seems justified

philo-following ablative surgery for intraoral cancer.

5 Randomized studies evaluating treatment and endresults Although randomized protocols certainly havedefinite advantages, there are a number of draw-backs When multiple institutions are included, varia-tions in technique among the surgeons involvedcause inevitable problems In addition, these studiesmay not be as valid as they are supposed to be if thenumber of patients is small or if a study lacks ade-quate stratification of the various factors involved

In one recent study (Corey, J.P., et al.: Surgical plications in patients with head and neck cancerreceiving chemotherapy Arch Otolaryngol 112:

com-437-439, 1986) evaluating surgical complications inpatients receiving chemotherapy, the patients were,

I believe, incorrectly stratified as follows:

evaluation of the patient basic information should

be tabulated along with the appropriate drawings,

and, if possible, photographs, which at any time can

then be transferred into virtually any TNM

classifi-cation that may be developed in the future (Kaufman,

S., and Lore, J.M Jr.: TNM classification and disease

description in head and neck cancer Am J Surg

136:469-473, 1978).

2 Prevention and treatment of premalignant lesions

Head and neck oncologic surgeons must face the

fact that to help achieve improved survival rates for

patients with head and neck cancer they should be

actively involved and cognizant of the premalignant

lesion as well as the management of "condemned

mucosa." This concept applies to the high-risk patients

and those with mucosal atypism and dysplasia

Obviously, the avoidance of tobacco and exposure to

carcinogens is foremost Next in line is the use of the

retinoic acids-vitamin A-as a dietary supplement,

recognizing, of course, the possible toxic side effects,

particularly of overdosage of vitamin A This leads

to the establishment of, or at least involvement by,

head and neck surgeons in basic research

3 Adjuvant chemotherapy Another consideration is the

admonition that adjuvant chemotherapy be relegated

to organized protocols rather than the haphazard

use of chemotherapeutic agents in the management

of head and neck cancer

4 Violation of the "Virgin Neck." Many years ago Hayes

Martin emphasized that limited surgical procedures

should be avoided in the unoperated neck, since this

could very well mask future metastatic disease This

admonition is still true for the most part For

exam-Patients

Stage IIStage 1IlStage IV

Control

5 8 6

Chemotherapy

1 12 10

IN THE THIRD EDITION

During the years taken to expand this atlas many

friends have contributed-some as formal contributors,

others in ways and at times unknown to them either

in the sharing or exchanging of knowledge, others in

technical help, and still others in the various phases of

patient care, which in effect has had significant bearing

on this revision and expansion

My wife, Chalis, has tolerated this third episode with

exceptional calm and has also helped in selective typing

For the third time, Bob Wabnitz has joined me as the

one and only medical artist and illustrator of all the

editions of this atlas, demonstrating his skill par

excel-lence Working with Bob is actually a pleasure His skill

in his chosen profession as well as his knowledge of

anatomy and surgical procedures is only surpassed by

his humor and cooperative attitude I repeat, "without

him, the atlas would not be."

For the bulk of the stenographic labor, I am deeply

indebted to Dottie Kane, who like Bob Wabnitz simply

smiled when I asked that more had to be done, and of

course, done yesterday

In the patient care arena, which is so important to

a surgeon and the success of patient management, I

extend gratitude in a special way to those primarily

associated with the Sisters of Charity Hospital of Buffalo

This includes in administration Sister Mary Charles and

Sister Eileen, and more recently, Sister Angela and her

staff; in the operating room, Sister Thomasine, and after

her, Pat Archambault, R.N., and on the special head

and neck nursing unit, the head nurse, Diane Smeeding,

R.N., and her staff of devoted and skilled nurses,

prac-tical nurses, aides and our floor secretary, Beth Powalski

Along with patient care and many of the facets related

to this endeavor, I am grateful to my office staff,

espe-cially Nan Sundquist, R.N and Debbie Foschio, and

also to Joan Bilger, R.N., who is our nurse clinician at

the Erie County Medical Center

I have picked the brains of many physicians,

espe-cially my former associate, Duck Kim, M.D., and my

current associate in practice, Keun Lee, M.D They

filled in for me while I struggled along with this

revi-sion Also in this aspect I am grateful to the Pathology

Department of Sisters Hospital To Paul Milley, M.D., I

am deeply grateful for his contributions both in his

section and in the chapter on endocrine surgery and for

his time, which he afforded me in the numerous lems associated with surgical pathology John Sheffer,M.D., and Ashok Koul, M.D., likewise were helpful inthis phase of surgical pathology, which is reflected inhidden ways in many of the surgical procedures Thesethree surgical pathologists are placed among the best

prob-in the field of head and neck surgical pathology, cially related to frozen section, cytology, and recuts andsearching through many surgical specimens This isspecifically applicable not only to carcinoma hidden inthose specimens that had a complete clinical response

espe-to chemotherapy but also in thyroid specimens wherethere has been a search for primary tumors as well asC-cell hyperplasia

I am indebted to Martha Schmidt, M.D., the expert

in nuclear medicine, especially that related to thyroidscanning, as well as to Joseph Prezio, M.D., who ischairman of the Department of Nuclear Medicine at theSchool of Medicine, State University of New York atBuffalo and Kwang Joo, M.D., who covers SistersHospital Gratitude is also extended to their technicians,who are most important in this particular phase ofdiagnostic imaging

In a similar vein, Monica Spaulding, M.D., andKandala Chary, M.D., our medical oncologists are agreat help in the management of patients with advancedneoplastic disease

Included on our team is William Bukowski, M.D.,our internist, and David Casey, D.D.S., our maxillofacialprosthodontist, who have contributed significantly tothe team approach in the management of our patients.Without the expert contribution of the Department

of Diagnostic Radiology and Imaging under the tion of David Rowland, M.D., and the person who Ipester the most, David Hayes, M.D., many of the surgi-cal procedures would not have been brought to a suc-cessful conclusion

direc-When speaking of "brain picking," the participants

in our endocrine conferences contributed much to myunderstanding of thyroid and parathyroid disease The

"regulars," Robert LaMantia, M.D., Donald Rachow,M.D., Jack Cukierman, M.D., and James Kanski, M.D.,are the stalwarts However, I must say if there aredifferences of opinion in the endocrine chapter, theseare my responsibility, not theirs Contributing in this

xxv

affording me a learning experience seldom available to

a surgeon.

I am deeply indebted to Paul J Davis, M.D., Professor

of Medicine and Chief of Endocrinology at the State

University of New York at Buffalo, for his review,

sugges-tions and addisugges-tions to the endocrinological aspects of

the chapter on Endocrine Surgery His help was most

important.

Part of the learning experience is exemplified by

many of my residents and fellows who were involved

in the exchange of knowledge and ideas-so well stated

by John Henry Cardinal Newman in his treatise "The

Idea of a University."

Several general surgeons have been significant

contri-butors to this endeavor in many facets Frank Marchetta,

M.D., a head and neck surgeon par excellence, is

respon-sible for many original contributions to head and neck

surgery, as is Alfred Luhr, M.D., who operated with me

on some two-team procedures Joseph Anain, M.D., a

certified general vascular surgeon and co-author of

Chapter 22, was and is a significant collaborator in our

head and neck vascular procedures He is not only

In all of this, a chairman of a department at a medical school needs the support of his chief, viz Dean John Naughton, M.D., who is also Vice President of Clinical Affairs This support is afforded in many ways-some not immediately recognized, but always appreciated.

In the publishing of a medical book with all its applications, decision making, changes, and additions, the staff of the W.B Saunders Company has been understanding, helpful, and cooperative.

When I try to remember all who have been an ration and at the same time contributed much to head and neck surgery, George Sisson, M.D., Chairman, Department of Otolaryngology, Northwestern Medical School, comes often to my mind Many thanks George Although my mother has passed away during the period between the second and third edition, she was and still is an inspiration, and once again I dedicated this atlas to my Dad, who was the inspiration behind this entire endeavor.

inspi-JOHN M LORE,JR.

TO THE SECOND EDITION

Eleven years have passed since the publication of the

first edition of this atlas The convictions expressed

in the preface of the first edition are reiterated here

and, in addition to them, the grave importance of the

cooperation of the various disciplines involved in

sur-gery of the head and neck-both in the management of

patients and in the training of residents-is

empha-sized The combined efforts, contributions, cooperation

and sharing of patient problems and management must

be part of every aim in medicine and surgery, especially

in head and neck surgery in which there is so much

overlap among the various disciplines.

Fortunately, during the past five years, a definite

cooperative trend among the prime disciplines of general

surgery, otolaryngology, plastic and reconstructive

sur-gery and oral sursur-gery has been developing A number

of various types of combined head and neck services at

universities known to the author are participants in this

trend-the State University of New York at Buffalo,

Northwestern University, the University of Virginia and

Yale University-and others are surely in existence.

However, even more important than these services is

the emergence of a spirit of cooperation which has been

spread as seeds throughout the surgical community.

Unfortunately, among the fruitful seeds are still the

weeds which attempt to choke out the wheat because

of inherent parochialism, insecurity, jealousy and greed

of power or whatever Regardless of the type of

arrange-ment of a combined venture, its success or failure depends

not so much on signed documents as on a spirit of equal

cooperation, understanding and trustworthiness. To insist

that a combined head and neck service lies solely within

one discipline or is a subspecialty of general surgery is

to lead the entire endeavor to certain doom.

Flexibility should be tolerated For example, if need

be, a multidiscipline head and neck service could be

established within one department and thus achieve an

objective similar to that of a head and neck service

which involves more than one department It is

interest-ing to note that durinterest-ing the past decade otolaryngology

has made significant strides and at present is believed

by many to be the prime discipline in the complete

train-ing of the head and neck surgeon.

The problem does not appear to lie among the various

head and neck surgeons of different backgrounds but

rather with certain autocratic and political forces who attempt to control a major portion of surgery-the so- called "umbrella of general surgery," an antiquated and obsolete concept However, it is the conviction that general surgery serves as the foundation and the special- ties as the superstructure Therefore it appears that the concept of regional surgery of the head and neck will

be the end-result.

It was not so long ago that mutual scorn and distrust between several disciplines were so intense that any exchange of ideas was tantamount to proclaimed heresy Now, it is changing toward a mood of basic ecumeni- calism The two head and neck societies, the Society of Head and Neck Surgeons and the American Society for Head and Neck Surgery, have had a joint meeting in 1973-an event which might well have been unthink- able a few years ago Both societies have opened their memberships to capable surgeons in the various disci- plines with similar standards and requirements It is believed that this cooperation is leading to a more com- plete exchange of ideas and that this can be achieved without the destruction of some of the good points of a competitive climate.

As we proceed along the common pathway, a ber of questions are encountered For example:

num-I What does the field of head and neck surgery pass?

encom-2 What is the need in quality and quantity of surgeons well trained in this field?

3 Should all residents in general surgery, otolaryngology and plastic and reconstructive surgery be trained as head and neck surgeons?

4 What should this training entail?

5 Should there be a cooperative effort among the various disciplines or boards, and if so, how best is this objec- tive achieved?

6 Should there be a certificate of competency issued

by the various boards involved?

7 Is some type of basic framework for residency training desirable, or rather, should there be an individual solu- tion to the training problem at the various large centers? These queries cannot be answered or solved over- night, and yet a few responses are possible at present.

xxvii

specific interests; there is no criticism of this action.

Nevertheless, it is important that the trainee develop

a versatility in the changing world of medicine and

surgery, and hence it is believed that to have a lasting

and firm foundation head and neck surgery should

encompass four categories

1 Malignant and benign tumors

2 Reconstructive surgery

3 Congenital lesions

4 Infectious surgical diseases

Thus it is quite obvious that such training crosses

and encompasses a number of specialties as we know

them today The old boundaries are no longer valid nor

practical, and the new boundaries are far more flexible

It must be emphasized that the various surgical

spe-cialties, as well as general surgery, are not in existence

for their own benefit but rather for the promotion of

ultimate excellence in patient care

Another point appears quite clear There is not a need

for a large number of head and neck surgeons, but rather

a need for a moderate number (how many??) of well

trained head and neck surgeons For example, many of

the procedures outlined in this atlas are not intended

for the occasional operator with limited background,

but are intended as a reminder or review for those

well educated in the overall field of head and neck

surgery For the latter audience, this atlas may be a

source of material in the ever-continuing field of medical

education

During the past six years as a program director, the

author has realized a number of problems First of all,

not all residents in either otolaryngology, general

sur-gery or plastic sursur-gery need be, nor should be, trained

as head and neck surgeons per se Secondly, a solid

block of time in general surgery (two to four years)

followed by a solid block of time in otolaryngology

(three years) has certain drawbacks There is a

psycho-logical problem of a candidate being a senior resident

in general surgery and then starting at the bottom in

otolaryngology This is no small matter Another

prob-lem is that of graded training in both fields It would

seem much easier to train a resident in physical

diag-nosis in both specialties at an early stage in his career

The same comparison goes for the senior levels in

which major surgery will be performed It is at this

stage of one's training that senior responsibility in both

specialties should be achieved, almost side by side, and

certainly not separated by several years, as is the case

in the solid block concepts

At any rate, it appears worthwhile to outline an

inte-grated step-wise plan for head and neck surgical

train-senting the American Board of Surgery, the AmericanCollege of Surgeons and the Council of MedicalEducation of the American Medical Association Thisexperimental program, applicable to certain selectedcandidates with approval on an individual basis, exists

at the State University of New York at Buffalo withinstruction in otolaryngology, general surgery andplastic surgery

This concept was originally planned with the eration of John R Paine, then Chairman of Department

coop-of Surgery Glenn Leak played an integral part in theoriginal outline With the untimely passing of both ofthese friends, G Worthington Schenk, Jr., now Chairman

of the Department of Surgery, gave his support andeffort to achieve the final approval of this plan Theprogram entails a five-year residency which, in step-wise fashion, integrates in graded responsibility the basicaspects of otolaryngology and general surgery and theprinciples of plastic surgery The years in training wouldalternate between general surgery and otolaryngology,with plastic surgery training incorporated within generalsurgery, and additional reconstructive surgery withinotolaryngology Senior resident levels in both generalsurgery and otolaryngology would be reached in thefinal two years Not all residents in either of these twofields would be included in the program-only one ortwo at the most in anyone year Nor is this programintended to be the only avenue of training in head andneck surgery

In summary, the second edition of this atlas isdirected to the ecumenical approach in both patientcare and resident training in the field of head and necksurgery

REFERENCES

Baker H w.: Head and neck surgery: The pursuit of excellence Amer J Surg., 122:433-436, 1971.

Beahrs, O.H.: The next plateau Amer J Surg. 114:483-485, 1967.

Bordley, J.E.: Problems facing otolaryngology today Ann Otol.,

80:783,1971.

Chase, R.A.: I'm against a rigid core curriculum prior to specialty

training in plastic surgery Plast Reconslr Surg., 46:384-388, 1970.

Chase, R.A.: The "core knowledge" principle and erosion of specialty barriers in surgical training Ann Surg., 171:987-990, 1970.

Eckert, C (panel member): Panel discussion: Head and neck surgical

training Medical Society of the State of New York Convention,

February 1972.

Fitz-Hugh, G.S (panel member): Panel discussion: Head and neck surgical training Medical Society of the State of New York Con- vention, February 1972.

James A.G.: Board to Death Amer J Surg., 116:477-481, 1968.

Klopp, C.T.: Presidential address Tenth annual meeting of Society of Head and Neck Surgeons Amer J Surg., 108:451-455, 1964.

Lore J.M., Jr.: Editorial Head and neck surgery Surg Gynec Obstet.

118:117-118, 1964.

Lore, J.M., Jr.: Future of head and neck surgery A combined head and

neck service: An ecumenical approach Arch Otolaryng 87:659-664,

1968.

Lore, J.M., Jr.: Head and neck surgery: The problem Arch Otolaryng.

78.842-843, 1963.

Lore, J.M., Jr.: Head and neck surgery: Proposed head and neck

training program Arch Otolaryng 79:112-113, 1964.

MacComb, WS.: Future of the head and neck cancer surgeon Amer.

J Surg., 118:651-653, 1969.

McCormack, R.M (panel member): Panel discussion: Head and neck

surgical training Medical Society of the State of New York

Con-vention, February 1972.

Sisson, G.A.: Otolaryngology, maxillofacial surgery embark on lenging course From the Department of Otolaryngology and Maxillo- facial Surgery, Northwestern University, Evanstown, Illinois Southwick, H.W: Presidential address Eleventh annual meeting of the Society of Head and Neck Surgeons Amer J Surg 110:499-501, 1965.

chal-Wullstein, H.L.: A concept for the future of otorhinolaryngology Ann 0101., 77:805-814, 1968.

IN THE SECOND EDITION

As with the first edition, my prime indebtedness is to

my wife Chalis, who single-handedly transcribed the

changes in the first edition and all the new text for this

expanded second edition In addition to the manuscript,

she typed the bibliography with some help in

classifi-cation from my daughters Margaret and Joan.

The medical artist and illustrator is the same skilled

and dedicated one-Robert Wabnitz Without him, this

atlas simply would not be His persistence in accuracy

and consistent drive for detail is obvious in the artwork.

To him, also, am I deeply indebted.

Again, I am thankful to my mother for her

encour-agement and prayers.

For his revisions and statistics relative to temporal

bone resection, I am thankful to John S Lewis, M.D.

I wish to thank William R Nelson, M.D., who has

contributed a new section on pre- and postoperative

care He has been kind enough to condense a much

larger treatise of this aspect of head and neck surgery,

which he originally produced in booklet form.

Gratitude is extended to James Upson, M.D., for his

review of the section on surgery of degenerative

vas-cular lesions and to John Bozer, M.D., as a consultant

internist.

I also wish to thank a number of photographers at

the various hospitals affiliated with the Medical School

at the State University of New York at Buffalo They are

Sheldon Dukoff and Charles Jackson, of the Edward J.

Meyer Memorial Hospital; Joseph A Dommer and

Dough Hanes, of Buffalo General Hospital; and Harold

C Baitz, Theodore A Scott and their secretary, Mrs.

Alfred Davis, of the Medical Illustration Service of the Veterans Administration Hospital, Buffalo, New York Although many of their photographs do not appear in the atlas, they served as a guide for the artwork and the text.

Thanks also go to Joan R Bilger, R.N., of the Edward

J Meyer Memorial Hospital, for help in preparing some

of the photographic arrangements and supplying other technical data; and to Bette Stinchfield, my secretary at the Buffalo General Hospital, for aid in obtaining some

of the reference material.

During the time between editions, many new niques and modifications have reached the surgical arena, a significant number of changes have occurred and friends have lent their ideas and methods; how- ever, one bit of philosophical admonition comes to

tech-mind-primum non nocere-first, do no harm I know not the originator of this phrase, but to Julius Pomerantz,

a senior fellow physician from Good Samaritan Hospital, Suffern, New York, I am indebted It is to my residents who have also contributed unwittingly to this endeavor that I often pass on this thought in management of our patients.

A great debt of gratitude is due the entire staff of the W.B Saunders Company for their unparalleled aid in publishing this atlas Their continuing help both as publisher and personal friends makes an otherwise burdensome task possible; their skill in the art of publication makes it all worthwhile.

JOHN M LORE,JR.

xxxi

TO THE FIRST EDITION

The purpose and intent of this atlas is to encompass in

one volume related regional procedures of the head

and neck It is actually a plea for a broader training

program to reunite with basic general surgery the many

surgical specialties and subspecialies concerned in this

area Surely, there will always be a need for such

specialty groups alone but there is an even greater need

for the amalgamation and dissemination of their skills

in the total treatment of problems of the head and

neck The foundation upon which this concept is built

is the basic principle that general surgery is the mother

and nurturer of all major surgery The specialties are

the fruits Hence, general surgery as well as the

special-ties of otolaryngology, plastic and reconstructive

sur-gery, maxillofacial sursur-gery, neurosursur-gery, oral surgery

and thoracic surgery are involved Disease knows not

the man-made barriers that have been set up

Each field can contribute to the others One has only

to reflect on the importance of mirror laryngoscopy

before and after thyroid surgery Adequate examination

of the larynx is felt to be a sine qua non for any

sur-geon who performs a thyroidectomy just as a

sigmoi-doscopy should be performed by the surgeon who

performs the abdominoperineal resection For anyone

who does major surgery in the neck, extension of

resectability must not be hampered by a lack of

famil-iarity with thoracic surgery when the disease has

extended below the clavicles This principle holds true

for both malignant disease and trauma Major surgery

on the larynx sooner or later will involve the cervical

esophagus and basic knowledge of bowel surgery will

enhance the armamentarium of the surgeon and aid

in his decision when selecting the most suitable type

of esophageal reconstruction Procedures on the nose,

except the very simplest, can be refined and well

select-ed only when the surgeon borrows from the

orolaryn-gologist, the plastic and reconstructive surgeon and the

general tumor surgeon

The skills and tricks of one field are often applicable

to another field In the definitive treatment of malignant

tumors the details of an elaborate reconstruction

proce-dure are of little avail unless the primary disease has

been handled correctly with full knowledge of the natural

history of the disease By the same token, radical surgical

treatment is incomplete if a suitable and adaptable

reconstructive procedure or prosthesis has been omittedpurely through a lack of versatility Obstructive vasculardisease affecting the intracranial circulation amenable tosurgical correction may have its center of trouble locatedeither in the chest or neck or in both regions The selec-tion of the best-suited vascular procedure is enhanced

by a working knowledge of general vascular surgery.With anticipation of the criticism that such a con-cept would lead to a Jack-of-all-trades, master of none,one need but read the history of surgery Many of thegreat surgeons of yesterday were first primarily generalsurgeons; with this basic knowledge they contributedlasting ideas both in the specialty fields and in generalsurgery Billroth was the master of gastrectomy and atthe same time contributed to cleft palate repair by frac-turing the hamulus of the pterygoid process, thus releas-ing the tensor veli palatini muscle King, a general sur-geon, made a significant contribution in the treatment

of bilateral abductor cord paralysis of the larynx Suchexamples are not intended to detract from the innu-merable contributions by the surgical specialists which

in their own fields outnumber these examples Nor

is the concept that is portrayed in this atlas intended

to lessen or minimize in any way the need for thespecialist Actually it supports the specialist and re-emphasizes the natural evolution of surgery

John Henry Cardinal Newman in his classic The ldea

of a University advocated a liberal education whichwould serve as the background for future endeavors

He pointed out that any student able "to think and toreason and to compare and to discriminate and to ana-lyze, who has refined his taste, and formed his judg-ment will not indeed at once be a lawyer, or a pleader,

or an orator, or a statesman or a physician but hewill be placed in that state of intellect in which he cantake up anyone of the sciences or callings with anease, a grade, a versatility, and a success to whichanother is a stranger." So in the art and science ofsurgery, a liberal basic foundation is necessary Fromsuch a foundation and broad outlook, the field of headand neck surgery seems to have drifted Reunification

of all groups interested in the field of surgical problemsrelated to the head and neck is the intention, hope andaim of this Atlas of surgical techniques

JOHN M LORE, JR.

xxxiii

IN THE' FIRST EDITION

.-,.-I am deeply grateful to my wife, Chalis, for her sacrifice,

patience and able skill as an executive secretary She

has typed and retyped the manuscript under

consid-erable duress

My children, John III, Peter, Margaret and Joan, have

all felt the pressures and sacrifices resulting from the

loss of many happy hours together which have been

missed because of the time consumed in the

prepara-tion of this work

I am indebted to my mother for her encouragement

and prayers

Professionally, my indebtedness extends from books,

journals and other collections of the surgical literature,

through various opinions voiced at surgical meetings

(the authors of which I regret to say have slipped my

memory), to my recent and past teachers and associates

All education is a compendium, and even more so

sur-gical education Hence many of the steps in this atlas

are the ideas, thoughts and work of surgeons under

whom I have trained or worked I owe much to my father

and to John J Conley who were my early teachers A

great many of the surgical procedures and techniques

concerned with the treatment of tumors of the head

and neck either originated with or were developed by

Hayes Martin and other surgeons on the Head and Neck

Service of Memorial Hospital In the basic background

of general surgery which forms an integral part of this

atlas, I owe a debt of great magnitude to John L Madden,

Director of Surgery at Saint Clare's Hospital

To make the decision after my father's death to

con-tinue surgical training in general surgery after

comple-tion of the first phase in otolaryngology presented a

crisis Two men convinced me and gave me advice of

immeasurable value They are Michael Deddish, M.D.,

and Alexander Conte, M.D Without them I never would

have completed my surgical training and never would

have come to realize the benefits of a multifaceted

surgical background

John S Lewis, M.D., who is mainly responsible for

the present technique of temporal bone resection in

cancer of the middle ear, has kindly contributed to that

section of the atlas

Edward Scanlon, M.D., has been kind in lending his

original experiences and thoughts in colon transplants

for reconstruction of the esophagus These ideas have

been of considerable aid and have been a guide topersonal experiences in this problem Again to AlexanderConte my thanks for supplying original photographs ofhis technique of cervical esophageal reconstruction.During the two years of pressure to complete thiswork, my surgical partner, Louis J Wagner, M.D., hasunselfishly covered our practice to allow me the neces-sary undisturbed time From him, I have also learned anumber of operative steps which have been successful

in the solution of some technical problems

When this atlas was in its infancy, it was only throughthe cooperation of John L Madden and the administra-tion of Saint Clare's Hospital, specifically the late Mother

M Alice, O.S.F, and her successor Sister M Columcille,O.S.F., that actual work began At Saint Clare's Hospital

I met Robert Wabnitz, the sole illustrator of this volume,who since then has spent many hours in the operatingroom making sketches and at the drawing board com-pleting the art work Without his skills as an artist andhis knowledge of anatomy, the illustrations would havebeen impossible Both he and I are grateful to the Univer-sity of Rochester where he now heads the MedicalIllustration Department for allowing him time to com-plete this work If it were not for the skill in its repro-duction, the best of art work would be for naught TheW.B Saunders Company has excellently completed thisendeavor I am deeply indebted to the staff of theCompany for their advice, suggestions and patience I

am grateful to my colleague William J McCann, M.D.,for initiating this most fortunate association with theSaunders Company

I wish also to acknowledge the cooperation of theAdministrator and Assistant Administrator of GoodSamaritan Hospital, Sister Miriam Thomas and SisterJoseph Rita, as well as the Operating Room Supervisor,Miss Martha Henry, and the entire nursing staff for theirhelp and vision in the treatment and care of the patientswith many of these operative and postoperative problems

I would be remiss if I did not add the aid of the istration and staff of Tuxedo Memorial Hospital

admin-My thanks to Anthony Paul for drawing many of thelead lines and some of the labels and to David Hastingsfor his care in photographing the x-rays in Chapter I

JOHNM LORE,JR

xxxv

1 SECTIONAL RADIOGRAPHIC ANATOMY

ANATOMIC RADIOGRAPHS • • • 1

john M. Lore, Sr., 1938

Sagittal Section Through the Midportion of the

Sagittal Section Through the Lateral Wall of the

Nose, Lateral Border of the Tongue, and Lamina

of the Thyroid Cartilage Showing Its Superior

and Inferior Cornua • 4

Sagittal Section Through the Floor of the Nose

and the Body of the Tongue • • 6

Sagittal Section Through the Middle of the Skull 8

Frontal Coronal Section in the Region of the

Frontal Coronal Section Just Beyond the

Frontal Coronal Section in the Region of the

CT AND MRI • • •• •.•.• • • 16

David F Hoyes and Scott Cholewinski

Frontal Coronal Section in the Region of the

Second Molar Teeth • 16

Frontal Coronal Section Just Beyond the

Third Molar Teeth • 17

Frontal Coronal Section in the Region of the

Anterior Faucial Pillar and Tonsil 18

Three-Dimensional Reconstructed CT Scans 18

Imaging in the Diagnosis and Treatment of

Overview • 26

Scott Cholewinski

ADVANCED TECHNIQUES FOR CT IN THE

HEAD AND NECK •.• • ••.• •.• • 34

Ronald A Alberico and Ahmed Abdehalim

The Role of Imaging in the Head and Neck 34

Detection of Perineural Disease at the Skull Base 35

Oblique Imaging of the Oral Pharynx to Avoid Dental

Multiplanar Techniques to Evaluate Tumor Location

Three-Dimensional CT of the Inner Ear • 39

Contrast Medium-Enhanced High-Resolution CT 40

CT Angiography of the Neck: Venous Malformation With Traumatic Arteriovenous Fistula 42

CT Venography of Facial Venous Malformation 44

Three-Dimensional CT of Vascular Tumor Relationship 46 Endoluminal and Cut-Away View of the Trachea

With Medial Deviation of the Carotid Artery •• 47 EXAMPLES OF MRI IN THE SUPERIOR

David F Hayes

POSITRON EMISSION TOMOGRAPHy •.• • 56

Rabert S Miletich and john M Lore, jr.

Role of FDG-PETin Head and Neck Cancer • 57

BLINDNESS AND OPHTHALMIC COMPLICATIONS

OF SURGERY OF THE HEAD AND NECK • 66

Daniel P Schaefer and Arthur f Schaefer

Blindness • • 66

xxxvii

125

Sequence of BLS •.• 70

Open Cardiac Massage Resuscitation • 72

Thoracentesis • • 74

Open Thoracotomy for Empyema Drainage 78

Intercostal Catheter Suction Drainage

With Underwater Seals • 80

Management of Acute Respiratory Emergencies 84

Emergency Establishment of Airway 84

Needle Biopsy Techniques • 87

Ashok Koul

Needle Aspiration Biopsy • ··· 87

Commonly Used Terminology for Squamous

Ashok Koul

Commonly Used Special Stains for Head and

Mucosal Biopsy: Toluidine Blue Staining Technique 91

Exfoliative Cytology Biopsy Technique , 91

Definition • •• 91

Technique of Basic Z-Plasty • 92

Basic Principles Relative to Bone and Cartilage

Rib, Iliac, and Costochondral Grafts 107

Iliac Bone Graft-"Trap Door Type" 110

Sural Nerve Grafts • • • 112

Skin Incision • 112

Nonabsorbable Sutures for Mucosal Repair 112

Preoperative and Postoperative Care 114

William R Nelson and R Lee Jennings

Lack of Multidisciplinary Approach

Tailoring the Scope of Surgical Resection

to the Ability of the Surgeon Rather Than

to the Objective Requirements Imposed

A Compromise of the Ablative Phase of Surgery

to Accommodate Limited Reconstructive Skills 126 Compromise of Surgical Margins Because

Radiation Therapy or Chemotherapy

of the Lesion During or Immediately

on the Completion of Treatment 126 Failure to Realize the Implication of the

"Condemned Mucosa" or Multiple Primary

Failure to Perform a Complete General Physical Examination as Well as a Complete Head

Prolonged Watch-and-Wait Attitude in the Face

Treating a Patient With Antibiotics for an Extended Period of Time Without a Biopsy 128 The Place for Chemotherapy in Management

of Squamous Cell Carcinoma of the Head and Neck 128

Monica B Spaulding

Recurrent or Metastatic Head and Neck Cancer 129 Preoperative Chemotherapy, Uncompromised Surgery,

and Selective Radiotherapy in the Management

of Advanced Squamous Cell Carcinoma of the

John M Lore, Jr., Sol Kaufman, Nan Sundquist,

A Comprehensive, Interdisciplinary Head and Neck

john M. Lore, jr., A.Charles Massaro, and Angela Bontempo

Scott Cholewinski, john Asirwatham, Daniel Broderick,

ond john M Lore, jr.

Methods of Bone Involvement: Mandible 142

VOICE, SPEECH, AND SWALLOWING

REHABILITATION OF THE HEAD AND NECK

Dental and Prosthetic Considerations in Head

PERORAL ENDOSCOPY OF THE HEAD AND NECK 179

Indirect Mirror Laryngoscopy and Nasopharyngoscopy

Direct Optical Laryngoscopy and Nasopharyngoscopy 180

Direct Rigid Laryngoscopy and Nasopharyngoscopy 181

Direct Rigid Laryngoscopy and Hypopharyngoscopy 182

Cervical Esophagoscopy After Total Laryngectomy

or Cervical Esophageal Surgery 194

Other Approaches to the Sphenoidal Sinus 228

Osteoplastic Approach to the Frontal Sinus 234

Partial and Radical Maxillectomy • 236

Removal or Saving Remainder of Soft Palate

Radical Resection of Maxilla With Orbital and Partial

Resection of Maxilla Including the Floor of the Orbit With Preservation of the Globe • 246 En-Bloc Resection for Chondrosarcoma 246

Cysts of Maxilla • 250

Excision of Nasopalatine Duct Cyst 254

Keith F Clark

6 THE NOSE AND THE NASOPHARYNX 267

Anatomy of the Lateral Wall of the Right Nasal Cavity 267

Anatomy of Epistaxis 270

Anterior and Posterior Packing for Epistaxis 272

External Ethmoidectomy Approach to Epistaxis 279

Ligation of Internal Maxillary Artery 282

Removal of Nasal and Nasopharyngeal Polyps 286

Transpalatine Exposure of the Nasopharynx and the

Transmaxillary Approach to Nasopharynx and Base

Newborn and Young Children • 295

Submucous Resection of Nasal Septum 300

Alternate Techniques of Rhinoplasty 324

Columellar Graft for Collapsed Nasal Tip 328

Septal Flap for External Nasal Defect 334

Excision and Reconstruction of Ala Nasi 336

Excision and Reconstruction of Columella 336

Resection and Reconstruction of Tumor of the

Reconstruction of Nose With Arm Flap 344

Nasal Reconstruction With Lateral Forehead Flap 346

Nasal Reconstruction With Combined Scalp

Transection of Forehead and Scalp Pedicle 352

Revision of Nasolabial Fold and Ala Nasi 352

Enlargement of Nares With Z-Plasty 352

Resection of Nasal Septum for Carcinoma

Hypoglossal-Facial Nerve Anastomosis 384 Masseter Muscle Transposition-Intraoral 386 Fascial Slings for Facial Paralysis 388 Treatment of Paralysis of the Depressors of the

Trigeminal Neuralgia (Tic Douloureux) 392 Incision and Drainage of Abscesses 394

8 GENERAL PURPOSE FLAPS

Introduction: Flap Selection and Design 399 Classification of Large Transposed Myocutaneous

Limitations and Pitfalls with Major Standard

Limitations and Pitfalls According to Specific Flaps 401

Pectoralis Major Myocutaneous Flap 404 Reconstruction of the Entire Hypopharynx

and Portion of Cervical Esophagus, Oropharynx,