PART 1-BASIC PRINCIPLES OF CANCER SURGERY OF THE HEAD AND NECK 1
1 Historical Notes 3
Recent Advances Permitting Relatively Safe Radical Surgery of the Head and Neck 13
2 Preoperative Considerations 14
Planning the Operation—Selection of the Operative Procedure 14
Local as Compared to Total Excision of an Organ or an Anatomic Part 15
Resection of an Adjacent Anatomic Structure 15
Excision of Bone 16
Extraction of Teeth 16
Preoperative Working Models for Postoperative Prostheses 16
Extent of Neck Dissection 16
The＂Forgotten Zone＂ 17
Combination of Neck Dissection with Excision of Primary Lesion 18
Excision of Primary Lesion Leaving an Open Defect for Later Closure 18
Medical Work-up 18
The Problem of Operative Risk 18
The＂Noli me Tangere＂in Head and Neck Surgery 19
Age in Relation to Operative Mortality 20
Biopsy 21
Punch Biopsy 21
The Problem of the＂Lump in the Neck＂ 21
Aspiration Biopsy 29
Technic of Aspiration Biopsy 29
Frozen Section 33
3 The Operation—Technical Considerations 35
Shaving and Sterile Preparation of the Operative Field 35
Anesthesia 36
Nerve Block or Regional Anesthesia 37
Hypotensive Anesthesia 38
Free Airway for Duration of Anesthesia and Measures to Prevent Aspiration of Blood 33
Endotracheal Tube with Packing in Pharynx 38
Endotracheal Tube with Inflatable Cuff 38
Simple Tracheostomy with Packing in Pharynx 38
Tracheostomy Tube with Inflatable Cuff 41
Balloon Cuff Anesthesia Tube 41
Position of the Patient on Operating Table 41
Draping of the Patient 41
Selection of Instruments for an Operation 44
Nomenclature of Operative Procedures 44
Names of Specific Instruments 44
Blood Transfusions 45
Skin Incision and Operative Exposure 45
Hemostasis，Ligatures，and Knot-Tying：Endothermy 48
Specific Reasons for the Excision of Bone in Head and Neck Surgery 49
Invasion of Bone by Cancer 49
For Access to Operative Site 49
To Permit Shifting of Soft Tissues to Facilitate Closure 49
Form and Extent of Mandibular Bone Excision 50
Partial or Complete Excision of the Hyoid Bone 50
Partial Resection of the Clavicle 50
Peripheral and Deep＂Safe＂Margins for Excision of Cancer 50
Cosmetic Appearance and Restoration of Function versus Adequately Wide Excision of Cancer 51
Closure of Operative Wounds of the Head and Neck 51
The＂Pull-Through＂Technic 53
Ligation by Wire of the Residual Stump in Cystic Cervical Lymph-hygroma 53
Isolation of the Oral Cavity by Primary Closure of the Pharyngeal Opening 54
Marsupialization of Benign Bone Cysts 54
Exploratory Laryngofissure in Cancer of the Intrinsic Larynx 54
Resection of a Thyroid Lobe to Facilitate Surgery in the Root of the Neck 55
Various Reconstructive Procedures 55
Skin Grafts for Operative Defects of the Maxilla，Orbit，and Mouth 55
Skin Grafts on Stents for Closure of Annular Pharyngeal Defects 56
Rotated or Sliding Flap Grafts 57
Skin Grafts for the Repair of Superficial Facial Defects 58
Tubed Pedicle Grafts 58
Bone Grafts 59
Buried Metal Splints 60
Limitations in Usefulness of Bone Gratts and Metal Splints for Mandibular Defects 60
Fixation of the Mandible by Bite Block or by Wiring the Teeth 60
Surgical Prosthesis 61
Wound Drainage 62
Sump Suction Drainage 63
Essential and Prophylactic Tracheostomy 63
Tracheostomy Trocar for Acute Respiratory Obstruction 67
Prophylactic Arterial Ligations 68
Surgery After Radiation Therapy 68
4 Postoperative Care 71
Recovery from Anesthesia—Management of Endotracheal Breathing Tube 71
Immediate Pressure Dressings 71
Air Cushion Pressure Dressings 72
Pressure Dressings over Skin Grafts and Rotated Pedicle Flaps 72
Early Ambulation 74
Prevention and Control of Postoperative Sepsis 74
Antibiotics 74
Zinc Peroxide 74
Bacillus Pyocyaneus Infections 74
Care of the Tracheostomy 74
Nutritional Care 76
Liquid Diets for Naso-esophageal Tube Feeding 77
Minor Role of Gastrostomy in Head and Neck Cancer 78
5 Immediate Operative Risk and Functional Disability Following the Sacrifice of Specific Anatomic Structures of the Head and Neck 79
Jugular Veins 79
External Carotid Arteries 80
Common or Internal Carotid Artery 80
Arterial Grafts and Vascular Anastomoses 81
Subclavian Artery 81
Recurrent Laryngeal Nerve 82
Superior Laryngeal Nerve 82
Phrenic Nerve 83
Seventh Cranial Nerve 83
Vagus Nerve 84
Hypoglossal and Lingual Nerves 84
Cervical Sympathetics 84
Carotid Sinus Syndrome 84
Horner＇s Syndrome 85
Exposure of Dura and/or Cerebral Cortex 85
Sacrifice of Eye 86
Submaxillary and Parotid Ducts 86
Thyroid and Parathyroid Glands 87
Thoracic Duct 87
6 General and Local Complications of Head and Neck Surgery 88
Shock 88
Hemorrhage 88
Gastrointestinal Hemorrhage 89
Hematoma and Chyloma 90
Hematoma in Thyroid Surgery 90
Chyloma 90
Subcutaneous Emphysema 91
Infection—Wound Sepsis 91
Separation of the Suture Line within the Mouth 91
Influence of Diabetes or Liver Dysfunction on Wound Healing 92
Pulmonary Complications—Respiratory Obstructions 92
Pneumothorax and Pneumomediastinum—Air-Sucking Wounds in the Neck 92
Malnutrition—Dysphagia—Dysmaseis—Dysgeusia 94
Lymphedema 95
Postoperative Granuloma of the Larynx and Trachea 95
Granuloma Following Partial Laryngectomy 96
Granuloma Following Intubation 96
Granuloma of the Trachea following Tracheostomy 96
Stricture(Anterior Webbing)of the Glottis Following Partial Laryngectomy 96
Anterior Webbing 97
Salivary Fistula—Pharyngostome 97
Temporary Pharyngostome 97
Trismus 97
Corneal Injuries and Other Eye Complications 98
Tracheitis Sicca 99
Microstomia Following Total Laryngectomy 99
Inflammatory and Traumatic Hypertrophy of the Tail of the Parotid Following Neck Dissection 100
Keloid 101
Treatment 101
7 Long-Term Cosmetic and Functional Disabilities Following Radical Surgery of the Head and Neck 102
Cosmetic Appearance 102
Disability and Paresthesias Following Neck Dissection Due to Section of the Eleventh Cranial Nerve and Cervical Plexus 103
Tissue Defects of the Mouth Producing Salivary Incontinence 103
Dysphagia and Masticatory Difficulties 104
Speech Disabilities 104
Speech Re-education 104
The Reed Larynx 104
The Electro-larynx 104
Esophageal Voice 105
BIBLIOGRAPHY 107
PART 2-ATLAS OF OPERATIVE PROCEDURES 117
8 Operative Procedures of a General Character or Application 119
Neck Dissection 119
Segmental Excision of the Common Carotid Artery and End-to-End Anastomosis 127
Maneuver to Avoid Inadvertent Injury to the Marginalis Mandibulae Nerve During Neck Dissection 128
Combination Neck Dissection and Axillary Dissection 129
Excision of Submaxillary Salivary Gland(Submaxillary Dissection) 130
Excision of Congenital Cervical Cysts and Fistulae 131
Thyroglossal Duct Cyst 131
Branchiogenic Cyst 134
Branchiogenic Fistula 135
Tracheostomy 136
Ligation of External Carotid Artery 140
Ligation of Parotid Ducts 142
Anterior Pharyngotomy 143
Fusion of Eyelids 145
Formation of Tubed Pedicle Grafts 146
Migration of Tubed Pedicle Grafts 148
Migration to Defects in the Submental Area 150
Migration to Lateral Cheek Area 151
Migration to Lateral Face Area 153
Donor Sites for Skin Grafts for Facial Defects 156
Pinch Grafts as an Aid to Incompletely Closed Incisions 158
Reduction in Size of Circular Defects by Purse-String Sutures Before Skin Grafting 159
9 Operations for Cancer of the Skin of the Face(Eyelids，Nose，Lip，and Ear) 161
General 161
Elliptical Incisions for Excision of Small Cancers of the Face 161
Eyelids 163
Excision of Small Growth of Upper Eyelid by Simple Ellipse 163
Excision of Growth of the Upper Eyelid Approaching the Palpebral Margin—Closure by Rotated Flap from Adjacent Upper Eyelid 164
Closure of Upper Eyelid Defect by Rotated Flap from the Temporal Area 165
Circular-Shaped Excision with Z-Plastic Closure for Growth near Palpebral Margin 166
Wedge-Shaped Excision of Growth of Palpebral Margin 167
Excision of Growth Below the Inner Canthus；Closure by Rotated Flap from the Upper Eyelid 168
Excision of Growth of the Lower Eyelid；Closure by Rotated Flap from the Upper Eyelid 169
Excision of Growth of Lower Eyelid near Outer Canthus；Closure by Rotated Flap from the Upper Eyelid 170
Rotated Flap from Nasolabial Groove for Closure of Defects of Lower Eyelid 171
Temple and Cheek 172
Excision of Growth of the Temporal Region；Closure by Skin Graft 172
Excision of Growth of the Skin of the Cheek；Closure by Full-Thickness Skin Graft 173
Closure of Large Cheek Defect by Split Graft 174
Excision of Growth of the Skin of the Cheek；Closure by Rotated Flap from the Temporal or the Mastoid Area 175
Nose 176
Excision of Growth of Bridge of the Nose；Closure by Direct Suture 176
Excision of Growth Near Tip of Nose：Closure by Skin Graft and Sandwich-Type Pressure Dressing 177
Excision of Growth of Nasal Ala；Closure by Rotated Flap from Cheek 178
Excision of the Full Thickness of the Margin of the Nasal Ala；Repair by a Doubled Rotated Flap 179
Excision of Growth Near Tip of Nose；Closure by Rhinoplasty 180
Radical Excision of the Nose and Nasal Cavity for Deeply-Invasive Cancer of the Skin of the Nose 183
Lips 184
Excision of Growth of the Upper Lip；Closure by Rotated Flaps 184
Excision of Growth of the Skin of the Upper Lip；Closure by Sliding Flap 185
Excision of Skin Cancer of Lower Lip；Closure by Skin Graft and Mattress-Suture Pressure Dressing 186
Chin 187
Excision of Radiation Sclerosis and Cancer of Skin of Chin and Repair by Pedicle Tube Graft 187
Ear 189
Excision of Growths in and About Auricle 189
Excision of Growths in the External Auditory Canal 191
Radical Excision of External and Middle Ear with Skin Graft 193
10 Operations for Cancer of the Mucosa of the Lip 195
Local Excision of Cancer of the Lip by Simple Ellipse 196
V-Excision of Lower Lip 197
Subtotal Excision of Mucosa of the Lower Lip(Lip-Stripping Operation) 198
Combined V-Excision and Lip-Stripping Operation 200
Estlander Cheiloplasty 201
Bridged Cheiloplasty for Cancer of the Lower Lip 201
Homolateral Nonbridged Estlander Cheiloplasty 203
Bernard Cheiloplasty for Advanced Cancer of the Lower Lip 204
Bridged Estlander Cheiloplasty for Cancer of the Upper Lip 206
Cheiloplasty for Cancer of the Upper Lip；Closure by Bilateral Sliding Flaps 207
11 Operations for Cancer of the Mucosa of the Cheek 209
Local Excision of Cancer of Mucosa of Cheek and Closure by Simple Suture 210
Irregularly-Shaped Excision of Cancer of Mucosa of Cheek 211
Excision of Tumor of the Mucosa of the Cheek；Closure by Skin Graft 212
Excision of Widespread Multiple Cancer or Precancer of the Mucosa of the Cheek，Lips，Gum，and Palate：Closure by Skin Graft on Prothesis and on Buried Stents 214
Excision of Posterosuperior Buccal Tumors Through Weber-Fergusson Approach 217
Through-and-Through Excision of Cancer of the Cheek and Closure by Estlander Flap 219
Excision of Deeply-Infiltrating Tumor of the Buccal Mucosa Combined with Neck Dissection：Access to the Cheek by Splitting the Lower Lip 220
Through-and-Through Excision of Advanced，Deeply-Infiltrating Cancer of the Cheek Combined with Neck Dissection 223
12 Operations for Cancer of the Gum 225
Local Excision of a Small Cancer of the Edentulous Gum 226
Excision of Cancer of the Gum and Closure by Lateral Shifting of the Floor of Mouth 228
Marginal Resection of Mandible(Alveolar Process)for Cancer of the Gum 229
Marginal Excision of the Lower Alveolus and a Portion of the Ascending Ramus for Cancer of the Retromolar Area(Combined with Neck Dissection) 231
Excision of Cancer Involving Both Upper and Lower Gums and Retromolar Area by Partial Resection of the Mandible and Neck Dissection 234
Variation in Procedure when Cancer of the Gum Involves the Edge of the Tongue 238
13 Operations on the Mandible：For Primary Tumors of Bone；For Temporary Section of the Mandible；Hemimandibulectomy 241
Hemimandibulectomy 242
Resection of Ramus for Primary Bone Tumor 245
Temporary Section of the Mandible for Approach to the Pterygomaxillary Space 247
Resection of the Mandible Through the Open Mouth 249
14 Buxied Metal Splints and Bone Grafts for Mandibular Defects 251
Wire Mesh Splints 251
Partial Resection of Mandible and Repair by Wire Mesh Splint 252
Partial Resection of Mandible and Repair by Wire Mesh Splint：Variation in Method of Attaching Wire Mesh Splint 255
Resection of the Mandible and Repair by Wire Mesh Splint：Variation in Position—Anterior Portion of Mandible 256
Total Resection of Mandible with Replacement by Wire Mesh Spiint 257
Bone Grafts 259
Rib Grafts 259
Iliac Crest Grafts 261
15 Operations on the Tongue 265
Local Excision 266
Lesions on the Lateral Border 266
Lesions on the Dorsum 267
Lesions through Vertical Ellipse 268
Partial Glossectomy 269
Growths at the Tip，Lateral Border，or Dorsum of the Tongue 269
Lesions on the Undersurface Near the Tip of the Tongue 270
Superficial Lesions Involving the Tip and Most of the Dorsum of the Tongue 271
Base of the Tongue Via Anterior Pharyngotomy 274
With Resection of the Mandible and Neck Dissection 275
Subtotal Glossectomy Combined with Neck Dissection 277
16 Operations for Growths of the Floor of the Mouth 281
Simple Elliptical Excision for Superficial Cancer 282
Marginal Resection of the Mandible for Cancer of the Anterior Floor 283
Excision of Cancer of the Anterior Floor Combined with Marginal Resection of the Mandible and Neck Dissection 286
The＂Pull-Through＂Operation：Marginal Resection of the Mandible for Cancer of the Lateral Floor of the Mouth Combined with Neck Dissection 288
Excision of Extensive Primary Cancer of the Floor Combined with Partial Resection of the Mandible and Neck Dissection 290
Excision of Salivary Cyst(Rannula) 294
17 Operations for Tumors of the Palate 295
Excision of Small Tumor of the Hard or Soft Palate and Closure by Secondary Intention 296
Excision of Superficial Warty Benign Tumors of the Hard Palate and Closure by Skin Graft 297
Excision of Deeply-Infiltrating Tumors of the Hard Palate on or Invading the Bone 298
Excision of Moderate-Sized Tumor of the Upper Gum and Palate 299
Partial Excision of Maxilla and Palate for Osteogenic Tumors 300
18 Operations for Tumors of the Nasal Cavity 303
Lateral Rhinotomy 304
Approach to the Nasal Cavity Through the Alveolar Process via Antrostomy 305
Snare Removal of Polypoid Nasopharyngeal Tumors 308
19 Operations on the Antrum and Maxilla 311
Partial Resection of the Maxilla for Early Cancer of the Antrum 312
Radical Resection of the Maxilla for Advanced Cancer of the Antrum and Paranasal Sinuses 315
20 Operations for Parotid Tumors 321
Some Cardinal Principles of Tumor Surgery of the Parotid Gland 321
Excision of Small Peripherally-Placed Parotid Tumors 322
Surgical Anatomy of the 7th Nerve 323
Superficial Parotidectomy 324
Excision of Retromandibular Tumors 327
Excision of Bulky Benign Parotid Tumors 330
Subtotal Parotidectomy with Preservation of the 7th Nerve 332
Total Parotidectomy with Preservation of the 7th Nerve 333
Subtotal Parotidectomy with Partial Preservation of the 7th Nerve Combined with Neck Dissection 334
Total Parotidectomy with Complete Sacrifice of the 7th Nerve Plus Neck Dissection 335
21 Operations on the Larynx 337
Variations in Form and Extent of Laryngeal Surgery for Cancer 337
Partial Laryngectomy 338
Through Laryngofissure 340
Through Anterior Pharyngotomy 344
Total Laryngectomy 345
Total Laryngectomy Combined with Neck Dissection 353
Variations in Management of Wide Pharyngostome Following Pharyngolaryngectomy 358
Pharyngolaryngectomy Combined with Neck Dissection 361
Maneuver to Obtain Direct Exposure and Visualization of the Vallecula and of the Base of the Tongue 362
Total Laryngectomy with Bilateral Neck Dissection 365
Subtotal Laryngectomy Combined with Neck Dissection for Postcricoid Cancer 371
Subtotal Laryngectomy Combined with Neck Dissection for Unilateral Cancer of the Extrinsic Larynx and/or Lateral Pharyngeal Wall 376
Repair of Pharyngeal Defect by Split-Skin Graft on Latex Stent 381
Z-Plastic for Enlargement of Microstomia Following Total Laryngectomy 384
Delayed Closure of a Pharyngeal Stoma Following Total Laryngectomy 385
Closure of Pharyngostome by＂Trap-Door＂Plastic 386
Closure of Large Pharyngeal Stoma by Tubed Pedicle Flap 387
Excision of Esophageal Diverticulum 389
22 Operations for Growths of the Pharyngeal Walls 391
Excision of Small Tumor of the Pharyngeal Wall Through Anterior Pharyngotomy 392
Removal of Extensive Cancer of the Posterior Wall Through Anterior Pharyngotomy：Closure by Secondary Intention 393
Removal of Submucous Bulging Tumor of Posterior Pharyngeal Wall 394
23 Operations for Thyroid Tumors 397
Hemithyroidectomy(Lobectomy) 398
Thyroidectomy and Neck Dissection 401
Window Resection of the Trachea for Invasion by Thyroid Cancer 406
Substernal Thyroid Tumors 408
Appendix 415
Index 425