presented at Department of ENT, NMCH, Patna by Dr Zeeshan Ahmad, PGY2

1. Principles of Conservative
Surgery in Head & Neck
Oncology
Dr Zeeshan Ahmad
M.S.(ENT,PGY2)
Department of ENT
NMCH, Patna.29-08-13

2. Introduction
 Surgery on Head and Neck has major impact on swallowing,
speech and aesthetic appearance.
 Organ preserving radiation techniques.
 New chemotherapeutic regimens.
 Greater understanding of tumour biology.
 Introduction of CO2 laser- transoral.
 endoscopes

3. Neck

4. Conservation surgery for Neck
 Single most imp factor for prognosis of SCC of HN – cervical nodes.
 5yr survival rate reduces by 50% if nodes involved.
 Memorial Sloan-Kettering Cancer Center – Levels I to VII.

5. N0 disease – Neck dissection
 N0 – 15-20% risk of occult metastatic disease.
 Selective neck dissection
 Spares all non-lymphatic tissue including SCM, IJV and SpAN.
 Only selected nodes on involved site removed.

6. Types of Selective Neck Dissection
 SupraOmoHyoid Neck Dissection
 Extended SupraOmoHyoid Neck Dissection
 Anterolateral Neck Dissection
 Posterolateral Neck Dissection
 Central compartment Neck Dissection

7. SupraOmoHyoid Neck Dissection
 SCC of Oral Cavity
 Lymph nodes of level I to III
 Submandibular Gland

8. Extended SupraOmoHyoid Neck
Dissection
 SCC of Lateral Tongue
 Small but increased risk of Skip Metastasis to level IV
 Lymph nodes of level I to IV
 Submandibular Gland

9. Anterolateral Neck Dissection
 Also called Jugular Neck Dissection.
 SCC of Larynx or Pharynx
 If primary tumour crosses midline A.N.D. is carried out bilaterally.
 Not required if Radiotherapy planned.
 Lymph nodes of level II to IV

10. Posterolateral Neck Dissection
 Primary cutaneous malignancies of Posterior Scalp.
 Lymph nodes of level II to IV and suboccipital LN.

11. Central compartment Neck Dissection
 Diferentiated Thyroid carcinoma.
 Lymph nodes of level VI to VII and
 Delphian
 Perithyroid
 Tracheo-osophageal groove
 Anterior-superior mediastinum

12. N+ disease - Neck Dissection
 Comprehensive neck dissection – removal of all lymphatic tissue in
lateral neck.
 Classified into Radical and Modified Radical depending upon other
structures removed.
 Gold standard – Radical Neck Dissection.
 Modified Radical Neck Dissection three types

13. Structures removed in RND along
with level I to V LN
 RND
 SSG
 IJV
 SCM
 Sp Acc N

14. Structures removed in MRND along
with level I to V LN
 MRND type I – (Spinal Accessory spared)
 SSG
 IJV
 SCM

15. Structures removed in MRND along
with level I to V LN
 MRND type II –( Spinal Accessory + SCM spared)
 SSG
 IJV

16. Structures removed in MRND along
with level I to V LN
 MRND type III – (Spinal Accessory + SCM + IJV spared)
 SSG

17. N+ Disease post Chemoradiation
 Generally acepted that N0 and N1 disease can be treated by
Chemoradiation alone.
 Insufficient data for N2 and N3
 Brizel et al – reported 4yr disease free survival rate
 75% in RT + ND
 53% in RT only
 Therefore ND is recommended for N2/N3.

18. Larynx

19. Conservation surgery for cancer of
Larynx
 Main aim is to
 Maintain speech
 Maintain swallowing
 Avoid tracheostomy
 Conservation laryngeal surgery may be
 Open
 endoscopic
 securing negative margins is crucial to success of procedure.

20. Crico-arytenoid unit
 It is the basic functional unit of larynx.
 Consists of
 An Arytenoid cartilage
 Cricoid cartilage
 Associated musculature
 Nerve suply
 Allows physiological speech and swallowing without the need for
tracheostomy.

21. Open Partial Laryngeal surgery
 General principles
 Consent for Total Laryngectomy
 Speech rehabilitation – patient and family active
 Good pulmonary function
 No medical problem

22. Types
 Glottic
 Vertical Partial Laryngectomy
 Lateral
 anterolateral
 Supracricoid Partial laryngectomy with Cricohyoidoepiglottopexy.
 Supraglottic
 Horizontal SPL
 Supracricoid Partial laryngectomy with Cricohyoidoepiglottopexy.

23. GLOTTIC

24. Vertical Partial Laryngectomy
 Vertical cuts through laryngeal cartilage
 Removal of majority of
 Ipsilateral thyroid cartilage
 True vocal cord
 Portions of subglottic mucosa
 False cord
 Tracheostomy 3-7 days.

25. Vertical Partial Laryngectomy
 Criteria for selection
 Lesion of mobile cord extending to anterior commissure
 Lesion of mobile cord involving vocal process and anterosuperior arytenoid
 Subglottic extension ≯5mm
 Fixed cord lesion not extending midline
 Anterior commissure/ VC lesion ≯ anterior 1/3 of opposite VC

26. Vertical Partial Laryngectomy
 Oncological results
 T1 glottic cancer
 Recurrence rates are <10%
 If ant comm not invoved 93% local control
 If ant comm invoved 75% local control( subglottic recurrence)
 T2 glottic cancer
 Failure rates of 4-26% ( cricoid and thyroid involvement)
 T3 glottic cancer
 Higher recurrence rates of 11-46%

27. Vertical Partial Laryngectomy
 Functional results
 Some degree of hoarseness
 Most impairment – if no reconstruction
 Least – replacement of glottis with adjacent false cord flap

28. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Resection of
 Both true cords and Both false cords
 Entire thyroid cartilage and One arytenoid
 Paraglottic spaces bialterally

29. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Reconstruction is done using
 Hyoid bone, Epiglottis, Cricoid and tongue
 Temporary tracheostomy and feeding tube
 Used for T1b with ant commissure involvement and selected T2 / T3
glottic carcinoma.

30. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Local recurrence rate
 T2 4.5% (3 of 67)
 T3 10% (2 of 20)
 Temporary dysphagia and aspiration is expected
 Nasogastric feeding tube for 9 to 50 days.
 Hyoid necrosis and neolaryngeal stenosis
 Voice quality is initially poor but improves over several months

31. SUPRAGLOTTIC

32. Horizontal Supraglottic Partial
Laryngectomy
 Parts removed
 Epiglotis and Pre-epiglottic space
 Hyoid bone
 Thyrohyoid membrane
 Upper half of thyroid cartilage
 Supraglottic mucosa

33. Horizontal Supraglottic Partial
Laryngectomy
 Closure is by approximating base tongue to lower half of thyoid
cartilage
 Temporary tracheostomy is required.
 Bilateral selective lymph node dissection is carried out at the same
time
 It is important to identify and preserve internal and external
branches of superior laryngeal nerve

34. Horizontal Supraglottic Partial
Laryngectomy
 Selection criteria
 At least 5mm margin at anterior commissure
 True VC must be mobile
 Only one arytenoid may be removed
 No cartilage invasion by the tumour
 Tongue mobility should be normal
 No extension to interarytenoid or postcricoid area
 Apex of pyriform sinus should be free
 Generally lesions should be <3cm

35. Horizontal Supraglottic Partial
Laryngectomy
 High local control for T1 and T2
 75% for T3 and 67% for T4

36. Other Laryngectomies
 Subtotal Laryngectomy =
supralottic partial laryngectomy+ipsilateral vertical partial
laryngectomy
 Near Total Laryngectomy =
this is a technically complex procedure to create a physiological
voice shunt based around one mobile arytenoid.
Requires permanent stoma

37. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Supraglottic carcinomas not amenable to supraglottic
laryngectomy due to
 Glottic level involvement through anterior commissure or ventricle
 Pre-epiglottic space invasion
 Decreased cord mobility
 Limited thyroid invasion

38. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Operation involves resection of
 Both true cords and both false cords
 Entire thyroid cartilage
 Both paraglottic spaces
 Maximum of one arytenoid
 Thyrohyoid membrane
 epiglottis

39. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Reconstruction using
 Hyoid bone
 Cricoid
 tongue
 Temporary tracheostomy tube and feeding tube is required.

40. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Indications
 T1 and supraglottic lesions with ventricle extension
 T2 infrahyoid epiglottis or posterior 1/3 of false cord
 Supraglottic lesions extending to glottis or anterior commissure
 T3 transglottic carcinoma
 Selective t4 lesions invading thyroid cartilage

41. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 Contraindications
 Bulky pre-epiglottic space involvement
 Gross thyroid cartilage destruction
 Interarytenoid involvement
 Fixed arytenoids
 Subglottic extension >10mm anteriorly and >5mm posteriorly
 Inadequate pulmonary reserve

42. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
 No local recurrence reported by Laccourreye et al
 3.3% reported by chevalier
 Nasogastric feeding is required for 30-365 days
 Total laryngectomy may be required in 10% of cases

43. Transoral Endoscopic LASER Resection
 Outpatient procedure possible
 Shorter operating time
 Less overtreatment
 Better voice quality
 Low morbidity
 No feeding tube
 No tracheostomy
 Similar oncologic results

44. Transoral Endoscopic LASER Resection
 As compared to radiotherapy it has similar oncologic and
functional results, lower cost.
 Radiotherapy is possible after endocopic laser if it fails

45. Hypopharynx

46. Conservation surgery for cancer of
Hypopharynx
 Cancer of hypopharynx includes
 Cancer of pyriform sinus (70%)
 Postcricoid (15%)
 Posterior pharyngeal wall (15%)
 Of all Head and Neck sites Hypopharyngeal Cancer has poorest
prognosis – 5yr survival rate of <20%
 Patients usually present with advanced diseaseAbout 66% of
patients have nodal disease at presentation
 Thus it requires treatment of primary and also of neck

47. Conservation surgery for cancer of
Hypopharynx
 T1 and small volume T2 without neck metastasis
 Usually treated by radiation
 Partial pharyngectomy and bilateral selective neck dissection can also be
performed
 T1 and small volume T2 with neck metastasis
 Comprehensive neck dissection
 Radiation to the primary

48. Conservation surgery for cancer of
Hypopharynx
 Large volume T2 / T3 / T4
 Radical surgery
 Excision of primary tumour
 Reconstruction
 Radiotherapy
 Endoscopic laser
 Excellent functional results
 With synchronous or separate neck dissection

49. Oral cavity

50. Conservation surgery for cancer of the
Oral cavity
 Limited resection of oral cavity is to be condemned
 However it is possible to perform conservative surgery to mandible
 Careful assessment is carried out by bimanual palpation.
 CT is helpful in assessing cortical invasion
 MRI helps to find marrow invasion and inferior alveolar nerve

51.  Segmental mandibulectomy is carried out if
 Gross invasion by cancer
 Tumour close to mandible in irradiated patient
 Invasion of inferior alveolar nerve or canal by tumour
 Massive soft tissue disease adjacent to tumour
 Marginal mandibulectomy is done if
 Superficial aspect of cortical bone is involved

52.  Marginal mandibulectomy is done if
 Superficial aspect of cortical bone is involved
 Marginal mandibulectomy is contraindicated
 Gross invasion into cancellous part
 Irradiated mandible
 Edentulous patient with pipestem mandible

53. Oropharynx

54. Conservation surgery for cancer of
Oropharynx
 Transoral laser resection is an alternatve to chemoradiation and
radical surgery
 With the use of appropriate retractors and distending
pharyngoscopes adequate access is obtained
 Temporary tracheostomy may be required
 Postoperative radiotherapy is recommended
 TORS

55. Nose and PNS

56. Conservation surgery for cancer of
Nose and PNS
 Certainly, endoscopic approach for benign disease has advantage
over open surgical resection
 Better function as well as cosmesis
 Availability of
 real time image guidance,
 neuro-navigation and
 intraoperative MRI has furthur improved the safety and accuracy of endoscopic
resections
 However, malignant disease management is still questionable

57. Conservation surgery for cancer of
Nose and PNS
 Indications
 Midline lesions with limited lateral extension
 Benign tumours – inverted papilloma and angiofibroma
 Low grade malignant tumours
 Palliation
 Medical comorbidity limiting open approach

58. Conservation surgery for cancer of
Nose and PNS
 Contraindications
 Lateral extension of tumour
 Intracranial invasion
 Intraorbital invasion
 High grade malignant tumours

59. Parotid

60. Conservation surgery for Tumours of
Parotid Gland
 Warthin’s tumour excision without parotidectomy
 Preservation of facial nerve unless they are adherent to or directly
invaded by tumour
 If major branches or the main trunk are involved, then immediate
cable grafts should be done using branches of Cervical plexus or
Sural nerve

62. NEXT 
05.09.13 Dr Sonu Kumar Singh
M.S.(ENT,PGY2)
Benign tumours of
mouth and jaw