mately 1cm above the clavicle inferiorly. An imaginary line drawn from the mastoid process to the angle of the mandible running along the lower border of the mandible to the midline is the upper limit. The anterior border of the trapezius muscle posteriorly, with an imagin ary line running from the middle of the chin to the medial end of the clavi- cle is the ant erior limit. (cid:142)(cid:3) If a McFee incision is used then the skin should be dissected off the unde rlying platysma muscle to the limits of the dissection described previously. Procedure (cid:142)(cid:3) Carry out dissection from the lower end. Divide the platysma mus cle, sternomastoid muscle and omohyoid muscle through the lower incision. (cid:142)(cid:3) Identify the lower end of the internal jugular vein under the omohyoid muscle and tie it of f, passing an upper and lower transfixion suture through the vessel and divide it. Check th at the thoracic duct has not been damaged. If there is a chyle leak, tie it off or clip it with a ligature. Identify and carefully dissect out the carotid artery and the vagus nerve, which are deep and slightly anterior to the internal jugular vein. Lift the fat of the pos terior triangle off the prevertebral muscles and identify the phrenic nerve as it passes ve rtically across the scalenus anterior muscle. (cid:142)(cid:3) Once all of these structures have been identified, resect the posterior tr iangle contents, the sternomastoid muscle, the omohyoid muscle and the internal jugular vei n which have been detached at their lower end upwards to the top of the neck preserving the phrenic nerve, the common carotid artery and the vagus nerve (Fig. 15.13). Divide branches of the internal jugular vein and the cervical nerve roots. (cid:142)(cid:3) Divide the ste rnomastoid muscle at the top end of the neck and amputate the lower part of the parotid gla nd. Tie and divide the CHAPTER 15 Head and neck surgery 668 posterior facial vein just deep the parotid gland, carry out dissection anteriorly to inclu de removal of the submandibular gland. Locate and divide branches of the external carotid a rtery such as the facial artery, preserving the hypoglossal nerve and the lingual nerve. (cid:142)(cid:3) Secure haemostasis once the dissection has been completed. Make a check fo r a chyle leak at the lower end of the internal jugular vein. Insert two small vacuum drain s through the skin below the lower incision line. One drain should run along the anterior b order of the trapezius muscle and the other should run up the anterior part of the neck to the submandibular region. (cid:142)(cid:3) Close the incision in layers with 3/0 Vicryl and the skin with clips and activate the vacuum drains. Postoperative complications Early (cid:142)(cid:3) Bleeding. The most common complication w hich usually necessitates a return to the operating theater if severe. Carotid artery ruptu re is potentially lethal and occurs in over 2% of cases, usually at a later stage. (cid:142)(cid:3) Infection. Wound dehiscence, necrosis and infection can occur if there has been poor flap design or poor wound closure. It is more likely after previous radiotherapy . These problems are less common when the McFee incision is used. (cid:142)(cid:3) Chyle leak. This is uncommon. A small leak may resolve itself with pressur e and intermittent suction. A severe leak requires total parenteral nutrition. (cid:142)(cid:3) Cerebral or facial oedema. This is due to poor venous drainage. It is rare with a unilateral neck dissection, but happens frequently with simultanous bilateral n eck dissections. (cid:142)(cid:3) Stroke. Manipulation of the internal carotid arteries in patients with known peripheral vascular disease can cause stroke. (cid:142)(cid:3) Salivary fistulas. This occurs in 6 \200\22330% of cases. Fistulas are usu ally small and resolve with regular dressings. Occasionally a fistula has to be ex- cised. (cid:142)(cid:3) Horner \200\231s syndrome. This is caused by accidental damage to the symp athetic nerve trunk behind the carotid sheath. It causes an ipsilateral constricted pupil, ptosis and absence of sweating of the face and neck. This tends to improve spontaneously. (cid:142)(cid:3) Death. The operative mortality rate is 1%. Late (cid:142)(cid:3) Shoulder syndrome. Sacrifice of the spinal accessory nerve usually results in a drooping shoulder, pain and reduced shoulder movement, particularly abduction. Physiotherapy may be helpful. (cid:142)(cid:3) Painful dysaesthesia. Patients may get severe discomfort when their neck is touched. This is thought to be caused by traumatic neuromas on surgically divided c ervical nerves. NECK DISSECTION1 669 Fig. 15.11 Y-shaped neck incision Fig. 15.12 McFee incision Internal jugular vein Accessory nerve (divided) Digastric muscle Hypoglossal nerve Omohyoid muscle (divided) Vagus nerve Fig. 15.13 Right, radical neck dissection with McFee incision CHAPTER 15 Head and neck surgery 670 External carotid artery ligation Anatomy The common carotid artery bifurcates at the level of the upper border of the thyroid cartilage. After the bifurcation, the external carotid a rtery lies external to the carotid sheath. The artery runs deep to the posterior belly of t he digastric muscle, crosses the styloglossus and stylopharyngeus muscles and pierces the p arotid gland, where it terminates as the superfi- cial temporal artery and the maxillary ar tery at the level of the neck of the condyle of the mandible. Indications Emergency (cid:14 2)(cid:3) Uncontrollable epistaxis (cid:142)(cid:3) Penetrating neck wounds Elective (cid:1 42)(cid:3) Tumor resection (cid:142)(cid:3) Large arteriovenous malformation Equipment requ ired (cid:142)(cid:3) Number 10 and 15 blades surgical blades. (cid:142)(cid:3) Mono- and b i-polar diathermy. (cid:142)(cid:3) Vascular slings. Position Supine with the head turned t o the opposite side and the neck extended. Incision Transverse lying within a neck crease a bout 2cm below the level of the mandible, at the level of the thyroid cartilage. Procedure (cid:142)(cid:3) Divide the skin and the underlying platysma muscle with a number 10 blade and reflect the deep cervical fascia overlying the sternomastoid muscle to allow posterior retraction of the muscle. (cid:142)(cid:3) Identify the internal jugular and mobilize it and retract it posteriorly. Careful palpation of the artery will help the operator to bluntly dissect down to the vesse l and expose it. (cid:142)(cid:3) Retract the hypoglossal nerve and posterior belly of digastric muscle supe riorly (Fig. 15.14). Find the carotid bifurcation and identify the external and internal ca rotid arteries. The internal carotid artery can be identified by the vagus nerve which acco mpanies it. The external carotid artery should be identified by finding a branch such as th e superior thyroid artery. (cid:142)(cid:3) Once the external carotid artery has been identified, dissect it out and p ass a sling under the vessel. Place one or two ties around it with 1/0 Vicryl and at this p oint, check that the bleeding is controlled. If the vessel has been penetrated and cannot b e repaired then tie the artery either side of the bleeding point. Clamp the vessel between the ties, divide it and then insert transfixion sutures at either end, again using a 1/0 Vi cryl. EXTERNAL CAROTID ARTERY LIGATION1 671 Closure Close the incision in layers with a vacuum drain if necessary. Use skin clips to cl ose the skin. Postoperative care The neck is inspected for haematoma. Skin clips can be rem oved at day seven. Complications Intraoperative (cid:142)(cid:3) Arterial hemorrhage (cid:1 42)(cid:3) Venous hemorrhage caused by injury to a large vein such as the common facial or internal jugular vein (cid:142)(cid:3) Accidental ligation of internal carotid artery. The incidence of perma- nent CVA is 30 \200\22335% and death approximately 20%. Postoperative (cid:142)(cid:3) Haematoma (cid:142)(cid:3) Specific to the surgical site e.g .; damage to the mandibular branch of the facial nerve (cid:142)(cid:3) Infection. External carotid artery Accessory nerve Posterior belly of diagstric Internal jugular vein retracted laterally Hypoglossal nerve Vagus nerve Lingual artery Superior thyroid artery Fig. 15.14 Exposure of right external carotid artery CHAPTER 15 Head and neck surgery 672 Excision of branchial cyst, sinus, or fistula Anatomy Branchial cysts are congenital second pharyngeal pouch abnormalities. They present as painless, fluctuant, slowly growing latera l neck swellings, anterior to the junction between the upper third and lower two-thirds of the sternomastoid. As they present in adolescence a congenital cause may be forgotten. It i s equally important to ensure that the cyst is not a lower pole parotid tumor. A CT scan wi ll usually distinguish where the cyst lies. A branchial fistula is formed by the downgrowth of the 2nd branchial arch over the 2nd, 3rd and 4th branchial clefts. The fistula opening can be located in the lower third of the ste rnomastoid. As the fistula lies between 2nd and 3rd cleft structures, it passes between the internal and external carotid arteries. Indications (cid:142)(cid:3) Recurrent infection (cid:142)(cid:3) Large cyst (cid:142)(cid: 3) Persistent discharge from sinus. Equipment required (cid:142)(cid:3) Number 10 and 15 surgical blades (cid:142)(cid:3) Monop olar and bipolar diathermy. Branchial cyst Mark the lesion preoperatively with surgical ink. Position Supine with the head-up tilt on the operating table. The neck extended and the hea d rotated, supported by a head ring. Incision Transverse directly over the swelling, but must be at least 20mm below the mandibl e to avoid the mandibular branch of the facial nerve. Procedure (cid:142)(cid:3) Divide the platysma and incise the deep cervical fascia overlyin g the sternomastoid. (cid:142)(cid:3) Retract the sternomastoid posteriorly, allowing the cyst lining to be diss ected free of adhesions. Carry out cautious mobilization on the deep surface of the cyst as it may extend between the internal and external carotid arteries. The accessory nerve lies close to the posteromedial surface and can be damaged by careless dissection or injudiciou s use of the diathermy. Postoperative care Monitor the patient for an expanding haematoma. This page intentionally left blank CHAPTER 15 Head and neck surgery 674 Complications Intraoperative (cid:142)(cid:3) Arterial hemorrhage (cid:142)(cid:3) Venous h emorrhage (cid:142)(cid:3) Accessory nerve damage due to injudicious use of diathermy. Post operative (cid:142)(cid:3) Haematoma (cid:142)(cid:3) Seroma (cid:142)(cid:3) Infection. Branchial sinus/fistula Mark the lesion preoperatively with surgical ink and outline the el lipse of skin to be excised. Position Supine with a head-up tilt on the operating table with the neck is extended and he ad rotated, supported by a head ring. Procedure (cid:142)(cid:3) Excise the skin sinus with an ellipse of adjacent skin (Fig. 15. 15) and deepen to platysma. Divide the platysma and incise the deep cervical fascia overlying the s ternomastoid. (cid:142)(cid:3) Retract the sternomastoid posteriorly, at the same time applying traction to the skin ellipse so that the tract can be identified and traced towards the car otid territory. Use a second transverse skin crease (step-ladder incision) to allow access to the carotid bifurcation. Locate the fistula between the arteries, passing over the hypog lossal nerve and alongside the glossophayngeal nerve until it terminates on the pharyn- gea l wall where it blends with the fibers of the middle constrictor muscle. (cid:142)(cid:3) Divide the fistula flush with the muscle, an intraoral approach is not req uired. Placing a finger in the mouth and manually displacing the pharyngeal wall can assist dissection. (cid:142)(cid:3) Place a closed suction drain along the length of the tract and close the tissues in layers. Postoperative care Monitor the patient for expanding haematoma. Complications Intraoperative (cid:142)(cid:3) Arterial hemorrhage (cid:142)(cid:3) Venous h emorrhage (cid:142)(cid:3) Hypoglossal and glossopharyngeal nerve damage due to careless dissection or injudicious use of diathermy. Postoperative (cid:142)(cid:3) Haematoma (cid:142)(cid:3) Seroma (cid:142)(cid:3) Infection . EXCISION OF BRANCHIAL CYST, SINUS, OR FISTULA1 675 External carotid artery Internal jugular vein External jugular vein (ligated) Sternomastoid muscle Hypoglossal nerve Superior thyroid artery Branchial fistula Fig. 15.15 Left branchial fistula CHAPTER 15 Head and neck surgery 676 Pharyngeal pouch excision Anatomy A pharyngeal pouch is a posterior, midline, protrusion of the pharyngeal mucosa through a weakness (Killian \200\231s dehiscence) between thyro- and cricopharyngeus (Fig. 15.16). Indications (cid:142)(cid:3) For relief of symptoms e.g.; dysphagia, halitosis, nocturnal c ough (cid:142)(cid:3) Prevention of secondary complications e.g.; aspiration pneumonia. Equipment required (cid:142)(cid:3) Number 11 and 15 surgical blades are needed (cid:142)(c id:3) Proflavin pack (cid:142)(cid:3) Monopolar and bipolar diathermy (cid:142)(cid:3) Naso gastric tube. Position Supine with head rotated to right, left arm by side, and a sandbag between the sho ulders. Pack the pouch with proflavin on ribbon gauze, which assists in identifying the pou ch. Insert a NG fine-bore feeding tube. Incision Make a transverse skin crease incision at the level of the cricoid cartilage. Procedure (cid:142)(cid:3) Incise the platysma and deep cervical fascia and retract the sternomastoid, internal jugular vein and carotid arteries postero- laterally. Use blunt dis section to locate the sac, which is usually adherent to the esophagus. (cid:142)(cid:3) Mobilize the sac and using gentle traction, identify the pedicle entering the inferior constrictor muscle. Withdraw the pack from the pouch. It is not essential to r emove the sac, but simply to transfix the pedicle to prevent continued contamination. (cid:142)(cid:3) If the sac is excised, test the oesophageal patency with a 28 \200\22330 F r gauge bougie before closing the wall defect. (cid:142)(cid:3) A cricopharyngeal myotomy is an essential adjunct to surgery and prevents postoperative fistula or late recurrence. Either insert a finger or curved artery forceps gently between cricopharyngeus and the oesophageal mucosa. Separate the two layers by opening the beaks of the forceps, followed by incising the cricopharyngeus with a No. 11 blade. This myotomy must be at least 40mm long and performed as far posteriorly as possibl e to avoid inadvertent damage to the recurrent laryngeal nerve. (cid:142)(cid:3) Close the mucosa with absorbable material (3/0 Vicryl) and the inferior co nstrictor muscles with 3/0 PDS. Close the wound over a suction drain. Postoperative care Keep the patient nil by mouth for 5 days. They can start clear fluids at 30ml/hr for the first 24 hours, before unrestricted free fluids. PHARYNGEAL POUCH EXCISION1 677 Superior constrictor Middle constrictor Hyoglossus Hyoid bone Thyrohyoid muscle Inferior constrictor Cricopharyngeus muscle Cricoid cartilage Killians area Fig. 15.16 Anatomy of the pharynx Complications Intraoperative (cid:142)(cid:3) Arterial hemorrhage (cid:142)(cid:3) Venous h emorrhage (cid:142)(cid:3) Recurrent laryngeal nerve damage (cid:142)(cid:3) Aspiration of pouch contents. Postoperative (cid:142)(cid:3) Haematoma (cid:142)(cid:3) Seroma (cid:142)( cid:3) Chest infection (cid:142)(cid:3) Mediastinitis (cid:142)(cid:3) Fistula formation. Alternative procedure Dohlman \200\231s procedure. Requires specialist equipment and traini ng. The esophagus and pouch are cannulated and the adjoining wall is coagu- lated and incis ed. CHAPTER 15 Head and neck surgery 678 Tonsillectomy Anatomy The tonsils are located on the lateral oropharyngeal walls. The main adjacent structures are: (cid:142)(cid:3) Deep (cid:142)(cid:3) Anterior (cid:142)(cid:3) P osterior Palatopharyngeus muscle Soft palate (cid:142)(cid:3) Superior (cid:142)(cid:3) Inf erior Lingual tonsil The arterial blood supply is through the external carotid artery and i ts branches. Of relevance are the ascending pharyngeal artery (tonsillar branches) and less er palatine artery superiorly and the dorsal lingual and ascending palatine arteries and br anches from the facial artery inferiorly. Superior constrictor muscle Palatoglossus muscle The venous outflow drains into a venous plexus around the tonsillar capsule, the lingual ve in, and the pharyngeal plexus. Lymphatic drainage is into the upper deep cervical and jugul odigastric nodes. There is an extensive sensory supply from the glossopharyngeal nerve and the lesser palatine nerve. Important structures deep to the inferior pole include the glosso- pharyngeal nerve, the li ngual artery, and the internal carotid artery. These structures are at risk if the surgical plane in the tonsillar bed is not respected. Indications (cid:142)(cid:3) Recurrent tonsillitis (>3 episodes requiring antibiotics in on e year) (cid:142)(cid:3) Quinsy (cid:142)(cid:3) Lymphoma (cid:142)(cid:3) Malignant tumor (cid:142)(cid:3) To exclude primary squamous cell carcinoma in the tonsil when patient pres ents with an isolated neck node and no discernible primary lesion (cid:142)(cid:3) In conjunction with UVPPP for obstructive sleep apnoea. Equipment required (cid:142)(cid:3) Monopolar and bipolar diathermy (cid:142)(cid:3) Boyle- Davis gag and attachment rods (cid:142)(cid:3) Tonsillar swabs (cid:142)(cid:3) Luc \200 \231s forceps (cid:142)(cid:3) Pillar retractors (cid:142)(cid:3) Tonsillar guillotine (cid :142)(cid:3) Head light for surgeon. Position Supine with a sandbag between the shoulders to extend the neck, with the head supp orted by the table only. Procedure (cid:142)(cid:3) Under direct vision, the field illumina ted by a headlight, grasp the tonsil and elevate it out of the tonsillar fossa using Luc \200\231s forceps (Fig. 15.17). TONSILLECTOMY1 679 The pillar retractor moves the anterior pharyngeal fold laterally and improves exposure. (cid:142)(cid:3) Incise the mucosa from the superior to inferior pole using either cut- tin g diathermy or MacIndoe scissors. Either method can be used to mobilize the tonsil off its bed. (cid:142)(cid:3) Identify the peritonsillar plane, as this is a safe plane between the ton- sillar capsule and superior constrictor muscle. Use careful dissection, sometimes using ga uze swabs held in long handled forceps to sweep the tissues in a superior to inferior direc tion, mobilizing the tonsil until it is held by the inferior pole. This contains the main b lood supply. Clip it to excise the tonsil and carefully tie it. Haemostasis can be assisted by packing the tonsillar fossa with gauze and slowly checking the area for bleeding vessel s in a superior to inferior direction. Pack gauze into the fossa while the contralateral to nsil is removed. At the end of the procedure haemostasis is rechecked and the pharynx caref ul aspirated to remove all clots that might compromise the airway on extubation. Tongue depressor attached to Boyle-Davis gag Posterior tongue Luc \200\231s forceps Uvula Fig. 15.17 Tonsillectomy (surgeon \200\231s view) CHAPTER 15 Head and neck surgery 680 Postoperative care Careful attention for postoperative hemorrhage, this may be hidden from the clinician as the patient the swallows blood. Complications Intraoperative (cid:142)(cid:3) Hemorrhage (cid:142)(cid:3) Dental trauma due to displacement of the mouth gag. Immediate postoperative (cid:142)(cid:3) Hemorrhage; eit her primary or secondary. The overall bleeding rate is 2.3 \200\2233.4% of cases. (cid:142)(cid:3) Primary hemorrhage happens within the first 24hr, due to inadequate haemos tasis at the time of surgery or the displacement of a tie from the inferior pedicle. Requir es return to theater in up to 1% of patients, although the majority of cases can be managed conservatively. (cid:142)(cid:3) Secondary, or reactive, hemorrhage occurs after discharge (1 \200\22310 days) and is due to separation of the slough in the tonsillar bed. The readmi ssion rate is approximately 5%, of which less than 1% are returned to theater. (cid:142)(cid:3) Pain. Discomfort at the operative site is to be expected, but can be referred (e.g. otalgia). (cid:142)(cid:3) Temporary dysphagia. Late postoperative (cid:142) (cid:3) Temporomandibular joint pain. (cid:142)(cid:3) Oronasal fistula, producing hypernas al speech. This can happen due to overuse of the diathermy and failing to appreciate the re lationship of the anterior tonsillar pillar to the soft palate. This page intentionally left blank CHAPTER 15 Head and neck surgery 682 Adenoidectomy Anatomy The posterior nasophayngeal wall contains a variable collection of su bepithelial lymphoid tissue. If this tissue becomes infected, it hypertro- phies to form ma sses that are commonly referred to as the adenoids (syn. pharyngeal tonsil). The adenoids a re particularly prominent in chil- dren, and atrophy with age. When excessively enlarged, t he adenoids can obstruct the posterior nasal aperture resulting in nasal congestion, mouth breathing and nocturnal snoring. The close anatomical relationship to the Eustachian tube c an cause deafness and recurrent middle ear effusions (glue ear). Blood supply is provided by the ascending palatine branch of the facial artery, ascending p haryngeal artery, pharyngeal branch of the internal maxillary artery, and the ascending cer vical branch of the thyrocervical trunk. Venous drainage is into the pharyngeal plexus, pte rygoid plexus and ultimately into the internal jugular and facial veins. Efferent lymphatic drainage flows from the retropharyngeal lymph nodes to the upper deep cervical lymph nodes , especially the posterior triangle nodes. Sensory innervation is derived from the nasophar yngeal branches of the glosso- pharyngeal and vagus nerves. Indications (cid:142)(cid:3) Recurrent otitis media with effusion. Several studies report improvements in Eustachian tube function following adenoidectomy, regardless of the size of the adenoid (cid:142)(cid:3) Chronic mouth breathing (cid:142)(cid:3) Recurrent or chronic maxillary si nusitis (cid:142)(cid:3) Obstructive sleep apnoea. Equipment (cid:142)(cid:3) Barnhill adenoid curette (Fig. 15.18) (cid:142)(cid:3) Boyle-Dav is gag. Position Supine with the head extended. Procedure The transoral approach is commonly practiced and safer than transnasal adenoidect omy. The Boyle-Davis gag improves access to the posterior nasopharynx. (cid:142)(cid:3) Pas s your index finger behind the soft palate and examine the postnasal space. This assists in determining the size, position, and consistency of the ade noid, the condition of the Eustachian tube orifices and the presence or absence of adhesion s attached to the Eustachian tubes. (cid:142)(cid:3) Retract the soft palate by passing a vascular sling or pediatric urinary c atheter through the nose and bringing it out through the mouth. (cid:142)(cid:3) If the pat ient also requires a tonsillectomy, always perform this after the adenoidectomy. ADENOIDECTOMY1 683 (cid:142)(cid:3) Use an adenoid curette of appropriate size and place it against the poster ior edge of the vomer. Using your thumb as a fulcrum, push the blade along the vault of the nasopharynx and over the odontoid process. This separates the adenoid free from its base a nd when it is withdrawn will shear the tonsil from the posterior nasopharyngeal wall. Avoid curettaging the Eustachian tube orifices. (cid:142)(cid:3) Observe for excessive hemorrhage, although packing is rarely required with the transoral approach. Postoperative care Most children recover rapidly. Short-term pain and discomfort is to be e xpected. Control it with simple analgesics. Encourage a normal diet. Complications Intraoperative Bleeding (0.4%). Bleeding can be controlled by packing the sit e with a vasoconstrictor (e.g. oxymetazoline) on ribbon gauze. Rarely requires a return to the operating theater. Immediate postoperative (cid:142)(cid:3) Ear pain. (cid:142)(cid:3) Velopharyngeal insuffic iency (0.05%). This occurs transiently in over 50% of all adenoidectomies as a result of removing the impingement to soft palate closure. (cid:142)(cid:3) Eustachian tube damage. This is rare and a result of uncontrolled use of surgical instruments. Late postoperative (cid:142)(cid:3) Nasopharyngeal stenosis (cid:142)(cid:3) Chronic (persi stent) otitis media with effusion (cid:142)(cid:3) Persistent symptoms, due to hypertrophy. Vr 0 3 1 4 2 Fig. 15.18 Barnhill adenoid curettes of various sizes CHAPTER 15 Head and neck surgery 684 Caldwell-Luc procedure Although infrequently performed and to a greater extent superseded b y endoscopic maxillary sinus surgery, the Caldwell-Luc procedure is still useful in gaining access to the maxillary sinus and pterygoid fossa. Indications (cid:142)(cid:3) Chronic maxillary sinusitis (cid:142)(cid:3) Suspected neoplas m for biopsy (cid:142)(cid:3) Antrochoanal polyp (cid:142)(cid:3) Fungal sinusitis (cid:142 )(cid:3) Drainage before radiation therapy (cid:142)(cid:3) Removal of displaced tooth root s (cid:142)(cid:3) Access for other procedures e.g. bone grafting prior to dental implants ( \200\230sinus lift \200\231). Position Supine. Use general anesthetic and nasal intubation. Incision Make an intraoral incision through the free gingival tissues halfway between the g ingival margin and the sulcus reflection. Avoid incision in the attached gingiva to allow t he wound to be closed without tearing. Raise a mucoperiosteal flap to identify the intraorb ital nerve and protect it. Procedure (cid:142)(cid:3) Identify the canine fossa, distal to the root apex of the maxill ary canine tooth. (cid:142)(cid:3) Create a window using a hammer and chisel and then enlarge with Hajek \200\231s forceps. When performed for chronic sinus disease, the mucosa is radically debrided and an intranasa l antrostomy is created below the inferior turbinate bone. Complications Immediate (cid:142)(cid:3) Pain (cid:142)(cid:3) Facial swelling and bruising (cid:142)(cid:3) Infraorbital nerve paraesthesia (cid:142)(cid:3) Damage to teeth apices. Intermediate Fistula. This page intentionally left blank CHAPTER 15 Head and neck surgery 686 Access incisions to the facial skeleton Principles Surgical exposure of the facial skeleton and access to the deeper struc- tures of the oropharynx, nasopharynx and anterior cranial fossa fall within the armamentarium of the maxillofacial/head and neck surgeon. Adequate ex posure is essential for the safe and efficient management of the surgical problem. Equally, any incision in the facial region must be designed to produce the minimum of visible scarr ing and avoid major neurovascular structures. The main principles of incision design within the facial region are: (cid:142)(cid:3) Allow adequate exposure Incisions on the face shou ld be as short as possible compatible with adequate exposure. Excessive traction on the soft tissues should b e avoided. (cid:142)(cid:3) Avoid neurovascular structures The main neurovascular structures to be avo ided are the sensory nerves of the face which include the supraorbital, infraorbital and me ntal nerves. Incision should avoid these areas and if necessary the nerves can be dissected out and carefully retracted. (cid:142)(cid:3) Use relaxed skin tension lines Incisions should be placed within lines of minimal tension, as the healed scar is imperceptible. (cid:142)(cid:3) Incise perpendicular to the skin This allows accurate reapproximation of wound edges. Oblique or tangential incisions are susceptible to over-riding and marginal necrosis. (cid:142)(cid:3) In the scalp, place incision parallel to the hair to avoid damaging the follicle These criteria can be achieved through a number of approaches (Figs. 15.19 \200\22320). (ci d:142)(cid:3) Intraoral (cid:142)(cid:3) Maxilla: Le Fort 1 horseshoe degloving incision. (cid:142)(cid:3) Mandible : Buccal sulcus degloving incision (cid:142)(cid:3) Extraoral (cid:142)(cid:3) Coronal flap (cid:142)(cid:3) Midface degloving approaches via the Weber-F erguson incision (Fig. 15.19) (cid:142)(cid:3) Periorbital (cid:142)(cid:3) Rhytidectomy and preauricular. Indications Emergency (cid:142)(cid:3) Treatment of maxillofacial fractures. Elective (cid: 142)(cid:3) Tumor resection (cid:142)(cid:3) Assist neurosurgical approaches to the posteri or orbit, anterior cranial fossa and pituitary gland (cid:142)(cid:3) Orthognathic surgery. ACCESS INCISIONS TO THE FACIAL SKELETON1 687 y Weber-Ferguson incision x Fig. 15.19 Access incision to left maxilla Incision extending to level of the first molar teeth Fig. 15.20 Leforeone access incision CHAPTER 15 Head and neck surgery 688 Equipment required (cid:142)(cid:3) Number 10 and 15 blades surgical blades. (cid:142)(cid: 3) Mono- and bi-polar diathermy with access to Colorado needle if required. (cid:142)(cid:3) GOS (Great Ormond Street) solution (Table 15.1). Position Secure the head and support it with a head ring or neurosurgical cranio- tomy atta chment. Place Jelonet in both ears and protect the eyes with simple eye ointment and tarsor raphy sutures. Incision Mark the incision line with surgical ink to avoiding areas of potential hair reces sion. The \200\230stealth \200\231 incision is commonly designed to avoid straight lines a nd sharp angles that might be subjected to tip necrosis. It also allows accurate reposition ing. Procedure: coronal flap Advantage: wide exposure of cranial vault, medial and superior orbi t, nasal bones and zygomatic arch. (cid:142)(cid:3) Make incision with a 10 blade or Colora do diathermy needle through skin, subcutaneous tissue and galea. (cid:142)(cid:3) Control bleeding from the scalp by using Rayney clips which are placed on the skin edge. Whether the dissection is carried out in the subpericranial or sub galeal plane depends on which part of the head or face needs to be exposed. If the cranial vault is to be excised then the dissection should proceed in the subpericranial plane leavi ng bare bone only. (cid:142)(cid:3) If the coronal incision is being used for access to the supraorbital ridge or orbit, then use a subgaleal dissection until within 20 \200\22330mm of the supraorbital ridge. At this point incise the pericranium and reflect it in continuity with the skin fla p. (cid:142)(cid:3) If the zygomatic arch has to be exposed, incise the superficial layer of temporal fascia in continuity with the coronal flap. This offers satis- factory access t o the zygomatic arch and at the same time protects the temporal branch of the facial nerve which lies superficial to the temporal fascia. (cid:142)(cid:3) Carry out meticulous closure to provide optimal healing. Use two small vacuum drains. Appose the galea and subcutaneous tissues with 2/0 Vicryl and use clip s for skin. (cid:142)(cid:3) Insert closed suction drains to evacuate haematoma. Pressure dressings are optional. Postoperative Remove the drain at 24 \200\22348 hours. Complications: immediate (cid:142)(cid:3) Subcutaneous haematoma (cid:142)(cid:3) Damage to the supraorbital nerves causing scalp numbness (cid:142)(cid:3) Later complications includ e facial ptosis and stretching of the scalp (cid:142)(cid:3) Incision leaving a broad visib le scar within the hair. ACCESS INCISIONS TO THE FACIAL SKELETON1 689 Table 15.1 GOS solution Hartman \200\231s solution 500ml Adcortvl 50mg Marcaine 0.25% 25ml Lignocaine 0.5% 25ml Hyalase 1500 IU 1amp Adrenaline 1:1 000 0.5ml Procedure: transoral approaches Advantage: excellent exposure of entire maxilla and mandibl e. (cid:142)(cid:3) Infiltrate local anesthetic widely. Design the incision so that it is placed 5mm away from the mucogingival junction (Fig. 15.20), this allows the unattached muc osa left on the alveolar segment to be reattached at the end of the procedure. Extend the i ncision as far posteriorly as necessary to facilitate tensionless exposure, although unnece ssary lengthening may compromise mucosal vascularity. (cid:142)(cid:3) Deepen the incision through periosteum and raise the entire flap in a subp eriosteal plane, with cautious dissection in the region of the mental or infraobital nerves . (cid:142)(cid:3) Then expose the maxilla or mandible. (cid:142)(cid:3) Close the mucosa wit h a tension-free continuous 3/0 Vicryl resorbable suture. (cid:142)(cid:3) Use an elasticated chin dressing after a mandibular degloving procedure to restrict haematoma and redrape the repositioned mentalis muscles. Complications Immediate (cid:142)(cid:3) Cutaneous paraesthesia due to traction neuropraxia (cid:142)(cid:3) Wound dehiscence Late (cid:142)(cid:3) Gingival recession (cid:142)(cid:3 ) Facial ptosis (cid:142)(cid:3) Nasal alar flaring and shortening of the upper lip after ( cid:142)(cid:3) Maxillary degloving procedure. Acknowledgement We wish to thank Mr Jerry Sharp FRCS, Consultant ENT surgeon, Derbyshire Ro yal Infirmary for his comments on the Thyroidectomy section. This page intentionally left blank Chapter 16 691 Thoracic surgery G. N. Morritt and A. N. Morritt Bronchoscopy 692 Rigid bronchoscopy 694 Flexible bronchosco py 696 Cervical mediastinoscopy 698 Anterior mediastinotomy 700 Chest drain insertion: tube thoracostomy 702 Posterolateral thoracotomy 706 Anterolateral thoracotomy 708 Median stern otomy 710 Lobectomy 712 Right upper lobectomy 714 Right middle lobectomy 716 Right lower lo bectomy 718 Left upper lobectomy 720 Left lower lobectomy 722 Pneumonectomy 724 Right pneum onectomy 726 Left pneumonectomy 728 Right intrapericardial pneumonectomy 730 Left intraperi cardial pneumonectomy 732 Open parietal pleurectomy and bullectomy 734 Open lung wedge biop sy 736 Open excision of pulmonary nodule 738 Excision of mediastinal mass 740 Thoracic neur ogenic tumors 742 Pectus excavatum repair 744 Pectus carinatum repair 746 Rib resection for empyema 748 Decortication for empyema 750 Airway stents 752 Video assisted thoracic surger y (VATS) 754 Vat parietal pleurectomy and bullectomy 756 Vat lung wedge biopsy 758 CHAPTER 16 Thoracic surgery 692 Bronchoscopy This is performed using a rigid bronchoscope or a flexible fibreoptic bronchos cope. The Negus rigid bronchoscope (cid:142)(cid:3) Different sizes e.g. adult, pediatric (cid:14 2)(cid:3) Halogen light source (cid:142)(cid:3) The three most commonly used telescopes are direct vision, 30(cid:13) angled, and 90(cid:13) angled. (cid:142)(cid:3) The telescopes are placed down the rigid barrel of the bronchoscope (cid:1 42)(cid:3) Instruments e.g. graspers, biopsy forceps, and suction devices (cid:142)(cid:3) Telescopes can be attached to a video camera for display on a monitor. The flexible bronchoscope (cid:142)(cid:3) Fibreoptic bronchoscope (cid:142)(cid:3) Outer d iameter \200\2243 \200\2236mm (cid:142)(cid:3) Light transmitted via fibreoptic bundles (ci d:142)(cid:3) Field of vision is usually 80(cid:13) (cid:142)(cid:3) Can be attached to vid eo camera for display on screen. BRONCHOSCOPY1 693 Fig. 16.1 The flexible bronchoscope Fig. 16.2 The flexible bronchoscope. Light is transmitted via fibreoptic bundles CHAPTER 16 Thoracic surgery 694 Rigid bronchoscopy An invasive procedure where a rigid bronchoscope is used to visualize th e oropharynx, larynx, vocal cords, and tracheobronchial tree. It may be combined with flexi ble bronchoscopy for improved distal airway visuali- sation and suctioning. It is preferred to flexible bronchoscopy for unsta- ble patients, centrally located tumors, and cases wher e there is severe airway obstruction and the patient needs to be ventilated. Indications Diagnostic (cid:142)(cid:3) Biopsy (where flexible bronchoscope specimen is ina dequate) (cid:142)(cid:3) Preoperative assessment for lung resection surgery (cid:142)(cid: 3) Massive haemoptysis (cid:142)(cid:3) Airway obstruction (cid:142)(cid:3) Benign strictur e (cid:142)(cid:3) Tracheobronchial toilet. Therapeutic (cid:142)(cid:3) Removal of secreti ons (cid:142)(cid:3) Cauterisation of bleeding points (cid:142)(cid:3) Removal of foreign b odies (cid:142)(cid:3) Relief of airway obstruction (cid:142)(cid:3) Treatment of bronchopl eural fistula (cid:142)(cid:3) Dilation of tracheal or bronchial strictures (cid:142)(cid:3 ) Laser therapy (cid:142)(cid:3) Insertion of airway stents. Contraindications Relative \200\224uncontrolled coagulopathy. Extra care should be taken with patients with active TB, HIV, and hepatitis to avoid the spread of infection. Preprocedure preparation (cid:142)(cid:3) Bleeding time and PTT if a bleeding problem is su spected (cid:142)(cid:3) Atropine 0.6mg IM (to reduce secretions) (cid:142)(cid:3) Patient starved for six hours. Position Supine. Anesthesia (cid:142)(cid:3) General anesthetic (cid:142)(cid:3) Ventilation is provided thr ough a Sanders injector utilizing a Venturi system to inject oxygen under pressure intermittently. Procedure (cid:142)(cid:3) Aspirate pharyngeal secretions. (cid:142)(cid:3) Introduce the b ronchoscope behind the tongue in the midline. (cid:142)(cid:3) Lift the epiglottis up using the beak of the bronchoscope to visualize the vocal cords. RIGID BRONCHOSCOPY1 695 (cid:142)(cid:3) Turn the bronchoscope 90(cid:13) and then pass through the vocal cords int o the trachea (identified by the cartilage rings). (cid:142)(cid:3) Then rotate the bronchoscope back to its original position and note any tracheal narrowing, constriction, deviation or mucosal abnormality. (cid:142)(cid:3) Advance the bronchoscope to the carina. Significant enlargement of the subcarinal nodes will result in widening of the carina. (cid:142)(cid:3) If the pathology is unilateral, then do the examination of the contra- lat eral side first ensuring a) a complete examination, and b) blood and cellular debris will n ot be carried to the other side. (cid:142)(cid:3) Biopsy any abnormal areas. (cid:142)(cid:3) Control bleeding with a cotton pledget on a pledget holder. (cid:142)(cid: 3) If bleeding is uncontrolled pass a Thomson bronchial blocker (or Fogarty catheter) and occlude the lobar or segmental bronchus. If an Nd: YAG laser is a vailable then this can be used to cauterize the bleeding area. (cid:142)(cid:3) If bleeding remains uncontrolled, then turn the patient so the affected side is dependent to maintain the airway to the good side. Provisions should be ma de for immediate thoracotomy. (cid:142)(cid:3) When the preliminary examination is complete, address the indication for the procedure eg extraction of foreign body or biopsy. (cid:142)(cid:3) Collection of specimen and biopsy: (cid:142)(cid:3) Collect aspirated material in a sputum trap and ensure the specimen bottle is labeled clearly before the specimen is sent for culture, sensitivity and cytology. Mark biopsies sent for histopathological examination. (cid:142)(cid:3) If secretions are scanty, a lavage with 50ml of 0.9% saline solution will yield sufficient cells for study. (cid:142)(cid:3) Telescopes may be inserted into the bronchoscope to visualize the distal segments. The side viewing telescopes are used to visualize the upper lobe and segme ntal bronchi. (cid:142)(cid:3) For a more detailed examination a flexible bronchoscope can be used. Complications Are rare. (cid:142)(cid:3) Complications of general anesthesia. (cid:142)(cid :3) Bleeding from biopsy site \200\224control this by applying pressure at the bleeding poi nt with a cotton pledget on a pledget holder soaked in 1:10 000 adrenaline solution. Repeat if necessary.