Head And Neck Surgery

Transcript

Head and Neck Surgery Marc Reinald G Santiago M.D., M.D., DPBO-HNS Selected Readings • • Anatomy Anatomy pp 12-16,19-22 Introduction to Head and Neck Surgery pp196197 • Thyroid Thyroid Masses pp 290-298 • Cancer of the Head and Neck pp 305-313 Selected Readings • • Anatomy Anatomy pp 12-16,19-22 Introduction to Head and Neck Surgery pp196197 • Thyroid Thyroid Masses pp 290-298 • Cancer of the Head and Neck pp 305-313 • Management of neoplasms • Most challenging and exciting exciting  – Senses in the region  – Crucial functions and appearance  – Survival, preservation and/or reconstruction reconstruction  – Multidisciplinary approach THYROID ORAL CAVITY • • • • • Oral cavity vermilion border of the lip posterosuperiorly - hard palate-soft palate  junction inferiorly - circumvallate papillae (linea terminalis) laterally - anterior tonsillar pillars • 7 subsites:  – Lips  – Dentoalveolar ridges  – Oral tongue  – Retromolar trigone  – Floor of the mouth  – Buccal mucosa  – Hard palate 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, ventral tongue, dorsal oral tongue • • • • 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 • Sensory Innervation • Anterior 2/3 – lingual N.  – Special sensory for taste • • Chorda tympani n Base of the tongue:  – Glossopharyngeal • • • • • • 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 Musculoskeletal framework of the Pharynx • Muscles 1. Superior pharyngeal constrictor 2. Middle pharyngeal constrictor 3. Inferior pharyngeal constrictor 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. Anterior Cervical Triangle 2. Posterior Cervical Triangle 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  Anterior Cervical Triangle 4. Submental triangle  –  –  – Superior: Inferior: Lateral: symphysis of mandible hyoid bone anterior belly of digastric Posterior Cervical Triangle 1. Occipital triangle  –  –  – Anterior: Posterior: Inferior: sternocleidomastoid  trapezius omohyoid  Posterior Cervical Triangle 2. Subclavian triangle  –  –  – Superior: Inferior: Anterior: omohyoid  clavicle sternocleidomastoid  Cervical Fascia • 2 major divisions: 1. Superficial Cervical Fascia 2. Deep Cervical Fascia a. Superficial layer b. Middle layer c. Deep layer Cervical lymph node groups • Submental (level IA)  –  – Contained within the submental triangle Harboring metastases from cancers arising from the floor of the  mouth, anterior oral  tongue, anterior  mandibular alveolar  ridge, and lower lip  Cervical lymph node groups • Submandibular (level IB)  –  – Within the submandibular triangle Harboring metastases from cancers arising from the oral cavity, anterior nasal cavity, soft-tissue structures of   the midface, and  submandibular gland  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 inferior border of the  hyoid bone below (clinical landmark) Surgical landmark: 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, nasal cavity, nasopharynx, oropharynx, hypopharynx, larynx, and   parotid gland  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  Cervical lymph node groups • Middle Jugular (level III)  – Harboring metastases from cancers arising from the oral cavity, nasopharynx, oropharynx, hypopharynx, and  larynx  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, thyroid, cervical  esophagus, and larynx  Cervical lymph node groups • Posterior triangle (level VA and VB)  –  – Encompasses all LN contained within the posterior triangle 3 predominant pathways: 1. 2. 3. Nodes located along the  SAN  Nodes along the  tansverse cervical  artery  Supraclavicular nodes  • VIRCHOW’s node (sentinel node) 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, oropharynx, cutaneous  structures of the   posterior scalp and neck  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, larynx, 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 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, the suspicion for carcinoma should increase Papillary Carcinoma • Most common form of thyroid malignancy • 60-70% of all thyroid thyroid cancer • 30-40 years of age • Female:male ratio of 2:1 • Predominant thyroid 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 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, carcinoembryonic antigen, histaminadases, prostaglandins, and serotonin associated with MEN 2 Total thyroidectomy should be performed by patient age of 2-3 years or before C cell hyperplasia occurs 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, or exsanguination The PCS-PSGS-PAHNSI Evidence-Based Clinical Practice Guidelines on Thyroid Nodules Recommendations for Diagnostic Workups What is the role of thyroid function tests (TSH, T3, T4 and FT4)? In the initial evaluation of a patient with a thyroid nodule, serum TSH and/or thyroid hormones are measured. 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. Recommendations for Diagnostic Workups • the over all diagnostic accuracy of FNAC ranges from a low of 85% to a high of 96% Table 1. Summary Characteristics for Thyroid Fine-Needle Aspiration: Results of Local Literature Survey. Author Specificity Sensitivity Diagnostic Likelihood (n) % % Accuracy Ratio+ % % de los Santos, ET 96.2 PGH 1985 (61) 66.7 91.8 17.5 Gomez, JA MMC 92.3 1995 (30) Guiang, J P UST 85 1999 (57) Kintanar, H R 97.1 QMMC 2002 94.4 93.5 12.25 100 96.5 6.7 57.1 85.7 19.7 • Sensitivity  – • Specificity  – • Fraction of patients with positive test results who have disease False-negative rate  – • Likelihood that patient without disease has negative test results Positive Predictive value  – • Likelihood that patient with disease has positive test results 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, 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. Magnetic Resonance Imaging and Computed Tomography should NOT be used routinely because they are rarely diagnostic for malignant lesions in nodular thyroid disease. 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 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, 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 Surgical Treatment • Solitary benign thyroid nodule lobectomy with isthmusectomy is sufficient. 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, inadequate or suspicious aspirate. 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. 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. This includes all patients with thyroid cancer except those with small (<1.5 cm), intrathyroidal, node-negative, low-risk tumors. Head and Neck Cancer Near total glossectomy Skin incisions Visor Flap with pull through technique Marginal mandibulectomy Inferior maxillectomy via lateral rhinotomy incision Neck Dissection Classification 1. Radical Neck Dissection   –  – Removal of all ipsilateral cervical lymph node groups, spinal accessory nerve, 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 2. 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 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 Neck Dissection Classification 4. Extended Neck Dissection   –  – Neck dissection extended to other adjacent structures (parotid) May also remove the hypoglossal nerve, levator scapulae muscle, or carotid artery And a lot more….