2. Introduction
ī´ Surgery on Head and Neck has major impact on swallowing,
speech and aesthetic appearance.
ī´ Organ preserving radiation techniques.
ī´ New chemotherapeutic regimens.
ī´ Greater understanding of tumour biology.
ī´ Introduction of CO2 laser- transoral.
ī´ endoscopes
4. Conservation surgery for Neck
ī´ Single most imp factor for prognosis of SCC of HN â cervical nodes.
ī´ 5yr survival rate reduces by 50% if nodes involved.
ī´ Memorial Sloan-Kettering Cancer Center â Levels I to VII.
5. N0 disease â Neck dissection
ī´ N0 â 15-20% risk of occult metastatic disease.
ī´ Selective neck dissection
ī´ Spares all non-lymphatic tissue including SCM, IJV and SpAN.
ī´ Only selected nodes on involved site removed.
8. Extended SupraOmoHyoid Neck
Dissection
ī´ SCC of Lateral Tongue
ī´ Small but increased risk of Skip Metastasis to level IV
ī´ Lymph nodes of level I to IV
ī´ Submandibular Gland
9. Anterolateral Neck Dissection
ī´ Also called Jugular Neck Dissection.
ī´ SCC of Larynx or Pharynx
ī´ If primary tumour crosses midline A.N.D. is carried out bilaterally.
ī´ Not required if Radiotherapy planned.
ī´ Lymph nodes of level II to IV
10. Posterolateral Neck Dissection
ī´ Primary cutaneous malignancies of Posterior Scalp.
ī´ Lymph nodes of level II to IV and suboccipital LN.
11. Central compartment Neck Dissection
ī´ Diferentiated Thyroid carcinoma.
ī´ Lymph nodes of level VI to VII and
ī´ Delphian
ī´ Perithyroid
ī´ Tracheo-osophageal groove
ī´ Anterior-superior mediastinum
12. N+ disease - Neck Dissection
ī´ Comprehensive neck dissection â removal of all lymphatic tissue in
lateral neck.
ī´ Classified into Radical and Modified Radical depending upon other
structures removed.
ī´ Gold standard â Radical Neck Dissection.
ī´ Modified Radical Neck Dissection three types
13. Structures removed in RND along
with level I to V LN
ī´ RND
ī´ SSG
ī´ IJV
ī´ SCM
ī´ Sp Acc N
14. Structures removed in MRND along
with level I to V LN
ī´ MRND type I â (Spinal Accessory spared)
ī´ SSG
ī´ IJV
ī´ SCM
15. Structures removed in MRND along
with level I to V LN
ī´ MRND type II â( Spinal Accessory + SCM spared)
ī´ SSG
ī´ IJV
16. Structures removed in MRND along
with level I to V LN
ī´ MRND type III â (Spinal Accessory + SCM + IJV spared)
ī´ SSG
17. N+ Disease post Chemoradiation
ī´ Generally acepted that N0 and N1 disease can be treated by
Chemoradiation alone.
ī´ Insufficient data for N2 and N3
ī´ Brizel et al â reported 4yr disease free survival rate
ī´ 75% in RT + ND
ī´ 53% in RT only
ī´ Therefore ND is recommended for N2/N3.
19. Conservation surgery for cancer of
Larynx
ī´ Main aim is to
ī´ Maintain speech
ī´ Maintain swallowing
ī´ Avoid tracheostomy
ī´ Conservation laryngeal surgery may be
ī´ Open
ī´ endoscopic
ī´ securing negative margins is crucial to success of procedure.
20. Crico-arytenoid unit
ī´ It is the basic functional unit of larynx.
ī´ Consists of
ī´ An Arytenoid cartilage
ī´ Cricoid cartilage
ī´ Associated musculature
ī´ Nerve suply
ī´ Allows physiological speech and swallowing without the need for
tracheostomy.
21. Open Partial Laryngeal surgery
ī´ General principles
ī´ Consent for Total Laryngectomy
ī´ Speech rehabilitation â patient and family active
ī´ Good pulmonary function
ī´ No medical problem
24. Vertical Partial Laryngectomy
ī´ Vertical cuts through laryngeal cartilage
ī´ Removal of majority of
ī´ Ipsilateral thyroid cartilage
ī´ True vocal cord
ī´ Portions of subglottic mucosa
ī´ False cord
ī´ Tracheostomy 3-7 days.
25. Vertical Partial Laryngectomy
ī´ Criteria for selection
ī´ Lesion of mobile cord extending to anterior commissure
ī´ Lesion of mobile cord involving vocal process and anterosuperior arytenoid
ī´ Subglottic extension â¯5mm
ī´ Fixed cord lesion not extending midline
ī´ Anterior commissure/ VC lesion ⯠anterior 1/3 of opposite VC
26. Vertical Partial Laryngectomy
ī´ Oncological results
ī´ T1 glottic cancer
ī´ Recurrence rates are <10%
ī´ If ant comm not invoved 93% local control
ī´ If ant comm invoved 75% local control( subglottic recurrence)
ī´ T2 glottic cancer
ī´ Failure rates of 4-26% ( cricoid and thyroid involvement)
ī´ T3 glottic cancer
ī´ Higher recurrence rates of 11-46%
27. Vertical Partial Laryngectomy
ī´ Functional results
ī´ Some degree of hoarseness
ī´ Most impairment â if no reconstruction
ī´ Least â replacement of glottis with adjacent false cord flap
28. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
ī´ Resection of
ī´ Both true cords and Both false cords
ī´ Entire thyroid cartilage and One arytenoid
ī´ Paraglottic spaces bialterally
29. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
ī´ Reconstruction is done using
ī´ Hyoid bone, Epiglottis, Cricoid and tongue
ī´ Temporary tracheostomy and feeding tube
ī´ Used for T1b with ant commissure involvement and selected T2 / T3
glottic carcinoma.
30. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
ī´ Local recurrence rate
ī´ T2 4.5% (3 of 67)
ī´ T3 10% (2 of 20)
ī´ Temporary dysphagia and aspiration is expected
ī´ Nasogastric feeding tube for 9 to 50 days.
ī´ Hyoid necrosis and neolaryngeal stenosis
ī´ Voice quality is initially poor but improves over several months
32. Horizontal Supraglottic Partial
Laryngectomy
ī´ Parts removed
ī´ Epiglotis and Pre-epiglottic space
ī´ Hyoid bone
ī´ Thyrohyoid membrane
ī´ Upper half of thyroid cartilage
ī´ Supraglottic mucosa
33. Horizontal Supraglottic Partial
Laryngectomy
ī´ Closure is by approximating base tongue to lower half of thyoid
cartilage
ī´ Temporary tracheostomy is required.
ī´ Bilateral selective lymph node dissection is carried out at the same
time
ī´ It is important to identify and preserve internal and external
branches of superior laryngeal nerve
34. Horizontal Supraglottic Partial
Laryngectomy
ī´ Selection criteria
ī´ At least 5mm margin at anterior commissure
ī´ True VC must be mobile
ī´ Only one arytenoid may be removed
ī´ No cartilage invasion by the tumour
ī´ Tongue mobility should be normal
ī´ No extension to interarytenoid or postcricoid area
ī´ Apex of pyriform sinus should be free
ī´ Generally lesions should be <3cm
36. Other Laryngectomies
ī´ Subtotal Laryngectomy =
supralottic partial laryngectomy+ipsilateral vertical partial
laryngectomy
ī´ 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
ī´ Supraglottic carcinomas not amenable to supraglottic
laryngectomy due to
ī´ Glottic level involvement through anterior commissure or ventricle
ī´ Pre-epiglottic space invasion
ī´ Decreased cord mobility
ī´ Limited thyroid invasion
38. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
ī´ Operation involves resection of
ī´ Both true cords and both false cords
ī´ Entire thyroid cartilage
ī´ Both paraglottic spaces
ī´ Maximum of one arytenoid
ī´ Thyrohyoid membrane
ī´ epiglottis
39. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
ī´ Reconstruction using
ī´ Hyoid bone
ī´ Cricoid
ī´ tongue
ī´ Temporary tracheostomy tube and feeding tube is required.
40. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
ī´ Indications
ī´ T1 and supraglottic lesions with ventricle extension
ī´ T2 infrahyoid epiglottis or posterior 1/3 of false cord
ī´ Supraglottic lesions extending to glottis or anterior commissure
ī´ T3 transglottic carcinoma
ī´ Selective t4 lesions invading thyroid cartilage
42. Supracricoid Partial Laryngectomy with
Cricohyoidoepiglottopexy
ī´ No local recurrence reported by Laccourreye et al
ī´ 3.3% reported by chevalier
ī´ Nasogastric feeding is required for 30-365 days
ī´ Total laryngectomy may be required in 10% of cases
43. Transoral Endoscopic LASER Resection
ī´ Outpatient procedure possible
ī´ Shorter operating time
ī´ Less overtreatment
ī´ Better voice quality
ī´ Low morbidity
ī´ No feeding tube
ī´ No tracheostomy
ī´ Similar oncologic results
44. Transoral Endoscopic LASER Resection
ī´ As compared to radiotherapy it has similar oncologic and
functional results, lower cost.
ī´ Radiotherapy is possible after endocopic laser if it fails
46. Conservation surgery for cancer of
Hypopharynx
ī´ Cancer of hypopharynx includes
ī´ Cancer of pyriform sinus (70%)
ī´ Postcricoid (15%)
ī´ Posterior pharyngeal wall (15%)
ī´ Of all Head and Neck sites Hypopharyngeal Cancer has poorest
prognosis â 5yr survival rate of <20%
ī´ Patients usually present with advanced diseaseAbout 66% of
patients have nodal disease at presentation
ī´ Thus it requires treatment of primary and also of neck
47. Conservation surgery for cancer of
Hypopharynx
ī´ T1 and small volume T2 without neck metastasis
ī´ Usually treated by radiation
ī´ Partial pharyngectomy and bilateral selective neck dissection can also be
performed
ī´ T1 and small volume T2 with neck metastasis
ī´ Comprehensive neck dissection
ī´ Radiation to the primary
48. Conservation surgery for cancer of
Hypopharynx
ī´ Large volume T2 / T3 / T4
ī´ Radical surgery
ī´ Excision of primary tumour
ī´ Reconstruction
ī´ Radiotherapy
ī´ Endoscopic laser
ī´ Excellent functional results
ī´ With synchronous or separate neck dissection
50. Conservation surgery for cancer of the
Oral cavity
ī´ Limited resection of oral cavity is to be condemned
ī´ However it is possible to perform conservative surgery to mandible
ī´ Careful assessment is carried out by bimanual palpation.
ī´ CT is helpful in assessing cortical invasion
ī´ MRI helps to find marrow invasion and inferior alveolar nerve
51. ī´ Segmental mandibulectomy is carried out if
ī´ Gross invasion by cancer
ī´ Tumour close to mandible in irradiated patient
ī´ Invasion of inferior alveolar nerve or canal by tumour
ī´ Massive soft tissue disease adjacent to tumour
ī´ Marginal mandibulectomy is done if
ī´ Superficial aspect of cortical bone is involved
52. ī´ Marginal mandibulectomy is done if
ī´ Superficial aspect of cortical bone is involved
ī´ Marginal mandibulectomy is contraindicated
ī´ Gross invasion into cancellous part
ī´ Irradiated mandible
ī´ Edentulous patient with pipestem mandible
54. Conservation surgery for cancer of
Oropharynx
ī´ Transoral laser resection is an alternatve to chemoradiation and
radical surgery
ī´ With the use of appropriate retractors and distending
pharyngoscopes adequate access is obtained
ī´ Temporary tracheostomy may be required
ī´ Postoperative radiotherapy is recommended
ī´ TORS
56. Conservation surgery for cancer of
Nose and PNS
ī´ Certainly, endoscopic approach for benign disease has advantage
over open surgical resection
ī´ Better function as well as cosmesis
ī´ Availability of
ī´ real time image guidance,
ī´ neuro-navigation and
ī´ intraoperative MRI has furthur improved the safety and accuracy of endoscopic
resections
ī´ However, malignant disease management is still questionable
57. Conservation surgery for cancer of
Nose and PNS
ī´ Indications
ī´ Midline lesions with limited lateral extension
ī´ Benign tumours â inverted papilloma and angiofibroma
ī´ Low grade malignant tumours
ī´ Palliation
ī´ Medical comorbidity limiting open approach
58. Conservation surgery for cancer of
Nose and PNS
ī´ Contraindications
ī´ Lateral extension of tumour
ī´ Intracranial invasion
ī´ Intraorbital invasion
ī´ High grade malignant tumours
60. Conservation surgery for Tumours of
Parotid Gland
ī´ Warthinâs tumour excision without parotidectomy
ī´ Preservation of facial nerve unless they are adherent to or directly
invaded by tumour
ī´ If major branches or the main trunk are involved, then immediate
cable grafts should be done using branches of Cervical plexus or
Sural nerve
61.
62. NEXT ī
05.09.13 Dr Sonu Kumar Singh
M.S.(ENT,PGY2)
Benign tumours of
mouth and jaw