David Lindley, DO

• Assistant Professor
• Department of Anesthesiology
• Critical Care Medicine and Pain Management
• University of Miami
• Miami, Florida

Unilateral maxillary sinusitis is most likely due to which of the following causes They both described a similar procedure treatment gout discount accupril 10 mg line, with Caldwell advocating an inferior meatal antrostomy and Luc advocating enlargement of the natural ostium in the middle meatus medicine 66 296 white round pill cheap accupril 10mg free shipping. Caldwell practiced in New York and published a report on anterior antrostomy in the New York Medical Journal in 1896 68w medications buy generic accupril 10mg on line. Luc was French treatment 20 nail dystrophy order accupril with visa, practiced in Paris treatment 1 degree burn buy accupril with amex, and independently reported his procedure in 1897 symptoms 28 weeks pregnant purchase cheap accupril on line. With the development of endoscopic sinus surgery for the treatment of chronic sinusitis as well as facilitating an approach for other conditions, including skull base surgery, most younger surgeons will have had a very limited exposure to this procedure. Open approaches were also used in a number of situations, apart from chronic sinusitis, including a corridor for the transantral ligation of vessels in the pterygopalatine fossa for epistaxis; in Vidian neurectomy, for the repair of fracture of the floor of the orbit, the repair of oroantral fistulas, and the removal of antrochoanal polyps; and as part of the surgical approach in a maxillectomy. While needed less frequently today, it is certainly important to understand and be able to perform the procedure in cases that are not suitable for an endoscopic approach. Oral cavity Note whether edentulous or not; the condition of teeth, especially the upper incisors; the site and location of an oroantral fistula, if present. Nasal Examine the nasal cavity and perform an endoscopy; check the septum alignment; note the anatomic findings, if previous surgery; check the inferior turbinate location and the relationship to the lateral wall. If surgery is indicated for a fracture of the orbital floor, document the findings and any muscle entrapment. Trigeminal nerve Examine and document the sensation of V2, particularly with regard to the infraorbital nerve. The maxillary sinus is entered anteriorly through the thin bone of the canine fossa, which lies lateral to the canine tooth root. The contents of the maxillary sinus can be viewed directly and removed with enlargement of the antrostomy. The inferior meatal antrostomy (if required) is made below the inferior turbinate 1 to 2 cm behind the anterior tip of the inferior turbinate. Images in both the coronal and axial planes define the size and extent of the sinus as well as its relationship to the surrounding structures. Neoplastic disease: biopsy of maxillary sinus tumors, removal of dental tumors, and staging of maxillary carcinoma 3. Access to orbital floor for orbital decompression and repair orbital floor fractures 6. Immunosuppressed patient with invasive sinusitis, overall medical condition, and underlying coagulopathies 2. Depending on indications for surgery, the patient may be neutropenic and coagulopathic if surgery is being performed for invasive fungal infection. The Caldwell-Luc procedure uses an antrostomy through the inferior meatus, which is essentially drained by gravity. Coronal computed tomography scan in a patient with chronic sinusitis and calcified foreign body ("sinolith"). A nasotracheal or transoral endotracheal tube may be placed in the side opposite the operative site and secured to the surrounding soft tissue with adhesive tape. Perioperative Antibiotic Prophylaxis While perioperative antibiotics can be given, there is no evidence that there is any benefit or decrease in postoperative infections. Headlight (surgeon) Periosteal or elevator Osteotome/mallet Kerrison forceps Blakesley forceps Bone-cutting forceps Preoperative Preparation 1. If patient has invasive fungal disease and is immunosuppressed with coagulopathy, a transfusion as needed. Gingivobuccal sulcus: located at the upper reflection of the buccal and gingival mucosa, just lateral to the midline labial frenulum 2. Canine tooth roots: prominent bony protuberance covering the root of the canine tooth, next to the lateral incisor 3. Canine fossa: slight indentation just lateral to the canine tooth root, over the anterior face of the maxilla. Infraorbital nerve: lies at the superior aspect of the surgical field, where it lies in the midline, just below the infraorbital rim 5. Inferior meatus: intranasal, lying below the inferior turbinate, with entry needed 1 to 2 cm behind the anterior end of the turbinate 6. The floor of the sinus is made up of the palatine and alveolar process of the maxilla; in adults, it extends approximately 4 to 5 mm inferior to the floor of the nasal cavity. In edentulous patients, the incision should be made over the attached gingiva to ensure proper fitting of dentures. In the correct plane, this is easily performed and, using a sponge, can be gently swept superiorly over the anterior wall of the sinus. Exposure of the canine fossa with elevation and blunt dissection of the overlying soft tissue. When dealing with an antrochoanal polyp, the mucosa of the antrum is elevated and bluntly dissected toward the natural ostium, to facilitate its removal intact with the polypoid component, which is then grasped in the posterior choana through the nasopharynx. The inferior meatal antrostomy is created inferior to the inferior turbinate after gentle medial mobilization of the turbinate. The infraorbital nerve is identified and preserved at the point where it exits the infraorbital foramen. The sinus is carefully opened with an osteotome and widened with a Kerrison rongeur. Stay slightly more superior, where the bone is thinner, approximately 1 to 2 cm behind the anterior aspect of the inferior turbinate. The inferior rim should be lowered as much as possible to facilitate gravitational drainage. An olive-tip curved suction can be introduced through the opening into the maxillary sinus. Make sure that the edges of the antrostomy are smooth and the packing is layered in the sinus cavity to avoid any difficulty with removal of the pack. Stay lateral to the canine tooth root, entering into the soft bone forming the canine fossa. The principle of mucociliary flow through the natural ostea in the middle meatus is well accepted. This may be fairly uncomfortable for the patient, and care should be taken to avoid "catching" on bony fragments. If a Foley catheter is used, the balloon can be deflated and observed for any bleeding before removal. Editorial Comment In the latter part of the 19th century, transatlantic communication was slow, unlike today when a call to Europe is made in seconds using a smart phone. George Caldwell, an otolaryngologist in New York City, reported a new operation in 1896 that he called a maxillary antrostomy, which he used in the management of chronic maxillary sinusitis-a common problem in the preantibiotic era. Henri Luc, an otolaryngologist in Paris, reported a similar but not identical operation in 1897. When the news of these two similar operations eventually crossed the Atlantic, the names of the two surgeons were kindly applied to the operation, which became known as the Caldwell-Luc operation (procedure). While the operation was originally designed to eliminate chronic maxillary sinusitis, it has been adapted by a series of imaginative surgeons to provide an entrance to the maxillary antrum to solve a variety of other problems. This remarkably versatile approach can be used to remove antrochoanal polyps intact, to reduce "blowout" fractures of the floor of the orbit, to retrieve foreign bodies, to close oroantral fistulae, to remove the floor of the orbit for decompression of thyroid exophthalmus, to remove mucoceles or small tumors, and to provide access for medial and total maxillectomy. The maxillary antrostomy also provides a corridor to the ethmoid to perform a transantral ethmoidectomy and to the pterygoid fossa for sectioning the Vidian nerve, for ligation of the internal maxillary artery and its branches, and for exposure of the skull base. I used this approach to remove the posterior wall of the antrum and to ligate branches of the internal maxillary artery in the management of epistaxis. This will usually stop spontaneously, but occasionally direct intervention with cautery and packing may need to be performed. Using a Foley catheter initially is very helpful in this situation, as the balloon can be deflated and the patient observed for any bleeding before removal of the catheter. Osteomyelitis of the maxillary bone is more of a historical complication and not something normally seen. Endoscopic technique if surgically feasible Anterior Antrostomy: the Caldwell-Luc Operation 699 to make this step unnecessary by preoperative intra-arterial embolization. The Caldwell-Luc procedure is still alive and well in parts of the world where modern technology is not available. The operation is also used in situations where the endoscopic approach has not yet solved the particular problem. Unfortunately, many otolaryngologists trained in the modern era have little or no experience with this operation, which should be part of the required curriculum in residency training programs. Results of Caldwell-Luc after failed endoscopic middle meatus antrostomy in patients with chronic sinusitis. Potential complications of the Caldwell-Luc procedure include all of the following, except a. Correct statements regarding the inferior meatal antrostomy include all of the following, except a. Placement 3 cm behind the anterior aspect of the inferior turbinate (correct answer 1 to 2 cm behind the anterior aspect of the inferior turbinate) b. An oroantral communication occurs when there is an abnormal connection between the maxillary sinus and the oral cavity. The communication may be the result of trauma, osteomyelitis, pathologic lesions, or foreign bodies such as dental implants or endodontic material. However, the most common cause of an oroantral communication is the extraction of a posterior maxillary tooth. The root apices are in close proximity to the floor of the maxillary sinus and, in some cases, are only separated by a thin layer of lamellar bone or sinus mucosa. For defects greater than 5 mm, closure using various intraoral flaps in conjunction with functional endoscopic sinus surgery increases the chance for long-term success. First choice of radiograph, especially if the fistula occurred after dental extraction(s) b. Assists in treatment planning and flap design, since there is no scatter from any existing maxillary dental restorations 2. Extraction of a posterior maxillary molar tooth is the most common cause of an oroantral fistula. Crossing the buccal vestibule with a flap can obliterate the sulcus and interfere with denture use. Panorex radiograph depicts gutta percha point within oroantral bony defect associated with extraction site tooth #3 (arrow). Presence of a communication or fistula can be confirmed by asking the patient if regurgitation of fluid from the nose occurs after drinking liquids. Bony defect in right maxilla forms a communication between the maxillary sinus and the oral cavity. Recommended with larger defects (>1 cm) or cases of chronic fistula from repeated failure of fistula closure c. Assess for mucosal thickening, maxillary opacification, and obstruction of the ostiomeatal complex. Ciprofloxacin, if there is a history of antibiotic-associated colitis with clindamycin and penicillin allergy d. Moxifloxacin, if there is a history of antibiotic-associated colitis with clindamycin and penicillin allergy 105 Monitoring 1. Nasal regurgitation of liquids through fistula Foul odor or chronic purulent drainage from the fistula Air leakage through the fistula Chronic pain in the fistulous site Instruments and Equipment to Have Available 1. Medically unstable for anesthesia or surgery (immune compromised, severely malnourished) 3. Multiple failures with no further tissue options available to close the defect (patient may require prosthesis/obturator to cover the defect) 4. Patient is unable to consent or declines surgical repair Key Anatomic Landmarks 1. The location and size of the defect, presence of adjacent teeth, topography of surrounding bone, and potential plans for dental restoration once the fistula is removed must all be considered when developing a surgical plan. Consists of a central body and four processes, including the buccal, pterygoid, pterygopalatine, and temporal extensions b. Derives its blood supply from the buccal and deep temporal branches of the maxillary artery, the transverse branch of the superficial temporal artery, and several branches of the facial artery Preoperative Preparation 1. Preoperative management with antibiotics, antihistamines, nasal decongestants, and irrigation of the fistulous tract to reduce the risk of failure 2. After flap design has been chosen, diagnostic impressions with alginate can be used to fabricate a clasp-retained acrylic partial denture. The denture protects the surgical site from oral trauma, improves patient comfort, and maintains adequate depth of the buccal vestibule during the healing phase. Previous experience with creating, mobilizing, and advancing flap(s) in a tension-free manner 3. Paralysis is not necessary, unless the oral opening is limited due to the patient clenching teeth. Flap design: Surgical closure of the fistula from the oral cavity is typically accomplished with traditional soft tissue flaps such as the Rehrmann buccal advancement flap6 or a palatal rotation flap. Patient is placed supine with mid- and lower face appropriately prepped and draped 2. Oral prep with chlorhexidine rinse or clindamycin-infused normal saline Perioperative Antibiotic Prophylaxis 1.

The only structure to identify and ligate is the retromandibular vein while dissecting over the posterior belly of the digastric muscle medicine 377 order accupril no prescription. The contents of the carotid sheath can be found just deep to the omohyoid muscle lower in the neck treatment 2 lung cancer accupril 10 mg amex. This should always be identified symptoms 39 weeks pregnant purchase accupril with a mastercard, lying on the superficial aspect of the anterior scalene muscle medicine bow national forest buy accupril 10mg free shipping. Keeping the nerve in view and staying superficial to the deep cervical fascia will prevent injury to the nerve symptoms bacterial vaginosis order accupril visa. Techniques from previous chapters discussing selective neck dissection and modified radical neck dissection also apply here medications list form order 10mg accupril with mastercard. We delineate and mark out the mastoid tip, the angle of the mandible, suprasternal notch, and the cricoid cartilage. If bilateral neck dissections are planned, the incision carries over to the opposite mastoid tip (an "apron" incision). Superior boundary: inferior border of the mandible that extends to a line joining the angle of the mandible to the mastoid tip b. Anterior boundary: superior belly of the omohyoid and anterior belly of the digastric muscle c. Posterior boundary: anterior border of the trapezius 1) Initially, the great auricular nerve and external jugular vein are identified and protected unless involved by cancer, in which case they may be sacrificed. Dissection of the marginal mandibular nerve from the submandibular gland posteriorly in order to preserve the nerve. A, Marginal mandibular nerve, emerging from the tail of the parotid gland, passes across the inferior border of the submandibular gland. B, Marginal mandibular nerve dissected free of the submandibular gland and elevated along with subplatysmal skin flap. Note that all branches of the great auricular nerve have been divided in this illustration. Operative photo of "hockey stick" incision used for unilateral radical or elective neck dissection. Its course can be quite variable, but generally blunt dissection starts about 1 cm below the antegonial notch near the point where it exits the parotid gland. Identification can be assisted with the use of magnifying loupes and the handheld nerve stimulator. Once located, it should be dissected anteriorly and posteriorly, freeing it from the submandibular fascia to allow for retraction with the superior subplatysmal flap that was elevated. Multiple branches may be identified, and they should all be preserved if possible. The Hayes-Martin maneuver involves identifying the facial artery and vein below the course of the marginal mandibular nerve, ligating these vessels and reflecting them superiorly with the subplatysmal flaps, in effect, preserving the marginal mandibular nerve. With the marginal mandibular nerve safely elevated, the fascia deep to it is incised and the anterior belly of the digastric muscle is identified. The submental adipose tissue and nodes are grasped and dissection is carried inferiorly along the anterior belly of the digastric muscle. The mylohyoid muscle is dissected and the free edge exposed posteriorly, then retracted with an Army-Navy retractor. Care must be taken to identify and cauterize the submental branches of the facial vessels. The edge of the mylohyoid muscle is delineated in its entirety and then retracted anteriorly. The submandibular duct and submandibular ganglion are then clamped and ligated, bringing the contents of submandibular triangle (level Ib) along with the specimen. The facial artery and vein are ligated at the level of the posterior belly of the digastric and the submandibular gland with level 1b contents delivered. The retromandibular vein is ligated, and this dissection often involves resecting the lower-most portion of the tail of the parotid gland. The gland is suture ligated with a silk tie to promote fibrosis and prevent salivary leak and sialocele formation. The proximal end of the muscle is then retracted superiorly, and the omohyoid muscle can be seen. This is an important landmark, as it is just anterior to the contents of the carotid sheath. The omohyoid is divided and traced toward the midline, marking the anterior limit of the neck dissection. The phrenic nerve is located on the anterior surface of the anterior scalene muscle. With the phrenic nerve in view, the surgeon can then clamp and ligate the contents of the supraclavicular adipose tissue pad, retracting it superiorly as part of the specimen. It is dissected free from the common carotid artery and clearly defined from the vagus nerve. Dividing the clavicular head of the sternocleidomastoid muscle and supraclavicular tissue lateral to the omohyoid muscle. The brachial plexus, carotid sheath, and phrenic nerve are protected by their deep position to this muscle. With the anterior border of the trapezius delineated, the dissection (of fibroadipose and lymph-node bearing soft tissues) now carries anteriorly, taking care to leave some fascia on the deep neck musculature, thus sparing as much as possible of the cervical plexus. The dissection continues, and the nerves of the cervical plexus are divided from the specimen high in the neck. With the critical anatomic structures under direct visualization, the lymphatic pedicle can now be clamped and ligated, freeing the inferior portion of the specimen. Now free superiorly and inferiorly, the specimen is connected to the previous level I dissection and brought to the midline with the lateral border of the strap muscles being the anterior limit. The neck is then copiously irrigated and the Valsalva maneuver is performed to check for hemostasis and/or any evidence of chyle leak. Physical therapy should be initiated early in the postoperative period to address shoulder dysfunction and minimize pain. Perioperative antibiotics reduce the risk of infection and should be continued for 24 to 48 hours postoperatively. There is a greater risk of infection when the upper aerodigestive tract is involved in the surgical field. Postoperative wound infections may manifest as erythema, edema, or purulent drainage from the suction drains. Antibiotics can be narrowed down following isolation and appropriate sensitivities. If there is no improvement with medical management, the neck may require exploration and drainage of an abscess in the operating room. Hematomas should be managed in the operating room with re-exploration, irrigation, and identification of the underlying bleeding vessel. Often, no definite vessel is found, but it is still important to evacuate an expanding hematoma and replace the drains, as they may now be clotted off and are no longer useful. An injury to the marginal branch may not be noticed until the postoperative period. Some of the asymmetry may be related to a neuropraxic injury from retraction or even weakness from the plastysmal contribution to the lower lip. Most patients have no issues with oral competency, and it can be managed expectantly in the immediate postoperative period. Unilateral phrenic nerve injury is tolerated by most patients, but for some patients with underlying pulmonary disease it can be problematic. Exposure of the cervical nerves (shown here in red) as they leave the cervical plexus. Extended neck dissection with sacrifice of the common and internal carotid artery with saphenous vein interposition grafting. Left: Star shows the internal carotid artery involved with cancer just distal to the bifurcation. Right: Arrow demonstrates the saphenous vein interposition graft from the common to the internal carotid artery. The physical therapy team should be involved early if there are findings of brachial plexopathy. Most chyle leaks are recognized intraoperatively; however, there can still be problems that manifest during the postoperative course. Low output fistulas can be managed conservatively with a medium chain triglyceride diet, pressure dressing, and medical management. For higher output fistulas or those that are not responding to conservative management, surgical re-exploration may be required. A clinical and radiographic preoperative evaluation should be completed to determine resectability of the primary cancer and regional lymph node metastasis. Additionally, there may be some patients who cannot tolerate the surgery or perhaps do not want to proceed with surgery. With these advanced cancers of the head and neck, there may be an occasion where other structures should be included in the specimen for oncologic reasons. Historically, involvement of the carotid artery has been a contraindication to surgical management of cervical lymph node metastasis. With initial complications and stroke rates greater than 50%, the morbidity and mortality of such intervention did not outweigh any potential benefits. With the advent of advanced imaging and new testing, there have been recent attempts to identify those patients who may tolerate carotid resection or ligation. Furthermore, 24% Radical Neck Dissection 457 of patients were found to ultimately have distant metastases. There are other retrospective studies to suggest an impact on survival in those patients with involvement of the carotid artery. The current standard is to perform preoperative balloon-occlusion testing to assess for patient tolerance and acceptable collateral cerebral perfusion. A thorough knowledge of rotational flaps such as the pectoralis major myocutaneous flap or levator flaps can be instrumental in providing robust and efficient options for carotid artery cover. Clinical outcome analysis of 47 patients with advanced head and neck cancer with preoperative suspicion of carotid artery invasion. Impact of surgical resection on survival in patients with advanced head and neck cancer involving the carotid artery. The appropriate management of the neck is vital to outcomes, quality of life, and palliation. The changing paradigm from primarily surgical management of head and neck cancer to nonsurgical approaches has brought on its own set of challenges, that is, operating in radiated fields with a high incidence of complications and equally important wound breakdown and infection that may lead to life-threatening complications such as carotid artery rupture. Which structure is at risk if not appropriately identified before ligating the lymphatic pedicle A low threshold for auto-transplantation of inferior parathyroid glands after pathologic verification 5. Complications are more common with paratracheal dissection, especially hypocalcemia, vocal fold paralysis, and injury to the esophagus. The central compartment contains the first nodal basin for cancer originating in the thyroid and parathyroid and can be involved in cancers of the laryngotracheal complex. In cases of squamous cell cancer involving the central compartment viscera or parathyroid carcinoma, comprehensive central compartment lymph node dissection is routinely employed, often in combination with ipsilateral thyroidectomy. However, the central compartment lymph nodes are most commonly affected by the regional spread of thyroid cancers. Subclinical micrometastases have been shown to be present in up to 90% of cases of thyroid cancer,1 presumably with less defined clinical significance when compared with macrometastases. There has been no survival benefit associated with prophylactic treatment of the central neck, with equivocal data on local control. Prophylactic central compartment dissection with total thyroidectomy has shown increased rates of postoperative hypocalcemia when compared with total thyroidectomy alone. However, the use of prophylactic central compartment neck dissection results in improved local control and decreases the potential risk of morbidity of reoperative surgery. The role of prophylactic central compartment neck dissection remains controversial, largely due to the lack of a large randomized prospective trial-the feasibility of which is questionable given the prohibitively large sample size it would require. The presence of medullary thyroid carcinoma, with or without evidence of nodal involvement, is an indication for dissection of the lymph nodes in the central compartment. Central compartment dissection is often employed in the case of a loco-regional recurrence of thyroid cancer. Invasive symptoms: hemoptysis, skin fixation, or voice changes from vocal cord paralysis 1) Fiberoptic laryngoscopy 2) Advanced imaging 2. Pre-existing vocal fold paralysis 1) Contralateral deficit may result in tracheostomy b. Hemoptysis or cough 1) May signify invasive component 2) Require cross-sectional imaging 3. Central compartment dissection is often a reoperative surgery and may require a different surgical strategy (lateral to medial). Thyroglobulin (Tg)/thyroglobulin antibody (Tg Ab) 458 Central Compartment Neck Dissection 459 a. Microcalcifications are associated with markedly increased risk of malignancy, while cystic and spongiform appearance may be associated with benign lesions. Low sensitivity of detecting lymphadenopathy in the central neck due to shadowing effect of the thyroid gland 2. Helpful for: 1) Substernal extension 2) Cervical and mediastinal lymphadenopathy 3) Invasion of surrounding structures such as trachea and esophagus 4) Metastasis to distant sites b. High sensitivity and specificity in detecting cervical lymphadenopathy, and less operator dependence, offers visualization of adjacent structures c. When multiple nodules are present, the largest and/or most sonographically suspicious should be biopsied preferentially. The bed can be shifted away or rotated 180 degrees from anesthesia to provide more surgical space. Prepare neck and upper chest with povidone-iodine or chlorhexidine (entire chest if sternotomy anticipated).

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Evaluation of prevertebral fascia: the sternocleidomastoid muscle is retracted laterally and the larynx medially medications qd purchase accupril 10 mg with amex. Finger palpation is then used to determine whether the cancer has infiltrated into the retropharyngeal or retroesophageal space or into the prevertebral fascia medicine 906 accupril 10mg cheap. If cancer is present in the retropharyngeal or retroesophageal space treatment brachioradial pruritus buy accupril 10 mg, the surgery should be terminated because it is impossible to get a clear margin of resection posteriorly when invasion of the prevertebral fascia is present symptoms leukemia order genuine accupril. In such cases symptoms sleep apnea buy accupril 10 mg on-line, a gastrostomy and possibly a tracheostomy should be carried out to provide a means of nutrition and maintenance of the airway medicine for anxiety order accupril 10 mg online. Tracheal resection: the extent of tracheal resection is dictated by the imaging studies and tracheoscopy. If there is no involvement of the trachea, the usual transection of the trachea between the second and third tracheal rings is appropriate. However, if cancer has extended into the trachea, more of the distal trachea may need to be resected. Ligation of the superior laryngeal arteries and veins is carried out during this procedure. Thyroid and parathyroid glands: Inspection of the thyroid gland will determine whether the thyroid gland should be left intact or be totally or partially removed. Superior surgical margin: Specimens should be taken from the superior margin of resection of the pharynx and sent to the pathology department for frozen section examination to make certain that the margins of resection are free of cancer. If not, the surgeon must take additional specimens until clear margins are obtained. Partial esophagectomy: In certain cases in which limited proximal cervical esophageal cancer is encountered, a partial esophagectomy can be undertaken, ensuring a minimum of 2-cm margins, followed by reconstruction with tissue transposition or free tissue flap. Esophageal stay sutures should be placed because tissue retraction into the mediastinum can occur following partial cervical esophagectomy. Reconstruction: In most patients undergoing an esophagectomy, reconstruction is performed using a gastric conduit with the ultimate goal to replicate the esophageal tract as close as possible. The options for reconstruction can be subdivided into pedicled enteric conduits, enteric free flaps, pedicled myocutaneous flaps, and myocutaneous free flaps, each demonstrating their own advantages and disadvantages. B, the incision is carried through the lateral and posterior pharyngeal wall to separate the pharynx from the base of the tongue. Using gentle traction on the specimen and the stomach allows the specimen to be delivered and the stomach to be brought into the neck to complete the pharyngogastric anastomosis. The specimen is elevated off the prevertebral fascia by finger dissection as far inferior as the superior mediastinum, where it is pedicled on the cervical esophagus. Other authors have described the use of a single-layer technique with a 4-0 absorbable monofilament with the knots tied in the lumen. Several nonabsorbable sutures are then placed between the stomach and the left diaphragmatic crus to prevent herniation of the stomach back into the thorax. Overall, a gastric transposition offers a simple reconstructive solution with adequate length and robust blood supply. Colonic interposition: this procedure is usually reserved for the rare situation in which either a gastric transposition or a free tissue transfer is not possible. Preparation of the bowel with a pure liquid diet and oral intake of antibiotics directed at colonic flora is instituted 48 hours before surgery. It will be opened lengthwise to inspect the mucosa of the pharynx and esophagus and to be certain that tumor clearance is macroscopically adequate. Postoperative chest radiograph demonstrating the stomach widening the mediastinal shadow. Because it preserves its active peristalsis, it may offer a superior functional substitute to the esophagus compared with the more passive gastric transposition. Lastly, this reconstructive technique requires multiple anastomoses, thus increasing the risk of anastomotic leaks. Jejunal free flap: this free tissue flap was the first use of a free tissue transfer in humans, reported by Seidenberg et al. Furthermore, its preserved peristalsis may help with the transport of the food bolus, and therefore care must be taken to insert the flap in an isoperistaltic orientation. We recommend having an exteriorized monitoring segment of jejunum based on the same pedicle that may be excised 5 to 7 days postoperatively. Finally, the jejunum has also shown strong tolerance to postoperative radiotherapy and will often allow for decreased rates of xerostomia due to its robust secretory surface. Gastro-omental free flap: First reported in 1979 this free flap has the advantage of including a large omental apron that can be used to fill large dead spaces or cover the anastomosis and previously or potentially irradiated vessels. Mucus secretion is also found in this flap and aids in deglutition, although its composition is significantly more acidic, and mucosal ulceration of adjacent tissues is possible. Furthermore, unlike in the jejunal free flap, patients are left with a gastric staple line. Deltopectoral or pectoralis major myocutaneous flaps: these myocutaneous flaps provide a large volume of well-vascularized tissue used to cover the newly reconstructed cervical esophagus and exposed major vessels after exenteration of the central compartment. Radial forearm free flap: A group from Detroit described the successful use of a radial forearm free flap for reconstruction of an esophageal defect following resection of a localized squamous cell carcinoma of the cervical esophagus. This free flap may also be rolled into a tube in an effort to replace a short circumferential defect after a cervical esophageal excision. Anterolateral thigh free flap: this free flap may be raised as a cutaneous, fasciocutaneous, or myocutaneous graft and provides a longer length than the radial forearm free flap. Yu described a novel technique performed in 10 patients for reconstruction of combined pharyngoesophageal, tracheal, and anterior neck defects with a single anterior thigh flap. One paddle was tubed and used for esophageal reconstruction and the other for repair of cutaneous defects. This technique provides good cosmetic and functional results with minimal morbidity and quick recovery. Tracheoesophageal puncture can be completed postoperatively, as described in Chapter 83, to achieve phonation with a reasonable degree of success; a "tracheogastric" puncture in patients in whom reconstruction involves gastric transposition and "tracheojejunal" puncture in those in whom repair is accomplished with a jejunal interposition flap can be made. This procedure is simple and safe, and a puncture into the jejunum produces a rather "moist" voice but one that is understandable. Puncture through the posterior wall of the trachea into the transposed stomach also produces a suboptimal, although understandable, low-volume voice. Occasionally, patients may present with small lesions where a limited resection of the cervical esophagus with preservation of the larynx and the function of the cricopharyngeus muscle and vocal cords may be possible. Interesting findings in laryngeal preservation surgery have been reported from a group in Japan, where 33 patients with cervical esophageal squamous cell carcinoma had a cervical esophagectomy followed by reconstruction with a jejunal free flap. Apart from mucosal resection, endoscopic therapy has evolved to include photodynamic therapy, argon plasma coagulation, multipolar electrocautery, laser therapy, cryotherapy, and radiofrequency ablation,8 showing comparable long-term survival rates to surgical resection, although these therapies are only applicable to patients with mucosal lesions and for whom lymph node metastases are rare. Attempts to resect the cervical esophagus while maintaining an intact laryngotracheal tract are challenging and require a nearly perfect combination of tumor location, stage, surgical, and reconstructive skills. Previous gastric surgery or placement of a gastrostomy tube to correct malnutrition may make gastric transposition impossible. A chronic alcoholic who continues to drink heavily before surgery is at high risk for delirium tremens. Antibiotic therapy, as discussed in the section "Perioperative Antibiotic Prophylaxis. Strict nil per os for 24 to 48 hours followed by nasogastric or percutaneous gastrostomy feeding 4. Thyroid hormone replacement therapy for patients whose thyroid gland has been removed at the time of the surgery with the specimen 5. Calcium levels should be monitored closely followed by adequate replacement therapy. Gastroesophageal reflux disease precautions should be taken, and every patient should receive proton pump inhibitors in the postoperative period. Drain (cervical, thoracic, abdominal) management is often variable from one center or subspecialty to the next. Such surgical procedures often lead to severe psychologic distress due to the mutilating aspect of the defect. An anastomotic leak with a gastric transposition should be aggressively treated because the acidity of gastric secretions may result in severe bleeding from neck vessels. Nonspecific complications: pneumothorax, pneumonia, pleural effusion, fluid shifts, hemorrhage, pulmonary atelectasis, intrathoracic chyle leak, ischemia or necrosis of reconstruction tissue, peritonitis or gastrointestinal perforation (for gastric conduit reconstructions), tracheobronchial injury, wound dehiscence, hypocalcemia 2. Gravity will instill an important tension on the anastomosis and may increase rates of anastomosis leaks (10% to 37%), which can rapidly evolve to mediastinitis, sepsis, and death. Early satiety, postprandial discomfort, dysfunctional propulsion/dumping syndrome 3. Ulceration of the distal colonic interposition due to gastric reflux-can lead to stricture or perforation 4. Stricture: treated by direct surgical revision, balloon dilatation, or placement of a stent b. Chronic fistulas can be treated with a pedicled myocutaneous flap Common Errors in Technique 1. Failure to adequately assess the extent of the cancer preoperatively will often result in inadequate resection of the cancer. Reconstruction was carried out via gastric transposition, colonic transposition, or a jejunal free flap. The survival rate without dysphagia is better in patients with gastric transposition than in those with jejunal grafts. The authors found no significant difference in survival between the techniques of reconstruction. However, better results were obtained with gastric transposition because of fewer postoperative complications, faster re-establishment of oral feeding, and better quality of life. Necrosis and fistula rates are higher in jejunal free flaps compared with gastric transposition. In one of their patients a stricture developed that was successfully treated by dilatation. Editorial Comment this article provides an important summary of the literature on cancer of the cervical esophagus. The prerequisite knowledge for management of this extremely difficult disease is contained in the other chapters in this section. In other words, it is important to understand all the principles of diagnosis and management of the entire hypopharynx, larynx, and upper esophagus to take on the challenge of cancer in this difficult location. Comorbidity is the rule rather than the exception, and treatment failure is common due to the high incidence of regional failure. Although surgery may not be curative, it is often the only way to effectively palliate patients. Reconstruction is covered not only here but also in other chapters, and the method of choice depends not only on tumor extent but also on coexisting conditions. The tolerance of visceral flaps, fasciocutaneous flaps, and the stomach to the high doses of radiation required to manage this cancer is an area of current and future investigation as improved methods of radiation delivery and new targeted drug therapies become available. The authors have done an excellent job of adding important material from the recent literature to the chapter from the prior edition. A rational approach to pulmonary screening in newly diagnosed head and neck cancer. Pharyngogastric anastomosis after oesophagopharyngectomy for carcinoma of the hypopharynx and cervical oesophagus. Pharyngolaryngoesophagectomy with pharyngogastric anastomosis for cancer of the hypopharynx: review of 101 operations. Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Survival rates at 2, 3, 5, and 10 years were 35%, 29%, 25%, and 10%, respectively. All patients still alive at their last follow-up had normal swallowing and no or mild esophageal symptoms. Which of the following is an absolute contraindication to a surgical intervention in cervical esophageal cancer Endobronchial ultrasound may be used to evaluate intrathoracic lymph node metastasis. Reconstruction of the pharyngeal wall by free transfer of greater omentum and stomach. Long-term results of definitive radiochemotherapy in locally advanced cancers of the cervical esophagus. Larynx-preserving limited resection and free jejunal graft for carcinoma of the cervical esophagus. Functional outcomes and donor site morbidity following circumferential pharyngoesophageal reconstruction using an anterolateral thigh flap and salivary bypass tube. Experimental use of free gastric flaps for the repair of pharyngoesophageal defects. Review of 346 patients with free-flap reconstruction following head and neck surgery for neoplasm. Surgical management of carcinoma of the hypopharynx and cervical esophagus: analysis of 209 cases. One-stage reconstruction of complex pharyngoesophageal, tracheal, and anterior neck defects. Population-based studies have been contradictory regarding the effect of snoring on mortality, cardiovascular disease, metabolic syndrome, and stroke. Snoring is the most common presenting symptom in sleep-disordered breathing patients, and therefore otolaryngologists should be aware of the proper workup as well as procedures and therapies available to treat this condition. Oral appliances have been shown to significantly reduce snoring, theoretically by increasing the size of the pharyngeal airway in both the lateral and the anterior-posterior dimensions.

A medications in mexico accupril 10 mg low price, Frontotemporal craniotomy provides additional access to intracranial compartments symptoms 2 weeks pregnant order cheap accupril on-line. For extensive nasopharyngeal tumors medications knee generic accupril 10 mg free shipping, this additional access will enable extirpation of tumor extensions involving the foramen ovale 9 treatment issues specific to prisons cheap accupril 10mg on line, the foramen spinosum medications lisinopril cheap 10mg accupril, and the orbital apex medications ending in zine generic accupril 10 mg mastercard, as well as drilling of the clivus if needed. Extensive invasion of brain parenchyma by a malignant tumor is another relative contraindication. In many tumors, resection of the brain is not an acceptable treatment; however, in some cases, such as an aggressive meningioma, resection of some brain tissue may be reasonable. Multidisciplinary planning with a Neurosurgeron is needed to discuss and plan treatment options and surgical techniques in these cases. This is particularly true in well-defined central skull base lesions that may be amenable to an endoscopic endonasal approach. Quantitative analysis of relative advantages of different methods of access to the skull base can be helpful in selecting the best approach6; ultimately, each surgeon or surgical team must select approaches based on their own experience and results. Biopsyproven hematologic lesions such as lymphoma and plasmacytoma are best treated with nonsurgical therapy. Consideration for surgical therapy for metastatic cancer is limited to decompression. Temporalis muscle transposed for reconstruction of cranial base defect after facial translocation approach. B, Magnetic resonance imaging showing transposed flap in place, reconstituting the lateral nasopharyngeal wall and isolating the cranium from aerodigestive contamination. Blood products should be available, especially when dealing with highly vascular lesions. Reconstructive considerations should be discussed prior to the start of the surgery and additional team members prepared to participate if necessary. Chordomas of the clivus and the surrounding structures, especially those with extension across the midline and to the craniovertebral junction 4. Preoperative assessment of the airway is critical to the safe induction of anesthesia. If an orotracheal endotracheal tube is used, it should be secured using either a dental wire to the teeth or a circum-mandibular wire on the contralateral side. This will prevent accidental dislodgment as the head is turned and repositioned throughout the case. To identify skull base foramina, the lateral pterygoid plate can be followed posteriorly to identify the foramen ovale, foramen spinosum, and the spine of the sphenoid bone. Hemi- or bi-coronal incision and flap elevation Parotidectomy techniques including facial nerve dissection Maxillectomy or additional facial skeletal osteotomies Midface/cranial plating Experience with incisions and closure of eyelid lacerations Regional muscle flap elevation Abdominal adipose tissue harvest Positioning 1. Mayfield pins are usually reserved for cases in which intracranial microneurovascular work is anticipated. The patient must be sterilely prepped and draped to allow exposure of the entire head and neck. Anithromboembolism stockings should be applied to the legs and the body properly padded to prevent pressurerelated ischemia. Temporary or permanent dysfunction of cranial nerves (especially frontalis paralysis and V2 numbness) 2. Antibiotic prophylaxis should provide coverage against the skin flora and upper aerodigestive tract flora. If intracranial surgery is anticipated, the use of an antibiotic with good penetration of the blood-brain barrier should be considered. Incisions will include a lateral rhinotomy incision and a hemicoronal incision extending preauricularly. An incision can be extended into the neck if necessary for management of metastases in the neck or control of the carotid artery. When making the horizontal incision across the zygoma, first incise just through the skin and superficial subcutaneous tissues, and then identify the frontalis branches of the facial nerve. Each frontalis branch should be sharply transected and a 7-0 nylon suture attached to each of the transected ends to facilitate locating each end and reapproximating them at the end of the procedure. Extend the dissection deeply to the temporal adipose tissue pad, then through this adipose tissue to the zygomatic arch. The lower facial soft tissue flap can then be released and retracted inferiorly dissecting in the plane of the parotid-masseteric fascia. Next, the lateral rhinotomy incision is made, up to the level of the medial canthus. The depth of this incision should extend to the periosteum of the nasal and maxillary bones. The palpebral conjunctiva of the lower lid is then incised, extending medially to divide the medial canthus and meet the lateral rhinotomy incision. The incision is then extended through the lateral canthus to connect to the temporal incision. Electrophysiologic monitoring (somatosensory evoked potentials or electroencephalography) is initiated in select cases depending on what neural and vascular territories are at risk. A lumbar drain is sometimes helpful if significant intradural dissection is anticipated. Nerve integrity monitoring system Magnifications (surgical loupes and/or microscope) Fine dissection scissors Periosteal elevators Rainey clips Reciprocating and oscillating saws Rongeurs 7-0 or 8-0 nylon sutures Crawford nasolacrimal tubes Midface/cranial plating system Vascular instrument set if the carotid artery is at risk Key Anatomic Landmarks 1. During elevation of the scalp flap, one must incise down to the deep temporalis fascia at a level above the superior orbital rim and follow this plane inferiorly to prevent injury to the frontal (a. The blood supply to the temporalis muscle is located deep in the muscle (deep temporal branches of the internal maxillary artery). The eyelid incision should be dissected deeply down to the orbital rim, freeing the eyelid from the surrounding maxilla and orbital rim in a subperiosteal plane. When the medial canthal ligament is released, it is helpful to mark the location to enable exact reattachment at the end of the case. The lower face flap is further released by dissecting the premaxillary soft tissue in a subperiosteal plane. The infraorbital nerve (V2) will be identified and transected, and it too will be tagged for re-approximation at the end of the procedure. The infraorbital nerve is mobilized by using a fine elevator to slightly widen the foramen and push the proximal nerve end through the foramen, and then it is released from attachments at the floor of the orbit. The premaxillary soft tissue is now mobilized down to the Le Fort I line, and the skeleton of the lower orbit, nose, maxilla, and zygoma should now be fully exposed. At this time, the hemicoronal incision is made, and the frontotemporal soft tissues are elevated from the underlying temporalis muscle, staying deep to the tagged frontalis branches. The periorbita is released from the medial and lateral walls of the orbit as well as the orbital floor to protect the orbit during osteotomies. The ethmoidal arteries should be tied, clipped, or cauterized if the tumor extends to the anterior cranial fossa or ethmoids. The last step in preparation for osteotomies is to release the masseter muscle from the zygomatic arch. Osteotomies can be extended or customized as needed depending on the extent of the lesion. The bone should be placed in a saline solution to preserve it for later reconstruction. Mucosa from the maxillary sinus should be removed, as the sinus will be obliterated during closure and reconstruction. To access the infratemporal space, the temporalis muscle should be detached in its entirety from its origin on the skull and reflected inferiorly. An osteotomy of the coronoid process of the mandible can now be performed, if needed, to increase inferior rotation of the temporalis muscle. An osteotomy is performed at the pterygoid plates at the skull base with a reciprocating saw or rongeurs. If there is intracranial tumor, a craniotomy can now be performed by the neurosurgical team. Bony reconstruction of the middle fossa floor is not necessary; however, it is necessary to have well-vascularized tissue against the dura to separate the cranium from the aerodigestive tract below. If this flap is not viable for any reason, or was part of the resection, vascularized tissue must be brought via free tissue transfer. If the carotid artery has been exposed, it must also be covered with well-vascularized tissue. Once the temporalis muscle is translocated for reconstruction or removed with tumor resection, the temporalis donor site must be reconstructed to prevent concavity and cosmetic deformity. Autologous free adipose tissue grafting is well tolerated and usually satisfactory for reconstruction. A variety of implants for this purpose are available, but in our experience adipose tissue is a better choice in the acute setting. The nasolacrimal duct should be redirected to its natural canal into the nose and stented using a Crawford stent for 6 to 8 weeks. Soft tissue re-approximation should be performed carefully to ensure proper positioning without tension. Medial and lateral canthal placement must be precise, especially in affixing the medial canthal ligament at the previously marked location. A temporary tarsorrhaphy is recommended to decrease scar contracture and the risk of ectropion. The frontalis branches are now re-approximated with neurorrhaphy sutures (7-0 or 8-0 nylon) or entubulation techniques. Improper placement of facial incisions or improper reapproximation, resulting in increased scar visibility 2. Failure to secure the bone graft may result in non-union and subsequent infection or deformity. Trismus may result from dissection of the masticator space and can be treated with a bite appliance. Alternative Management Plan Some neoplasms in this area are amenable to treatment with external beam radiation with or without chemotherapy. Discussion at a multidisciplinary tumor board will assist in deciding the best and alternate treatment plans. The anatomy of each patient as well as the pathology and extent of the tumor requires careful evaluation prior to selecting an approach for resection. Sacrifice of the trigeminal nerve or any of its branches may be required for tumor resection, so some of these complications may be unavoidable. Facial anesthesia puts the patient at risk for self-inflicted injury, especially when chewing food. V1 anesthesia carries a high risk of corneal ulcer and must be managed aggressively. The transection and re-attachment of the frontalis (facial) nerve branches will lead to forehead paralysis that can be expected to resolve within 6 to 9 months when careful neurorrhaphy is done. Trismus is common postoperatively both immediately due to pain and chronically due to pterygoid musculature scarring/fibrosis. Beginning 2 to 3 weeks after surgery, patients should regularly perform jaw opening and stretching exercises to prevent trismus. Cosmetic deformities may arise even with careful planning of incisions and reconstruction. Facial scarring is generally acceptable, especially if placed along the margins of facial subunits. If the temporalis muscle is sacrificed or transposed, this leads to a depression in the temple that should be reconstructed with a free graft or implant at the time of surgery or at a secondary procedure. Velopharyngeal insufficiency may result if extensive pterygoid resection and disruption of the tensor veli and levator veli palatine muscles have taken place. In order to avoid transection of the temporal branches of the facial nerve, I prefer to omit the skin incision from the lateral canthus to the preauricular incision. By working on both sides of this bridge of skin, visualization and tumor dissection are adequate in most cases. Combined anterior approaches (endoscopic endonasal and transmaxillary) provide adequate visualization and room for instrumentation. Surgical exposure of the nasopharynx: anatomical basis for a transfacial approach. Master Techniques in Otolaryngology-Head and Neck Surgery: Skull Base Surgery Wolters Kluwer Philadelphia. Quantitative evaluation of transtemporal and facial translocation approaches to infratemporal fossa. Morbidity profile and functional outcome of modified facial translocation approaches for skull base tumors. During elevation of a bicoronal scalp flap, which plane is correct for dissection During dissection, it is important to know the location of all cranial base foramina and neural structures. What is the main blood supply for the temporalis, and where does it travel in relation to the muscle For which tumor scenario should the Facial Translocation Approach be considered when planning surgical options Esthesioneuroblastoma extending through the cribriform plate with intracranial extension as well as posterior extension of tumor into the sphenoid sinus b. T3N1M0 Nasopharyngeal carcinoma that was just diagnosed with no previous treatment c. T3N1M0 Nasopharyngeal carcinoma recurrent 2 years following radiation treatment d.