Head and Neck Surgery

Head and Neck SurgeryMarc Reinald G Santiago M.D., DPBO-HNS Selected Readings • Anatomy pp 12-16,19-22 • Introduction to Head and Neck Surgery pp196197 • Thyroid Masses pp 290-298 • Cancer of the Head and Neck pp 305-313 • Management of neoplasms • Most challenging and exciting – Senses in the region – Crucial functions and appearance – Survival, preservation and/or reconstruction – Multidisciplinary approach . THYROID . circumvallate papillae (linea terminalis) • laterally .anterior tonsillar pillars .hard palate-soft palate junction • inferiorly .ORAL CAVITY • Oral cavity • vermilion border of the lip • posterosuperiorly . • 7 subsites: – Lips – Dentoalveolar ridges – Oral tongue – Retromolar trigone – Floor of the mouth – Buccal mucosa – Hard palate . dorsal oral tongue . ventral tongue.Oral Tongue • Muscular structure with overlying nonkeratinizing squamous epithelium • Ventral portion – contiguous with anterior floor of the mouth • Posterior limit – circumvallate papillae • Subsites: lateral tongue. anterior tip. • Superior-inferior Longitudinal • Transverse • Vertical • The intrinsic musculature of the tongue provides a minimal barrier to tumor growth . • • • • Genioglossus Styloglossus Palatoglossus Hyoglossus . • Lingual A. . • All muscles of the tongue – innervated by Hypoglossal N. • Except – Palatoglossus – Pharyngeal branch of Vagus N . – Special sensory for taste • Chorda tympani n • Base of the tongue: – Glossopharyngeal .• Sensory Innervation • Anterior 2/3 – lingual N. • • • • Lymph Drainage Tip – submental nodes Lateral tongue – level 1 & ll Lack of anastomoses between anterior tongue – ipsilateral drainage • Skip metastasis to level lV 20-33% • Base of tongue – upper cervical (crossover) . Anatomy of the Pharynx . Pharynx • Common aerodigestive tract • Divided into : – Nasopharynx – Oropharynx – Laryngopharynx . Inferior pharyngeal constrictor . Superior pharyngeal constrictor 2.Musculoskeletal framework of the Pharynx • Muscles 1. Middle pharyngeal constrictor 3. Nasopharynx • Opening of eustachian tube • Salpingopharygeal fold • Rosenmueller’s fossa • Guerlach’s tonsil • Roof of NP: – Sphenoid bone – Floor of Sphenoid sinus – Pharyngeal tonsil or adenoids . Oropharynx • Borders – Sup: soft palate – Inf: epiglottis. tonsillar crypts and palatine tonsil – Ant: post 3rd of tongue – Post: midline wall of superior constrictors . Oropharynx • Sulcus – Ant 2/3 & Post 1/3 – Circumvallate papillae – Divides somatic & visceral innervations of tongue . Oropharynx • Base of Posterior tongue – 2 small fossae – Bounded by median glossoepiglottic fold and paired lateral glossoepiglottic folds . • Lateral Pharyngeal Wall – Bed of tonsillar crypt – Palatoglossal and palatopharyngeal folds . Hypopharynx • Posterior pharynx • Post cricoid • Pyriform sinus . Triangles of the Neck • 2 major triangles of the neck: 1. Posterior Cervical Triangle . Anterior Cervical Triangle 2. . Anterior Cervical Triangle 1. Digastric triangle – Superior: – Anterior: – Posterior: mandible anterior belly of digastric posterior belly of digastric . Anterior Cervical Triangle 2. Carotid triangle – Superior: – Anterior: – Posterior: posterior belly of digastric superior belly of omohyoid sternocleidomastoid . Anterior Cervical Triangle 3. Muscular triangle – Superior: – Anterior: – Posterior: superior belly of omohyoid midline sternocleidomastoid . Submental triangle – Superior: – Inferior: – Lateral: symphysis of mandible hyoid bone anterior belly of digastric .Anterior Cervical Triangle 4. Posterior Cervical Triangle 1. Occipital triangle – Anterior: – Posterior: – Inferior: sternocleidomastoid trapezius omohyoid . Posterior Cervical Triangle 2. Subclavian triangle – Superior: – Inferior: – Anterior: omohyoid clavicle sternocleidomastoid . Deep Cervical Fascia a.Cervical Fascia • 2 major divisions: 1. Middle layer c. Superficial Cervical Fascia 2. Deep layer . Superficial layer b. Cervical lymph node groups • Submental (level IA) – Contained within the submental triangle – Harboring metastases from cancers arising from the floor of the mouth. anterior mandibular alveolar ridge. anterior oral tongue. and lower lip . Cervical lymph node groups • Submandibular (level IB) – Within the submandibular triangle – Harboring metastases from cancers arising from the oral cavity. and submandibular gland . soft-tissue structures of the midface. anterior nasal cavity. Cervical lymph node groups • Upper Jugular (level IIA and IIB) – Located around the upper third of the IJV – Extending from the level of the skull base above o the level of the (clinical landmark) – Surgical landmark: inferior border of the hyoid bone below level of carotid bifurcation . Cervical lymph node groups • Upper Jugular (level IIA and IIB) – Divided into IIA (anterior) and IIB (posterior) by the spinal accessory nerve – Harboring metastases from cancers arising from the oral cavity. hypopharynx. nasal cavity. and parotid gland . larynx. oropharynx. nasopharynx. Cervical lymph node groups • Middle Jugular (level III) – Located around the middle third of the IJV – Extending from the inferior border of the hyoid bone above to the inferior border of the cricoid cartilage below (clinical landmark) – Surgical landmark: junction of the omohyoid with IJV . oropharynx. and larynx .Cervical lymph node groups • Middle Jugular (level III) – Harboring metastases from cancers arising from the oral cavity. nasopharynx. hypopharynx. cervical esophagus.Cervical lymph node groups • Lower Jugular (level IV) – Located around the lower third of the IJV – Extending from the inferior border of the cricoid cartilage above to the clavicle below – Harboring metastases from cancers arising from the hypopharynx. and larynx . thyroid. Cervical lymph node groups • Posterior triangle (level VA and VB) – Encompasses all LN contained within the posterior triangle – 3 predominant pathways: 1. 2. . Nodes located along the SAN Nodes along the tansverse cervical artery Supraclavicular nodes • VIRCHOW’s node (sentinel node) 3. cutaneous structures of the posterior scalp and neck . oropharynx.Cervical lymph node groups • Posterior triangle (level VA and VB) – Level VA (superior) and VB (inferior) is separated by a horizontal plane marking the inferior border of the anterior cricoid arch – Harboring metastases from cancer arising from the nasopharynx. larynx.Cervical lymph node groups • Anterior compartment (level VI) – Encompasses LN of the anterior compartment of the neck • • • • Perithyroidal LN Pre and Paratracheal LN LN along the RLN Precricoid LN (Delphian node) – Harboring metastases from cancer arising from the thyroid. piriform sinus. and cervical esophagus . REVIEW OF THYROID NEOPLASMS . Thyroid Adenoma • Is a true benign neoplasm derived from follicular cells • Occasionally multiple and may arise in the setting of a normal thyroid. nodular goiter. toxic goiter. or thyroiditis • Occur most commonly in women older than 30 years . the suspicion for carcinoma should increase .Thyroid Cyst • Presence of a cyst does not signify a benign lesion because papillary carcinomas and parathyroid tumors may present with cystic masses • Differentiated by ultrasound • FNA: thyroid cyst should be drained completely – may prove curative in majority of simple cysts • If a cyst persist after 3 drainage attempts or reaccumulates quickly. Papillary Carcinoma • • • • • Most common form of thyroid malignancy 60-70% of all thyroid cancer 30-40 years of age Female:male ratio of 2:1 Predominant thyroid malignancy in children (75%): presnt more commonly with advanced disease, including cervical and distant metastases, prognosis remains quite favorable Follicular Carcinoma  10% of thyroid malignancy  Female/male ratio of 3:1  Occurs more frequently in iodine deficient areas, esp in areas of endemic goiter  A definitive preoperative diagnosis is usually not possible with FNAC  Spread through local extension and hematogenous spread Hurthle Cell Tumor • • • • Diagnosed by FNAC Subtype of follicular cell neoplasm 20% of these lesions are malignant Represent approximately 3% of all thyroid malignancies • More aggressive than follicular CA • Often multifocal and bilateral at presentation • More likely to metastasize to cervical nodes and distant sites Medullary Carcinoma • 5% of all thyroid carcinomas • Arise from parafollicular C cells and may secrete calcitonin. prostaglandins. carcinoembryonic antigen. histaminadases. and serotonin • associated with MEN 2 • Total thyroidectomy should be performed by patient age of 2-3 years or before C cell hyperplasia occurs . or exsanguination .Anaplastic carcinoma • One of the most aggressive malignancies. with few patients surviving 6 months beyond initial presentation • Represent fewer than 5% of all thyroid carcinomas • Long standing neck mass that enlarges rapidly • Most will succumb to superior vena cava syndrome. asphyxiation. The PCS-PSGS-PAHNSI Evidence-Based Clinical Practice Guidelines on Thyroid Nodules . T4 and FT4)? In the initial evaluation of a patient with a thyroid nodule. T3. serum TSH and/or thyroid hormones are measured. .Recommendations for Diagnostic Workups What is the role of thyroid function tests (TSH. Recommendations for Diagnostic Workups Ultrasound evaluation is recommended for the following: • High-risk patients (patients with history of familial thyroid cancer. previous diagnosis of MEN2. childhood cervical irradiation) • Patients with suspicious nodule for cancer in the background of MNG • Those with adenopathy suggestive of a malignant lesion • Evaluation of the patient with nodular goiter . Recommendations for Diagnostic Workups What is the role of fine needle biopsy in the diagnosis of thyroid nodule? FNAC is recommended for the diagnosis of benign and malignant thyroid lesions. . 7 .25 100 96.4 93. JA MMC 92.1 QMMC 2002 (49) 66.5 12.8 17.7 19. Author Specificity Sensitivity Diagnostic Likelihood Accuracy Ratio+ (n) % % % % de los Santos.7 57.7 91. ET 96. Summary Characteristics for Thyroid Fine-Needle Aspiration: Results of Local Literature Survey.3 1995 (30) Guiang. J P UST 85 1999 (57) Kintanar.1 85.5 94.Recommendations for Diagnostic Workups • the over all diagnostic accuracy of FNAC ranges from a low of 85% to a high of 96% Table 1.5 6.2 PGH 1985 (61) Gomez. H R 97. • Sensitivity – Likelihood that patient with disease has positive test results • Specificity – Likelihood that patient without disease has negative test results • Positive Predictive value – Fraction of patients with positive test results who have disease • False-negative rate – Fine-needle aspiration negative. histology positive for cancer • False-positive rate – Fine-needle aspiration positive. histology negative for cancer . Recommendations for Diagnostic Workups What is the role of other imaging modalities such as CT scan. . • Magnetic Resonance Imaging and Computed Tomography should NOT be used routinely because they are rarely diagnostic for malignant lesions in nodular thyroid disease. MRI and PET scan? • PET scan with 18F-FDG is an accurate diagnostic tool in the detection of thyroid cancer in inconclusive cytologic diagnosis of thyroid nodules. Recommendations for Medical Treatment What is the role of TSH suppression for benign thyroid nodule/s? TSH suppression may be considered in young patients with small (< 3 cm) cytologically benign thyroid nodules. . Recommendations for Medical Treatment • TSH Suppression – result in at least a 50 percent reduction in the size of the thyroid nodule – prevented the development of additional nodules . . it may be given to cases of benign non-toxic goiter patients who have cosmetic complaints or compression symptoms but who refuse surgery or who are at high risk for surgery.Recommendations for Medical Treatment What is the role of radioactive iodine (RAI) therapy for benign thyroid nodule/s? Radioactive iodine is not the primary management for benign thyroid nodule/s. However. Recommendations for Surgical Treatment • Solitary benign thyroid nodule  lobectomy with isthmusectomy is sufficient. . . inadequate or suspicious aspirate.Recommendations for Surgical Treatment What is the role of frozen section in the diagnosis of thyroid CA? Frozen section has limited utility in diagnosing thyroid malignancies if the fine needle aspiration biopsy result shows follicular neoplasm. Recommendations for Surgical Treatment • Well-differentiated thyroid carcinoma What is the recommended surgical procedure for the treatment of WDTC? The recommended surgical procedure for the treatment of WDTC is near-total or total thyroidectomy. . . . node-negative. intrathyroidal. This includes all patients with thyroid cancer except those with small (<1. . low-risk tumors.5 cm).Recommendations for Surgical Treatment What is the role of completion thyroidectomy in the treatment of WDTC? Completion thyroidectomy should be offered to those patients for whom a near-total or total thyroidectomy would have been recommended had the diagnosis been available before the initial surgery. Head and Neck Cancer . . Near total glossectomy . Skin incisions . Visor Flap with pull through technique Marginal mandibulectomy . . . . . . . . Inferior maxillectomy via lateral rhinotomy incision . . . . . Radical Neck Dissection – Removal of all ipsilateral cervical lymph node groups. internal jugular vein. and sternocleidomastoid – Indicated for patients with extensive LN metastases or extension beyond the capsule or involvement of SAN and IJV .Neck Dissection Classification 1. spinal accessory nerve. Modified Radical Neck Dissection – En bloc removal of lymph node bearing tissue from one side of the neck (I-V) – There is preservation of one or more of the ff structures: • • • SAN IJV SCM .Neck Dissection Classification 2. Neck Dissection Classification 3. Selective Neck Dissection – En bloc removal of one or more LN groups that are at risk for harboring metastatic caner – Assessment based on the location of the primary tumor – Performed for patients who are at risk for early LN metastases . Extended Neck Dissection – Neck dissection extended to other adjacent structures (parotid) – May also remove the hypoglossal nerve. or carotid artery . levator scapulae muscle.Neck Dissection Classification 4. .And a lot more…. Thank you .